Harbour sites as a support to the reconstruction of networks and influences: the case of the Mistras Lagoon (Sardinia, Italy)

Ancient harbours and anchorages are valuable contexts to investigate the different material culture that could reach a region, and to reconstruct ancient commerce and connections between different areas. Moreover, as they usually present waterlogged and anoxic sedimentation conditions, organic materials are preserved in addition to ceramics and other inorganic objects, giving more elements to the archaeological reconstruction. This is the case of the Mistras lagoon in Central-West Sardinia. The lagoon has been identified as the harbour of the city of Tharros, active during the Punic period, from the 7th to the 3rd century BC. It is characterised by an interior sandy barrier, recognised as a palaeobeach; here the University of Cagliari held two archaeological excavations during the years 2014 and 2015, revealing a natural stratigraphy rich in archaeological materials, typical of a waterlogged site. The analysis of the carpological remains, seeds, and fruits, recovered by sampling 29 different stratigraphic units, reveals the presence of a great number of cultivated species. Some of the species identified were possibly introduced during that period to the island, together with agricultural practices and technologies that improved local cultivations. Concerning the xylological remains found in the excavations, some fragments of manufactured wood provide important information about objects of common use, while other fragments are attributable to remains of ships.Gli antichi porti e approdi sono siti di grande valore per ricostruire le antiche rotte commerciali e più in generale le connessioni tra diverse regioni. Inoltre, grazie alla frequente presenza di condizioni di sedimentazione anossiche, essi possono restituire non solo ceramiche e altri materiali inorganici, ma anche elementi organici, raramente preservati sui siti terrestri, che forniscono elementi aggiuntivi alla ricostruzione archeologica e paleoambientale. È questo il caso della laguna di Mistras, nella Sardegna centro-occidentale. La laguna è stata identificata come porto della città di Tharros in età punica, tra il VII e il III sec. a.C. Essa è caratterizzata nella parte interna da una cuspide sabbiosa, riconosciuta come una paleospiaggia; in quest’area, durante gli anni 2014 e 2015, l’Università degli Studi di Cagliari ha condotto due campagne di scavo archeologico che hanno consentito di indagare una stratigrafia di formazione naturale ricchissima di materiali archeologici, tipica di un sito impregnato d’acqua. L’analisi dei reperti carpologici, semi e frutti recuperati grazie al campionamento sistematico dei sedimenti, sta rivelando la presenza di un gran numero di resti di specie coltivate. Alcune di queste furono probabilmente introdotte nell’Isola durante il periodo in questione, altre sono già attestate durante i periodi precedenti e continuano ad essere sfruttate con nuovo impulso. Per quanto riguarda i resti xilologici rinvenuti negli scavi, alcuni frammenti di legno lavorato forniscono importanti informazioni su oggetti di uso comune, mentre altri sono attribuibili a resti di imbarcazion

Agglomeration and growth with endogenous expenditure shares

We develop a New Economic Geography and Growth model which, by using a CES utility function in the second-stage optimization problem, allows for expenditure shares in industrial goods to be endogenously de- termined. The implications of our generalization are quite relevant. In particular, we obtain the following novel results: 1) catastrophic agglom- eration may always take place, whatever the degree of market integration, provided that the traditional and the industrial goods are su¢ ciently good substitutes; 2) the regional rate of growth is a¤ected by the interregional allocation of economic activities even in the absence of localized spillovers, so that geography always matters for growth and 3) the regional rate of growth is a¤ected by the degree of market openness: in particular, depend- ing on whether the traditional and the industrial goods are good or poor substitutes, economic integration may be respectively growth-enhancing or growth-detrimental

