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To assess the cost-effectiveness of prophylactic Zn supplementation for preventing diarrhoea in young children in Tanzania.
Cost-effectiveness analysis using decision-analytic modelling. Cost-effectiveness ratios were calculated as the incremental cost (2019 USD) per disability-adjusted life year (DALY) averted, from a societal perspective, and with a 3 % discount rate applied to future outcomes. Sensitivity analyses were performed to test the robustness of results to alternative assumptions.
A hypothetical cohort of 10 000 children aged 6 weeks to 18 months.
The intervention costs of Zn supplementation were estimated as $109 800 (95 % uncertainty interval: 61 716, 171 507). Zn supplementation was estimated to avert 2200 (776, 3737) diarrhoeal episodes, 14 080 (4692, 25 839) sick days, 1584 (522, 2927) outpatient visits, 561 (160–1189) inpatient bed days, 0·51 (0·15, 1·03) deaths and 19·3 (6·1, 37·5) DALY (discounted at 3 % per year). Zn supplementation reduced diarrhoea care costs by $12, 887 (4089, 25 058). The incremental cost per DALY averted was $4950 (1678, 17 933). Incremental cost-effectiveness ratios (ICER) estimated from a health system perspective were similar to the results from the societal perspective. ICER were substantially lower (more favourable) when future outcomes were not discounted, but all ICER were above contemporary thresholds for cost-effectiveness in this setting.
Prophylactic Zn reduced diarrhoea incidence and associated healthcare utilisation; however, it did not appear to be cost-effective for prevention of childhood diarrhoea in the scenario examined in this study. Reducing intervention costs, or identifying high risk groups for intervention targeting, may be needed to improve cost-effectiveness in this setting.
To develop a candidate definition for central line–associated bloodstream infection (CLABSI) in neonates with presumed mucosal barrier injury due to gastrointestinal (MBI-GI) conditions and to evaluate epidemiology and microbiology of MBI-GI CLABSI in infants
Multicenter retrospective cohort study.
Neonatal intensive care units from 14 US children’s hospitals and pediatric facilities.
A multidisciplinary focus group developed a candidate MBI-GI CLABSI definition based on presence of an MBI-GI condition, parenteral nutrition (PN) exposure, and an eligible enteric organism. CLABSI surveillance data from participating hospitals were supplemented by chart review to identify MBI-GI conditions and PN exposure.
During 2009–2012, 410 CLABSIs occurred in 376 infants. MBI-GI conditions and PN exposure occurred in 149 (40%) and 324 (86%) of these 376 neonates, respectively. The distribution of pathogens was similar among neonates with versus without MBI-GI conditions and PN exposure. Fifty-nine (16%) of the 376 initial CLABSI episodes met the candidate MBI-GI CLABSI definition. Subsequent versus initial CLABSIs were more likely to be caused by an enteric organism (22 of 34 [65%] vs 151 of 376 [40%]; P = .009) and to meet the candidate MBI-GI CLABSI definition (19 of 34 [56%] vs 59 of 376 [16%]; P < .01).
While MBI-GI conditions and PN exposure were common, only 16% of initial CLABSIs met the candidate definition of MBI-GI CLABSI. The high proportion of MBI-GI CLABSIs among subsequent infections suggests that infants with MBI-GI CLABSI should be a population targeted for further surveillance and interventional research.
Infect Control Hosp Epidemiol 2014;35(11):1391–1399
The March on Rome did not seem to most contemporaries to mark a watershed. No riots or demonstrations broke out; the routine of daily life continued uninterrupted; and the press reported the events as if they were just one more dramatic episode in Italy’s chaotic and violent post-war drama. The general mood was, if anything, one of relief – a sense that the confusion and uncertainty of the last few years was now over and normality about to return. Most observers anticipated that the squadristi would be absorbed into the system; and many believed that this would provide a badly needed injection of spiritual energy, that would strengthen the institutions and narrow the gap between ‘real’ and ‘political’ Italy. Politicians such as Giolitti were quietly dismissive of Mussolini, whose plebeian manner and evident insecurity encouraged them to think that he could be manipulated without difficulty, used, and then discarded when he had served their turn.
Mussolini was appointed prime minister in an essentially constitutional way, but in deference to the rank and file a ‘victory’ parade of squadristi was held through the streets of Rome in order to foster the illusion of a coup d’état. This schizophrenic start set the tone for the following two years. Mussolini had to alternate between appeasing the establishment (on whom he depended for continuance in office) and reassuring the provincial fascist bosses and their followers that he was still a subversive. However, for all their intemperance of language, it was not evident what the radical or ‘intransigent’ fascists wanted in place of the liberal regime. They knew what they loathed and what they aimed to destroy, but few of them had any constructive political ideas. Fascism was without a distinctive programme.
