The Business of FashionAgenda-setting intelligence analysis and advice for the global fashion community ignoring red flags in the interest of convenience and cost a BoF investigation has found.The luxury industry has shrugged off labour scandals in the past but the current controversy comes amid increased regulatory scrutiny a market slowdown and growing debate on social media over whether luxury brands are really worth it.The Daily Digest NewsletterThe essential daily round-up of fashion news access one complimentary BoF Professional article of your choice Receive news, offers and invites from BoFOur newsletters may include 3rd-party advertising, by subscribing you agree to the Terms and Conditions & Privacy Policy The brands named in the probe have painted the incidents as an aberration a glitch in the matrix of careful controls they say they have put in place to ensure operations they contract out live up to the expectations of high-quality ethical craftsmanship that come with their high price points “We had no idea about this situation,” Jean-Jacques Guiony, chief financial officer of Dior-owner LVMH, told analysts on an earnings call in July “We thought we were doing quite a lot already referring to the company’s efforts to police its supply chain Prosecutors say the issues are systemic and entrenched: they are not a bug but a feature in a luxury system designed to prioritise maximising profits over worker welfare an illegal practice has emerged so entrenched and proven [that it could] be considered part of a broader business policy exclusively aimed at increasing profit,” Milan’s public prosecutor said in court documents reviewed by The Business of Fashion have luxury brands’ sourcing practices diverged so radically from the marketing mythology they have spent decades — and billions of dollars — constructing according to a months-long investigation by BoF that spanned more than two dozen industry executives supply-chain experts and people familiar with the Italian probe “Everybody is aware of the situation,” said Hakan Karaosman associate professor at Cardiff University who wrote his PhD on luxury supply chains But like it or not, more questions are being asked, amid increased regulatory scrutiny, a market slowdown and growing debate on social media over whether luxury brands are really worth it luxury labels are being taken to task in court even if the consequences — so far — amount to little more than a slap on the wrist Milanese police raided a single-room factory where Chinese workers were assembling handbags for Armani for €75 a piece operating machinery with the safety mechanisms disabled One told police he was being paid a little over €6 an hour Italy doesn’t have a minimum wage; instead base salary levels are set through sector-specific collective bargaining agreements The minimum hourly wage agreed for leather workers is €9.82 according to the Italian General Confederation of Labour Armani had not contracted directly with the factory but its presence in the brands’ supply chain was no mystery; when police arrived an employee of the luxury label’s manufacturing division was visiting He told the officers that he’d been at the factory every month for the last six to check that glue being used in the bags was up to snuff but that his focus was quality control and he wasn’t qualified to assess working conditions He didn’t know if Armani’s production arm even had such capabilities Armani has said it has always had measures in place to minimise the risk of supply-chain abuses The company said it could not comment further because it is collaborating with authorities in an ongoing legal proceeding LVMH has sought to distance its operations from the scandal CFO Guiony told analysts that the issues occurred at “suppliers of suppliers.” Milanese investigators disagreed; two of the four businesses police linked to Dior had direct relationships with a unit of the luxury giant though in reality it was little more than a shell company with no ostensible manufacturing capabilities Dior said the findings don’t reflect its commitment to ethical standards and that suppliers succeeded in hiding illegal practices despite its auditing efforts The company said it is working to strengthen its internal procedures with the support of Italian authorities both Armani and LVMH have established codes of ethical conduct suppliers must commit to follow often conducted by third-party contractors failing to identify key issues in their supply chains “There is a corporate culture seriously lacking even minimal control of the production chain,” court documents said of Armani an illegal practice has emerged so entrenched and proven [that it could] be considered part of a broader business policy exclusively aimed at increasing profit.” Human rights groups have long criticised the fashion industry’s reliance on such social auditing tools arguing they do little more than provide brands with a veneer of deniability when allegations of supply-chain misconduct arise These largely privatised systems of inspection are riddled with conflicts of interest and highly subject to corruption have little