Essays in New Economic Geography

The recent Nobel Prize assigned to Paul Krugman "for his analysis of trade patterns and location of economic activity" witnesses the important role that the scienti�c community gives to the insights of the so-called New Economic Geography (NEG) literature. This field of economic analysis has always been particularly appealing to policy makers, given the direct link between its results and regional policy rules. For the same reason it is useful to deepen the analysis of its most important outputs by testing the theoretical robustness of some of its more relevant statements. This thesis tries to o¤er a contribution in this direction by focusing on a particular sub-field of NEG literature, the so-called New Economic Geography and Growth (NEGG) literature, having in Baldwin and Martin (2004) and Baldwin et. al (2004) the most important theoretical syntheses. These two surveys collect and present in an uni�ed framework the works by Baldwin, Martin and Ottaviano (2001), where capital is immobile and spillovers are localized, Martin and Ottaviano (1999) where spillovers are global and capital is mobile. Other related papers are Baldwin (1999) which introduces forward looking expectations in the so-called Footloose capital model developed by Martin and Rogers (1995); Baldwin and Forslid (1999) which introduces endogenous growth by means of a q-theory approach; Baldwin and Forslid (2000) where spillovers are localized, capital is immobile and migration is allowed. Some more recent developments in the NEGG literature can be distinguished in two main strands. One takes into consideration factor price differences in order to discuss the possibility of a monotonic relation between agglomeration and integration (Bellone and Maupertuis (2003) and Andres (2007)). The other one assumes firms heterogeneity in productivity (first introduced by Eaton and Kortum (2002) and Melitz (2003)) in order to analyse the relationship between growth and the spatial selection e¤ect leading the most productive firms to move to larger markets (see Baldwin and Okubo (2006) and Baldwin and Robert-Nicoud (2008). These recent developments are related to our work in introducing some relevant departures from the standard model. Indeed this thesis develops and extends the theoretical framework of New Economic Geography theory along several routes. In the third chapter of the thesis we develop a New Economic Geography and Growth model which, by using a CES utility function in the second-stage optimization problem, allows for expenditure shares in industrial goods to be endogenously determined. The implications of our generalization are quite rel-evant. In particular, we obtain the following novel results: 1) catastrophic agglomeration may always take place, whatever the degree of market integration, provided that the traditional and the industrial goods are su¢ ciently good substitutes; 2) the regional rate of growth is affected by the interregional allocation of economic activities even in the absence of localized spillovers, so that geography always matters for growth and 3) the regional rate of growth is af- fected by the degree of market openness: in particular, depending on whether the traditional and the industrial goods are good or poor substitutes, economic integration may be respectively growth-enhancing or growth-detrimental. In the fourth chapter of the thesis we build a New Economic Geography and Growth model based on Baldwin, Martin and Ottaviano (2001) with an additional sector producing Non-tradable goods (services). By assuming intersectoral and localized knowledge spillovers from the innovation sector to the service sector, we show that firms'allocation affects regional real growth. More precisely we assume that the unit labour requirements (and thereby the prices) in the service production are a negative function of the output of innovation, i.e. the stock of knowledge capital. Due to this new specification, real growth rates in the two regions always diverge when the firms allocation pattern differs from the symmetric one. This result is a novelty in the standard theoretical NEGG literature where regional gap in real growth rate is always zero. Moreover, this result has strong policy implications because it suggests that concentrating in- dustries in only one region may also bring a dynamic loss for the periphery. By analyzing the trade-o¤ between the dynamic gains of agglomeration (due to localized intertemporal spillovers) and the dynamic loss of agglomeration (due to localized intersectoral spillovers), we also discuss different notions of optimal level of agglomeration. The thesis will proceed as follows: in the chapters one and two we describe the state of the art in New Economic Geography and its further developments such as the New Economic Geography and Growth, the possibility of a monotonic relation between agglomeration and integration, and finally the firms heterogeneity in New Economic Geography models. Instead in chapters three and four we present our original contribution to the theory, i.e. the analysis of endogenous expenditure shares and intersectoral knowledge spillovers on the agglomeration patterns and economic growth

Current multivariate risk scores in patients undergoing non-cardiac surgery

Several indexes to predict perioperative cardiovascular risk have been proposed overtime. The most widely used is the Revised Cardiac Risk Index (RCRI) developed by Lee since 1999. It predicts major cardiac outcomes from five independent clinical determinants: history of ischemic heart disease, history of cardiovascular disease, heart failure, insulin-dependent diabetes mellitus, and chronic renal failure (i.e. serum creatinine >2 mg/dl). In external validation studies, the RCRI showed high negative predictive value in all groups of age, indicating that it may be used to identify people at low risk for perioperative adverse cardiovascular events in noncardiac surgery. However its accuracy is suboptimal in many clinical settings. More recently the National Surgical Quality Improvement Program database) (NSQIP) hasdeveloped a new index to predict perioperative myocardial infarction (MI) or cardiac arrest (MICA) from a cohort of 211,410 patients (the Gupta index) and afterwards a universal surgical risk estimation tool has been developed, using standardized clinical data from 393 ACSNSQIP hospitals in US (a cohort based on 1,414,006 patients), showing a good performance for mortality (C-statistic = 0.944) and morbidity (C-statistic =0.816) as compared with procedure-specific models. Other risk scores include the Vascular events In noncardiac Surgery patIents cOhort evaluatioN (VISION), which has evaluated cardiac complications in 15,065 patients, the Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) and the large Preoperative Score to Predict Postoperative Mortality (POSPOM) that was built up from data collected in the National Hospital Discharge Data Base (NHDBB) including a cohort of 7.059.447 patients. In Italy a new risk index (the Orion score) builkt up from a cohort of 9000 patients generated four classes of major cardiovascular adverse events perioperative risk ranging from 1 (0.6%); 2 (2.4%); 3 (7.4%) and 4 (23.1%). The AUROC curves showed higher accuracy as compared to the RCRI score both in the derivation than in the validation cohort (AUROC= 0.872 ± 0.028 vs 0.807 ± 0.037). Thus, many risk indices are available nowadays. Despite the latest European guidelines recommended them for risk stratification (class I, level of evidence B), their use in clinical practice is still scarce