In the late spring of 1860 Giuseppe Garibaldi, a flamboyant irregular soldier, who had spent much of his life abroad fighting as a guerrilla leader, set sail for Sicily from a port near Genoa. On board his two small ships was a motley collection of students and adventurers, many of them barely out of their teens. Their mission was to unify Italy. The prospects for success seemed limited: the group was ill-armed, and few among them had any experience in warfare or administration. Moreover, they did not constitute a promising advertisement for the nation-to-be. Among the thousand or so volunteers were Hungarians and Poles, and the Italian contingent included a disproportionate number from the small northern city of Bergamo. However, in the space of a few months they succeeded in conquering Sicily and the mainland South from the Bourbons; and in March 1861 Victor Emmanuel II, King of Piedmont–Sardinia, became the first king of united Italy.
The success of Garibaldi and his ‘Thousand’ was both remarkable and unexpected; and when the euphoria had died down, many sober observers wondered whether the Italian state could survive. France and Austria, the two greatest continental powers of the day, both threatened to invade the new kingdom, break it up, and reconstitute the Papal States, which had been annexed by Victor Emmanuel in the course of unification. A much more insidious long-term threat, however, to the survival of the new state, was the absence of any real sense of commitment or loyalty to the kingdom among all except a small minority of the population. The country’s new rulers justified their demands for heavy taxes and military service, the often harsh repressive measures, and the unfamiliar institutions, by appealing to the sanctity and inviolability of the Italian ‘nation’: but for the overwhelming mass of Italians, the ‘Italian nation’, indeed ‘Italy’ itself, meant almost nothing.
Just as Austria’s defeat by Prussia in 1866 had brought Italy the Veneto, so France’s defeat by Prussia in 1870 led to the capture of Rome. Throughout much of the 1860s the Holy City had been defended by a garrison of French soldiers. When this was withdrawn in the summer of 1870 to fight Prussia, and Napoleon III was defeated and forced to abdicate, there was little to stop the Italian government seizing the historic capital. On 20 September, less than three weeks after the Battle of Sedan, Italian troops blew a hole in the Leonine walls at Porta Pia and marched into the city. Pius IX was left with the small enclave of the Vatican. A law was passed in May 1871 that guaranteed the safety of the pope, provided him with an annual grant, and gave him the full dignities and privileges of a sovereign; but Pius IX rejected it out of hand. The rift between the liberal state and the Church was now broader and deeper than ever.
The acquisition of Rome had long been the supreme ambition of most Italian patriots. For Mazzini’s followers in particular, the city was always much more than just a piece of territory. It was a symbol of moral regeneration, pregnant with the idea of mission and responsibility; and just as the Rome of the Caesars and the Rome of the popes had each brought the world a new civilisation, so the ‘Third Rome’, that of ‘the people’, would arise and convey to the oppressed the gospel of liberation and peace. Even such a rational moderate as Quintino Sella could not escape the spell of Rome: he longed, he said, to underline the universal significance of destroying the pope’s temporal power by making the city into a great centre for science. However, not everyone was smitten. Massimo d’Azeglio and Stefano Jacini objected to Rome becoming the capital of Italy precisely because of its historical associations, which, they felt, would weigh dangerously on the country’s rulers.
The fall of Mussolini was met with enthusiasm and a widespread feeling that the war would soon be over. When Pietro Badoglio, the new prime minister, announced that fighting continued, few, not even himself, believed it. The government’s aim was to humour the Germans until an armistice had been signed quickly change sides, and then, with Allied help, seize Rome. But there were delays and no proper plans were made to prepare the army for what was about to take place (Badoglio and the king were terrified of the Germans – who already deeply mistrusted the Italians). By the time an armistice was signed on 3 September the Germans were pouring reinforcements into the peninsula. Besides, the Italian army had no real stomach for a fight, on whoever’s side; and although it had been agreed that Italian troops would aid an American offensive to capture Rome, in the event no support was forthcoming. Without any orders from above, the Italian forces simply dissolved, leaving the Germans free to secure all of northern and central Italy.
This left Italy divided. The king and his government fled Rome to escape the nazis, and set up residence in Brindisi: an act easily construed as cowardice, which sealed the fate of the monarchy in 1946. Meanwhile the Germans had seized Mussolini from his prison on the Gran Sasso mountain, taken him up north, and installed him at the head of a puppet government on the shores of Lake Garda. The Republic of Salò, as this last incarnation of fascism was called, was notable for the brutality of its various police forces (some of them just private criminal gangs) and for attempts to resurrect the syndicalist elements of the early movement: a law of 1944, for instance, declared that half of the management board of large firms should consist of representatives elected by the workers.
The year of revolutions in Europe of 1848–9 was more an outcry at the shortcomings of the restoration states than a conscious struggle for a new social order. Many of the intellectual leaders or interpreters of this ‘springtime of the peoples’, from Karl Marx to Mazzini, hoped and indeed believed that a world free of oppressors and tyrants was about to be born; but the artisans, shopkeepers, and urban poor who made up the backbone of the insurrections, and took to the streets of Palermo, Berlin, and Vienna, threw up barricades and stormed town halls, acted more from a spontaneous anger at unemployment, prices, or taxes than a desire to create a wholly different society. Nevertheless, in at least one important respect 1848–9 did look to the future: it sounded the death-knell of absolutism. The idea that a government should prevent change and freeze society in the interests of a narrow elite, seemed untenable in a world that was already beginning to be transformed by industry and science.
