The Legal Status of General Practitioners at the dawn of the New Primary Care in Italy

Abstract: A debate is developing in Italy on the reform of the employment status of general practitioners. The dispute was prompted by the extraordinary resources the European Union has allocated to Italy on the condition of several structural reforms, among which lies the renewal of the primary care system. One of the most debated questions is whether general practitioners should become civil servants or remain autonomous workers. The issue is not only relevant to the quality and efficiency of primary care but is propitious for improving the legal certainty of this "hybrid figure" in Italian health law. The commentary suggests that, from a public law point of view, the employment status of civil servants better agrees with the foreseeable conditions of general practitioners working in Community Houses. In any case, national and regional policymakers must take into consideration possible controversies and litigation arising from an inappropriate qualification of the legal status of general practitioners in building the new system of Italian primary care.Nella sanità italiana è in atto un vivace dibattito sulla possibile revisione dello status giuridico dei medici di medicina generale. La discussione è occasionata dagli eccezionali fondi che l’Unione europea ha attribuito all’Italia a condizione di riforme strutturali tra cui, appunto, il rinnovamento del sistema di assistenza primaria. Una delle questioni più dibattute concerne la trasformazione dei medici di medicina generale in dipendenti pubblici, ovvero la conservazione dello status di lavoratori autonomi, sebbene “parasubordinati.” Tale circostanza non è rilevante soltanto per la qualità e l’efficienza dell’assistenza primaria ma può rappresentare anche un momento per dare maggiore certezza giuridica ad una figura “ibrida” del diritto sanitario italiano. Nel contributo si conclude che, da un punto di vista giuspubblicistico e costituzionale, il rapporto di lavoro dipendente è quello che meglio si attaglia alle verosimili condizioni lavorative dei medici di medicina generale nelle Case della comunità. A livello generale, in ogni caso, è opportuno che legislatore nazionale e regionale tengano in adeguata considerazione i possibili riflessi legali e giudiziali della ridefinizione giuridica dei medici di medicina generale nel nuovo sistema di assistenza primaria italiana

The role of statistical significance testing in public law and health risk assessment

Following a fundamental statement made in 2016 by the American Statistical Associations and broad and consistent changes in data analysis and interpretation methodology in public health and other sciences, statistical significance/null hypothesis testing is being increasingly criticized and abandoned in the reporting and interpretation of the results of biomedical research. This shift in favor of a more comprehensive and non-dichotomous approach in the assessment of causal relationships may have a major impact on human health risk assessment. It is interesting to see, however, that authoritative opinions by the Supreme Court of the United States and European regulatory agencies have somehow anticipated this tide of criticism of statistical significance testing, thus providing additional support to its demise. Current methodological evidence further warrants abandoning this approach in both the biomedical and public law contexts, in favor of a more comprehensive and flexible method of assessing the effects of toxicological exposure on human and environmental health

Assessment of selenium levels and risk factors for stroke and other cardiovascular disease: a cross sectional study in a seleniferous area of Punjab, India

Background and aims: Rural areas of Punjab in India have been found to have soil rich in selenium (Se); about 2160 hectare area is seleniferous and is populated by about 10,000 inhabitants. Selenium concentrations in these villages were reported to be as high as 65 times over non-seleniferous areas. The aim of this cross-sectional study was to evaluate selenium levels in blood, hair and nails in a group of subjects living in this area, and to evaluate the correlation between selenium exposure levels and a relevant cardiovascular risk factor and blood pressure. Methods: In a random sample of rural residents in three districts of a seleniferous area of Punjab, we determined selenium concentration in hair, nail clippings and serum samples. Analyses were carried out using atomic absorption spectrophotometry at National Dairy Research Institute (NDRI), Karnal, India. Data analysis was performed using the STATA 15.0 software (STATA Corp. TX). Results: A total of 680 human subjects were recruited in this study, with a male/female ratio of 0.65 and a median age of 43 (IQR 32-52). Medium selenium levels in blood, hair and nail were 86.7 µg/l (IQR 55.9-200.3), 20.7 µg/g (IQR 12.6-40.3) and 56.9 µg/g (IQR 42.8-83.9), respectively, with lower levels in women in all three kind of samples. Concerning systolic blood pressure, Pearson’s correlation coefficients were 0.102 (95 % CI -0.025 to 0.226, p=0.116); 0.076 (95% CI -0.010 to 0.160, p=0.085); 0.072 (95% CI -0.015 to 0.157, p=0.104) with blood, hair and nail, respectively. For diastolic blood pressure, Pearson’s correlation coefficients are 0.106 (95% CI -0.022 to 0.230, p=0.104), 0.036 (95% CI -0.050 to 0.122, p=0.409), 0.049 (95% CI -0.038 to 0.135, p=0.272), respectively. Conclusions: Our findings indicate a positive correlation between selenium content in blood, hair and nails and increasing systolic and diastolic pressure levels, in line with previous epidemiologic findings, indicating a possible health concern for this highly exposed population. The possible relation between selenium over-exposure and onset of hypertension and other cardiovascular diseases deserves further investigation