incentive to flag issues that might prove disruptive to their suppliers and may even be reprimanded for including too much detail in their reports according to one industry veteran who has spent decades monitoring big brands’ supply chains and who declined to speak on the record because they’re still involved in the work suppliers typically get a heads up before an inspection takes place giving them time to hide evidence of any infractions Scrutiny is often limited to direct contractors only Sourcing teams regularly ignore or delay addressing red flags in the interest of convenience and cost according to people with direct knowledge of luxury’s sourcing practices chronically under-sourced sustainability and social compliance teams are left chasing shadows no one really wants found “This is something [the luxury brands] are very careful to touch because they run the risk of reducing the marginality of the product,” said an executive who has worked in the C-suite in Italy’s luxury sector and who declined to be named because they still work in the industry “If you look in reality at what’s the effectiveness of all the controls [the brands] are doing it seems that from time to time they turn the eye not to see where the big problems are.” One former sustainability lead at a brand owned by a major luxury group who also spoke on condition of anonymity because of ongoing links to the sector described pouring resources into mapping the company’s Italian supply base uncovering widespread unauthorised subcontracting in the process “There were many concerns around health and safety undocumented migrant workers … and issues of blatantly not paying the minimum wage,” the executive said But even with documented evidence of persistent misdemeanours efforts to remove problematic suppliers were routinely derailed by sourcing managers who said they couldn’t meet volume or margin targets without them “We were getting evidence of sites that didn’t meet our code of conduct and in some cases even legal standards,” the executive said “The production team routinely said ‘We can’t phase suppliers out until next year.’ We would say ‘We can’t live with that for a year.’ And then it would get buried.” Most brands didn’t look that closely at what was going on beyond their direct suppliers Even infractions for which there is normally “zero-tolerance,” typically spanning things like child labour or forced labour may be allowed to slide in the interest of maintaining a steady pace of supply an industry veteran who has held leadership roles on sustainability teams at several major luxury companies such decisions ultimately rest with the C-suite regardless of the requirements of internal sustainability policies referring to general practices within the industry “Executives have been known to prioritise getting products on shelves,” he added Klajdi Koci started working in Italy’s leather sector when he was still a teenager eventually helping to expand his family’s business to operate as a subcontractor making bags for some of luxury’s most prestigious brands The idea that the Italian investigation has revealed a dark and previously hidden corner of the market “is like a joke,” he said referencing a character in the Commedia dell’Arte famed for never shutting up — a common Italian touchpoint to describe something everybody knows Though the “Made in Italy” label is a lynchpin of the luxury trade its cultural cachet long serving as shorthand for top-notch production the reality is darker and more complicated Roughly half of the world’s luxury clothing and leather goods are made in Italy by thousands of small manufacturers Brands typically work directly with just a handful with most work subcontracted out through complex shifting networks of outsourcing that are fiendishly difficult to keep track of and manage The convoluted system serves to obscure unsavoury practices that have become embedded in the industry’s operating model as it’s adjusted to globalisation and the rise of fast fashion over the last 30 years when the first significant wave of Chinese immigrants arrived in the industrial zone around Prato a city to the northwest of Florence with a 1,000-year history of textile and clothes manufacturing Profits in the sector were already shrinking as fashion brands took advantage of loosening trade agreements to move production to lower-cost regions The new Chinese arrivals found ready work in roles abandoned by young Italians Soon they were setting up their own small textile businesses importing cheap cloth from China that they turned into “pronto moda,” or fast fashion their position in the market expanded to provide services to mid-tier and luxury fashion houses as well Often the factories cut costs in other ways employing illegal migrant workers under the table and disregarding regulations on wages suppliers were saying it was “impossible” to find alternative subcontractors for certain manufacturing processes according to an internal memo written at the time by the large luxury group’s sustainability lead and reviewed by BoF These Chinese-owned factories offered good quality products with extremely