Cardiovascular risk prediction in the real world. The discouraging evidences coming from literature

Risk prediction plays a leading role in cardiovascular (CV) prevention. Thus, several risk charts have been developed in different Countries in the attempt to identify subjects at high risk who might benefit from more aggressive and early interventions. However despite the availability of several risk charts, they are underutilized in clinical practice. Indeed risk charts show main limitations: they estimate absolute, but not individual risk; their performance is affected by changes on the incidence of CV diseases; they do not take into account the duration of risk exposure, which is related to the progression of atherosclerosis. Moreover, risk estimate might be less accurate in younger, in women, and in the elderly. Addition of novel risk markers have substantially failed to improve risk charts' discrimination power. Imaging has recently gained relevance in CV risk stratification for its ability to detect subclinical atherosclerosis. Among imaging techniques coronary artery calcium score(CACS) emerged as the most powerful and independent predictor of CV events. Hence, a CACSbased screening strategy have been proposed in all asymptomatic middle-aged people. However since CACS it is still quite expensive and not-radiation free, it is not recommended by most scientific guidelines. Conversely, detecting subclinical organ damage (SOD) like LV hypertrophy, carotid plaque, renal failure, microalbuminuria or the metabolic syndrome in subjects at intermediate risk is pretty cost-effective yielding to reclassification of subjects into higher-risk strata. Thus, merging information coming from different tools (risk scores, biomarkers, and non-invasive imaging) individual risk might be better stratified saving costs. In the next future, an integrated, semi-automated, high-reproducible and inexpensive ultrasound approach could represent a key point to approach the individual risk

Arterial hypertension. Does the J curve exist? And then?

The concept that 'the lower the blood pressure (BP) achieved the better the outcome' rests on the demonstration of a direct relationship between BP and incident outcomes, down to levels of 115 mmHg of systolic BP (sBP) and 75 mmHg of diastolic BP (dBP) carried out in 1 million individuals from 61 cohorts recruited between 1950 and 1990 and followed for about 14 years. The alternative to the 'lower the better' concept is the hypothesis of a J-shaped relationship, according to which the benefits of reducing sBP or dBP to low values may be dangerous leading even to an increase in total mortality and/or in CV outcomes. Data from contemporary epidemiologic observations, (CALIBER study), showed that the relationships between rising BP and increased incidence of outcomes rise continuous even over 85 years of age without the evidence of a J-shaped association with any of the outcomes at any age strata. In the English Longitudinal Study of Ageing study (ELSA), a tailored analysis for octogenarians showed that the increase in mortality rates associated with BP ranges appears at sBP <110 mmHg and ≥170 mmHg. In randomized controlled trials (SPRINT, HYVET and INVEST), the J curve seems to concern mainly patients with an extensive atherosclerotic burden, rather than. An impaired autoregulation of coronary blood flow (CBF) leading to a fall in diastolic BP and resulting in a lowering in the perfusion pressure distal to the epicardial coronary artery stenosis, can eventually lead to myocardial ischemia. Diastolic dysfunction can concur in worsening CBF in diastole. These features are often seen in elderly patients with heart failure with preserved ejection fraction. The steeper position of the slope of the end-systolic elastance can lead to dramatic increases and decreases in BP for the same change in afterload or preload. This may explain why elderly hypertensives are more prone to suffer of hypertensive crisis and/or hypotension than younger hypertensives. "Pseudo-hypertension" caused by structural sclerotic changes in the brachial artery wall may cause overtreatment related falls in blood pressure. Thus, the J curve exists but only in patients with multiple comorbidities and/or extensive atherosclerotic burden

Arterial hypertension: which targets in over-75-year people?