Association between Outdoor Air Pollution and Childhood Leukemia: A Systematic Review and Dose-Response Meta-Analysis.

BackgroundA causal link between outdoor air pollution and childhood leukemia has been proposed, but some older studies suffer from methodological drawbacks. To the best of our knowledge, no systematic reviews have summarized the most recently published evidence and no analyses have examined the dose-response relation.ObjectiveWe investigated the extent to which outdoor air pollution, especially as resulting from traffic-related contaminants, affects the risk of childhood leukemia.MethodsWe searched all case-control and cohort studies that have investigated the risk of childhood leukemia in relation to exposure either to motorized traffic and related contaminants, based on various traffic-related metrics (number of vehicles in the closest roads, road density, and distance from major roads), or to measured or modeled levels of air contaminants such as benzene, nitrogen dioxide, 1,3-butadiene, and particulate matter. We carried out a meta-analysis of all eligible studies, including nine studies published since the last systematic review and, when possible, we fit a dose-response curve using a restricted cubic spline regression model.ResultsWe found 29 studies eligible to be included in our review. In the dose-response analysis, we found little association between disease risk and traffic indicators near the child's residence for most of the exposure range, with an indication of a possible excess risk only at the highest levels. In contrast, benzene exposure was positively and approximately linearly associated with risk of childhood leukemia, particularly for acute myeloid leukemia, among children under 6 y of age, and when exposure assessment at the time of diagnosis was used. Exposure to nitrogen dioxide showed little association with leukemia risk except at the highest levels.DiscussionOverall, the epidemiologic literature appears to support an association between benzene and childhood leukemia risk, with no indication of any threshold effect. A role for other measured and unmeasured pollutants from motorized traffic is also possible. https://doi.org/10.1289/EHP4381

Concerted changes in tropical forest structure and dynamics: evidence from 50 South American long-term plots

Several widespread changes in the ecology of old-growth tropical forests have recently been documented for the late twentieth century, in particular an increase in stem turnover (pan-tropical), and an increase in above-ground biomass (neotropical). Whether these changes are synchronous and whether changes in growth are also occurring is not known. We analysed stand-level changes within 50 long-term. monitoring plots from across South America spanning 1971-2002. We show that: (i) basal area (BA: sum of the cross-sectional areas of all trees in a plot) increased significantly over time (by 0.10 +/- 0.04 m(2) ha(-1) yr(-1), mean +/- 95% CI); as did both (ii) stand-level BA growth rates (sum of the increments of BA of surviving trees and BA of new trees that recruited into a plot); and (iii) stand-level BA mortality rates (sum of the cross-sectional areas of all trees that died in a plot). Similar patterns were observed on a per-stem basis: (i) stem density (number of stems per hectare; 1 hectare is 10(4) m(2)) increased significantly over time (0.94 +/- 0.63 stems ha(-1) yr(-1)); as did both (ii) stem recruitment rates; and (iii) stem mortality rates. In relative terms, the pools of BA and stem density increased by 0.38 +/- 0.15% and 0.18 +/- 0.12% yr(-1), respectively. The fluxes into and out of these pools-stand-level BA growth, stand-level BA mortality, stem recruitment and stem mortality rates-increased, in relative terms, by an order of magnitude more. The gain terms (BA growth, stem recruitment) consistently exceeded the loss terms (BA loss, stem mortality) throughout the period, suggesting that whatever process is driving these changes was already acting before the plot network was established. Large long-term increases in stand-level BA growth and simultaneous increases in stand BA and stem density imply a continent-wide increase in resource availability which is increasing net primary productivity and altering forest dynamics. Continent-wide changes in incoming solar radiation, and increases in atmospheric concentrations of CO2 and air temperatures may have increased resource supply over recent decades, thus causing accelerated growth and increased dynamism across the world's largest tract of tropical forest