flexible lead times and prices about 20 percent under wider market rates “specifically because they don’t respect the Italian law,” the memo said “Companies just got hooked on this growth and profit train … it switched from craftsmanship to greed.” executives looked for ways to drive down manufacturing costs speed goods to market and boost profit margins without sacrificing their “Made in Italy” marketing halo Some luxury labels quietly added production in Asia and Eastern Europe where manufacturing was cheaper And as brands pushed Italian suppliers for lower prices and quicker turnarounds they didn’t always peer too deeply into where — and under what conditions — their products were being made The result was a tacitly accepted tangling of high luxury and poor working conditions to the point where “the industry only functions on the basis that the price of ‘Made in Italy’ has been kept down by cheap Chinese labour,” said one expert in luxury supply chains who declined to speak on the record because they still work in the industry the luxury sector has enjoyed a period of staggering growth Gucci-owner Kering’s revenue doubled while its net profit more than tripled Rival LVMH saw sales at its fashion and leather goods vertical increase fourfold over the same period The division’s operating profit grew even faster to hit €16.8 billion last year The explosive growth has helped make LVMH owner Bernard Arnault one of the world’s richest men profit margins among Italian manufacturers — already a fraction of those brands enjoy — have declined a senior partner and director of the fashion unit at consultancy and think tank The European House - Ambrosetti “At a certain point the mentality switched,” said Beutler Manufacturers say the issues start with the prices brands are willing to pay and the timelines they demand. A statement issued by the United Nations Working Group on Business and Human Rights following a visit to Italy in 2021 came to a similar conclusion “Grave abuses and exploitation” in the country’s garment and textile sector “are facilitated by unfair purchasing practices of contracting companies and fashion brands,” it said Koci said he is looking to pivot his family’s business in a new direction rather than continuing to try and compete with unscrupulous players in a down market The company has expanded into 3D printing components opening up the opportunity to move into industries he believes are more inclined to innovation and transparency than luxury “You cannot have luxury if you rush artisans to make the product in the fastest way at the smallest cost.” Days after Guiony addressed the Dior scandal with analysts this summer, LVMH launched a blockbuster marketing blitz at the Olympics The luxury giant spent a reported €150 million to secure a spot as a premium sponsor of the games, a mega deal geared towards expanding the group’s cultural clout dancers spun Louis Vuitton trunks along the banks of the Seine and performers Moët & Chandon champagne and Hennessy cognac flowed freely at VIP bars and the medals designed by LVMH-owned jewellery brand Chaumet were presented in Louis Vuitton medal trays declining quality and questionable labour practices in the luxury sector Such myth-making marketing muscle has enabled the luxury industry to ignore deny and obfuscate links to scandals and practices it would prefer remained fixed in consumer investor and regulator minds as a fast-fashion problem “Italian brands are always very smart in trying to present the luxury supply chain as differently organised than the rest,” said Alessandra Mezzadri a feminist political economist of global development at SOAS who has written extensively about exploitation in fashion’s supply chains Meanwhile, a vocal tribe of online critics is already stoking questions about the sector’s value proposition, calling out punchy price increases that have far outpaced inflation amid reports of declining quality and lacklustre product offerings. The jarring disconnect between big brands’ elevated price points and alleged low manufacturing costs revealed by the Italian investigation has only amplified this conversation. “Are people getting temporarily disillusioned with luxury, or is the illusion getting broken for good?” cult fashion Instagram account Diet Prada asked in a July post that highlighted reactions to reports that Dior’s thousand-dollar handbags cost just tens of euros to make. Luxury and luxury-adjacent forums on the social network Reddit were filled with users expressing “existential feelings over the curtain being pulled back on luxury markups,” Diet Prada said. View this post on Instagram A post shared by Diet Prada ™ (@diet_prada) Dior said the allegations made about the production of its handbags are “blatantly inaccurate and false.” The suppliers targeted by the Italian investigation were not producing women’s handbags but partially assembling men’s leather goods Nonetheless, the scandal has exposed a seedy underbelly the luxury industry would rather not acknowledge at a precarious moment for the sector. growth at many of luxury’s biggest brands has cooled as a post-Covid consumer