Arterial hypertension has always been considered the main risk factor in cardiovascular prevention. However, the goals of anti-hypertensive treatment (targets) in the elderly has long been under discussion. The results of the studies in favor of the hypothesis "the lower the better" than those that argue against the existence of the phenomenon of the J-curve, that is, the hypothesis according to which mortality increases to too low pressure values  lower than 115/75 mmHg, are still controversial. However, in elderly patients the association between blood pressure lowering and increased cardiovascular events seems to depend on the general health status, that means the presence of comorbidity, frailty and / or disability. Recent data from the SPRINT study show that the benefit of an intensive blood pressure target (SBP <120 mmHg) compared to a usual target (SBP <140 mmHg), appears to be greater in the oldest hypertensive patients (≥75 years). The cardio-geriatric functional assessment can provide useful information to better stratify the elderly and to define more accurately the pressure targets, the choice is individual. Riassunto L’ipertensione arteriosa è da sempre  considerata il fattore di rischio centrale in prevenzione cardiovascolare. Tuttavia gli obbiettivi del trattamento anti-ipertensivo (target pressori) nei soggetti anziani è  da molti anni oggetto di discussione. Il risultati degli studi a favore dell’ipotesi “the lower the better” rispetto a quelli contrari che sostengono l’esistenza del  fenomeno della cosiddetta curva J, l’ipotesi cioè secondo la quale la mortalità aumenta per valori di pressione troppo bassi, inferiori a 115/75 mmHg, sono tutt’ora controversi. Tuttavia in pazienti anziani l’associazione tra riduzione dei valori di pressione arteriosa e aumento degli eventi cardiovascolari  sembra dipendere dallo stato di salute generale, ovvero alla presenza di comorbidità, fragilità e/o disabilità. I recenti dati dello studio SPRINT. Mostrano che il beneficio di un target pressorio intensivo  (PAS<120 mmHg) rispetto ad un target usuale  (PAS<140 mmHg), sembra essere maggiore nei soggetti  ipertesi più anziani (≥75 anni). La valutazione funzionale cardio-geriatrica può fornire informazioni utili a stratificare meglio  i soggetti anziani e a definirne in maniera più accurata i target pressori, la cui scelta rimane individuale.

COVID-19 pandemic: what consequences for cardiac rehabilitation?

The ongoing COVID-19 pandemic spreading all around the world has stressed over its capabilities and determined profound changes in the health systems in all countries and has caused hundreds of thousand deaths. Health professionals have been called to a tremendous effort to deal with this emergency, often contaminating or succumbing themselves to the disease

Secondary cardiovascular prevention in clinical practice: what do we need today?

In the last decades, the post-hospital mortality from coronary artery disease (CAD) has significantly increased. This new trend in the epidemiology of CAD has been largely attributed to the improvement of survival from acute coronary syndromes that generated increasing incidence of population at high risk of recurrences and rehospitalization for major adverse cardiovascular events (MACE) and heart failure (HF). Thus, much longer after the acute event than we had thought, we have now been facing with higher complexity of "chronic" CAD phenotypes which deserve high clinical attention and more and more intricate pharmacological management. Although the guidelines recommend implementing secondary prevention programs through cardiac rehabilitation (CR) facilities in order to achieve a better outcome, i.e. decreased morbidity, re-hospitalization and increased adherence to evidence-based interventions, the referral rate to CR is paradoxically scarce. The Italian Association of Clinical Preventive Cardiology and Rehabilitation (AICPR) has been launching a survey involving the Network of Italian CR centers, which will make possible to observe trends, implement guidelines recommendations and then verify the effectiveness of the interventions and outcomes in post-acute and chronic CAD

preoperative evaluation before non cardiac surgery in subjects older than 65 years

Non cardiac surgery is becoming increasingly common in elderly patients; they are usually affected by overt cardiac disease or show multiple risk factors, responsible for a higher incidence of perioperative fatal or nonfatal cardiac events. Of interest, acute myocardial infarction occurring in the perioperative period shows a high mortality rate in people over 65 years old. The cardiovascular risk stratification and perioperative management of subjects undergoing noncardiac surgery have been recently updated in the 2014 European Society of Cardiology Guidelines. However, several critical points still lack of strong evidence and are based on expert opinions only. For example, the use of drugs, such as betablockers, before, during and after the surgery, presents many uncertainties regarding the selection of patients more likely to benefit, dosage and duration of therapy, and effects on outcome. Data on elderly patients undergoing non cardiac surgery are scarce. Accordingly, a prospective registry enrolling a large number of aged subjects undergoing non cardiac surgery (particularly at high or intermediate risk) should be able to give us adequate insights on the management strategies currently used, on the incidence of death or cardiovascular events in the postoperative period and on the areas of potential improvement in care. Furthermore, the effects on outcome of structured programs of Guidelines implementation in the clinical practice of cardiologists, anesthesiologists and other health personnel involved in perioperative care, could be positive and should be evaluated