The quickening pace of Europe’s economic life from the 1830s was to quicken even more after the 1840s. Britain led the way: in the mid-1840s it had some 3,000 miles of railways; by 1850 this figure had more than doubled; and by 1860 the total stood at over 10,000 miles. Output of cotton and pig-iron, the cornerstones of industry in this period, soared; so too did production of an enormous variety of other often newly invented goods, as world demand, depressed for more than thirty years, picked up dramatically. Faith in the march of progress seemed boundless, and was enshrined in the Great Exhibition, opened in 1851. In France, Belgium, and the German states the rhythm of economic life was similarly, if rather less dramatically, transformed. Small workshops became great factories; towns became sprawling cities; peasants became proletarians; and everywhere, the middle classes grew more numerous and assertive.
The history of Italy is tied up inseparably with its geographical position. For centuries the peninsula formed the crossroads of Europe. To the north, the Alps were always much less of a barrier than their height suggested: of the twenty-three main passes, seventeen were already in regular use under the Romans. The relatively low Julian and Carnic Alps to the north-east offered an easy crossing point for invading armies. It was over them that the Visigoths, the Huns, the Lombards, and other central European tribes marched in the centuries after the fall of Rome. During the Middle Ages the dense flow of commercial traffic over the Simplon, the St Gotthard, and Brenner passes was crucial to the prosperity of Genoa, Milan, Venice, and many smaller cities in the Po valley. The accessibility of the Brenner to heavy German carts was particularly important for the Venetian economy.
Of no less importance than this close link with the continental land mass of Europe was Italy’s position in the centre of the Mediterranean. With its long coastline, gently sloping beaches, and many natural harbours, the peninsula was highly attractive to overseas settlers. Greeks from Corinth, Euboea, and elsewhere, travelling west on the prevailing currents, landed in Sicily and on the southern mainland from the eighth century bc. Their settlements flourished: during the fourth century Syracuse was the most powerful city-state in the Mediterranean. The short distance between Sicily and North Africa (about 160 km at the narrowest point) made it particularly prone to attacks from the south: the Carthaginians invaded on many occasions between the fifth and third centuries bc; and in the ninth century ad the Arabs conquered the island. In July 1943 Sicily was the first Axis territory to fall to the Allies following victory in the Desert Campaign.
Despite political and economic uncertainties, the leading families of the Italian city states in the later fifteenth century enjoyed a strong sense of superiority. They formed an elite, not entirely closed, but one whose values and aspirations were in general more aristocratic than those of their merchant forebears. The Medici and the Strozzi were still great banking families, but their wealth was invested increasingly in urban palaces, country villas, and works of art. Sensibility, learning, and a certain disdain for money per se became the touchstones of status: when Giuliano Zancaruol commissioned a painting from Giovanni Bellini, he stressed that the cost was unimportant, ‘as long as it is beautiful’. The achievements of Alberti, Pisanello, Mantegna, Botticelli, Bramante, or Leonardo gave their patrons feelings of importance that spilled over all too frequently into complacency. There were many in Italy who felt that their civilisation not only rivalled but perhaps even surpassed that of the ancients.
The sense of self-assurance was undermined by the long sequence of wars that rocked the peninsula from 1494. Charles VIII’s conquest of Naples and the subsequent invasions by Spanish, French, and Imperial troops were widely seen as acts of divine retribution, punishments for the excess of wealth and worldliness in Italy. The historian Francesco Guicciardini reported that the arrival of Charles VIII’s army was preceded by awesome prodigies: in Apulia, three suns shone in the middle of the sky at night, while in Arezzo, ‘an infinite number of armed men on great horses passed through the air, with a terrible noise of trumpets and drums’. By the time Guicciardini wrote this in the 1530s, the Italian states had been reduced to mere pawns in an international power struggle. Spain controlled Sicily, Naples, Sardinia, and Lombardy; the constitutions and boundaries of other territories had been radically redrawn; and Rome had been sacked. Disillusionment had begun to replace the earlier feelings of supremacy.
Since its formation in 1861, Italy has struggled to develop an effective political system and a secure sense of national identity. This new edition of Christopher Duggan's acclaimed introduction charts the country's history from the fall of the Roman Empire in the west to the present day and surveys the difficulties Italy has faced during the last two centuries in forging a nation state. Duggan successfully weaves together political, economic, social and cultural history, and stresses the alternation between materialist and idealist programmes for forging a nation state. This second edition has been thoroughly revised and updated to offer increased coverage of nineteenth- and twentieth-century Italy, as well as a new section devoted to Italy in the twenty-first century. With a new, extensive bibliographical essay and a detailed chronology, this is the ideal resource for those seeking an authoritative and comprehensive introduction to Italian history.