An international network to monitor the structure, composition and dynamics of Amazonian forests (RAINFOR)

The Amazon basin is likely to be increasingly affected by environmental changes: higher temperatures, changes in precipitation, CO2 fertilization and habitat fragmentation. To examine the important ecological and biogeochemical consequences of these changes, we are developing an international network, RAINFOR, which aims to monitor forest biomass and dynamics across Amazonia in a co-ordinated fashion in order to understand their relationship to soil and climate. The network will focus on sample plots established by independent researchers, some providing data extending back several decades. We will also conduct rapid transect studies of poorly monitored regions. Field expeditions analysed local soil and plant properties in the first phase (2001–2002). Initial results suggest that the network has the potential to reveal much information on the continental-scale relations between forest and environment. The network will also serve as a forum for discussion between researchers, with the aim of standardising sampling techniques and methodologies that will enable Amazonian forests to be monitored in a coherent manner in the coming decades

The relation between amyotrophic lateral sclerosis and inorganic selenium in drinking water: a population-based case-control study

<p>Abstract</p> <p>Background</p> <p>A community in northern Italy was previously reported to have an excess incidence of amyotrophic lateral sclerosis among residents exposed to high levels of inorganic selenium in their drinking water.</p> <p>Methods</p> <p>To assess the extent to which such association persisted in the decade following its initial observation, we conducted a population-based case-control study encompassing forty-one newly-diagnosed cases of amyotrophic lateral sclerosis and eighty-two age- and sex-matched controls. We measured long-term intake of inorganic selenium along with other potentially neurotoxic trace elements.</p> <p>Results</p> <p>We found that consumption of drinking water containing ≥ 1 μg/l of inorganic selenium was associated with a relative risk for amyotrophic lateral sclerosis of 5.4 (95% confidence interval 1.1-26) after adjustment for confounding factors. Greater amounts of cumulative inorganic selenium intake were associated with progressively increasing effects, with a relative risk of 2.1 (95% confidence interval 0.5-9.1) for intermediate levels of cumulative intake and 6.4 (95% confidence interval 1.3-31) for high intake.</p> <p>Conclusion</p> <p>Based on these results, coupled with other epidemiologic data and with findings from animal studies that show specific toxicity of the trace element on motor neurons, we hypothesize that dietary intake of inorganic selenium through drinking water increases the risk for amyotrophic lateral sclerosis.</p

Friend or foe? The current epidemiologic evidence on selenium and human cancer risk.

Scientific opinion on the relationship between selenium and the risk of cancer has undergone radical change over the years, with selenium first viewed as a possible carcinogen in the 1940s then as a possible cancer preventive agent in the 1960s-2000s. More recently, randomized controlled trials have found no effect on cancer risk but suggest possible low-dose dermatologic and endocrine toxicity, and animal studies indicate both carcinogenic and cancer-preventive effects. A growing body of evidence from human and laboratory studies indicates dramatically different biological effects of the various inorganic and organic chemical forms of selenium, which may explain apparent inconsistencies across studies. These chemical form-specific effects also have important implications for exposure and health risk assessment. Overall, available epidemiologic evidence suggests no cancer preventive effect of increased selenium intake in healthy individuals and possible increased risk of other diseases and disorders