splurge has given way to a gloomy economy and more cautious spending Sales at LVMH rose just 1 percent in its most recent quarter The slowdown is hurting Italy’s manufacturing sector even more many brands are pursuing elevation strategies that lean heavily on heritage and craft to justify hefty price tags the industry has shrugged off such reputational black eyes in the past But regulators are also paying more attention than they ever have before “The legal context has completely changed,” said Matilde Rota a partner in the Milan team at the law firm Withers In what is arguably the most direct assault on luxury’s marketing myth to date, Italy’s Competition Authority announced it was investigating whether Dior and Armani misled consumers with claims of ethical and artisanal manufacturing in July That puts the brands in a bracket alongside fast-fashion companies like Boohoo and Asos that have faced similar investigations in the UK for greenwashing Possible penalties of €5,000 to €10 million are small Armani has previously said it believes the probe “has no merit.” Dior declined to comment Future lapses in supply-chain controls could result in much more severe fines companies that fail to adequately monitor and prevent labour abuses in their supply chains could be hit with penalties of up to five percent of global revenue The industry says it is making moves to tighten up monitoring processes and crackdown on subcontracting in response to the scandal But companies that sell themselves on the pursuit of perfection still fumble basic points of supply-chain compliance Until July, Dior was years behind on publishing supply chain disclosures required by UK law large companies operating in the UK must publish annual statements detailing how they are addressing risks of forced labour in their supply chains Dior’s statement dated from 2020 until an inquiry from Reuters this summer prompted a hasty update the statement currently available on Louis Vuitton’s website is from 2022 Armani and Kering-owned Balenciaga and Bottega Veneta haven’t updated the information on their sites since 2019 Kenzo and Marc Jacobs either had no publication available at all or even more dated information Kering said it publishes a group-level modern slavery statement that covers all its brands Armani said it provides updates about its approach to supply-chain management in annual sustainability reports Many of the efforts the industry has undertaken so far More structural changes that create real accountability and more equal partnership between brands and their suppliers require effort The real pressure to change may only come if the industry feels the impact on its bottom line “This has persisted because it is very convenient; it is very convenient to have cheap labour available and great margins … [but] for an industry as rich as luxury fashion paying workers fairly is something that is just an imperative,” said Bernstein analyst Luca Solca who first warned about labour issues in Italy’s supply chains 15 years ago “It’s down to the regulators and … the overall community around the luxury and fashion industry to make sure that we’ve evolved from that approach.” Disclosure: LVMH is part of a group of investors who hold a minority interest in The Business of Fashion All investors have signed shareholders’ documentation guaranteeing BoF’s complete editorial independence Amid growing disillusionment with luxury brands a series of Italian investigations linking major players like Dior and Armani to sweatshop labour is putting new pressure on the sector's most powerful asset: brand image Luxury’s results ‘superweek’ underscored just how far consumer demand has fallen Macroeconomic gloom is part of the problem but there may be deeper issues with big luxury’s value proposition Sarah Kent is Chief Sustainability Correspondent at The Business of Fashion She is based in London and drives BoF's coverage of critical environmental and labour issues For more information read our Terms & Conditions The nascent textile recycling industry has been positioned as a holy grail solution to fashion’s environmental challenges Chinese creators claiming to manufacture for luxury brands have gone viral on the platform offering cut-price ‘dupes’ in response to Trump’s punitive tariffs on the country Some have hailed America’s escalating trade war as a means to finally curb overconsumption of cheap goods the economic hardship its likely to bring on will eviscerate efforts to transform the industry for the better is ditching the industry’s biggest sustainable cotton scheme amid a deforestation scandal and a wider push to prioritise organic fibres The essential daily round-up of fashion news Receive news, offers and invites from BoFOur newsletters may include 3rd-party advertising, by subscribing you agree to the Terms and Conditions & Privacy Policy. Archive Architecture Coronary access via the distal radial artery for interventional procedures reduces the risk of arterial occlusion and higher-grade hematomas compared with the traditional radial approach according to results of a new meta-analysis The distal approach was associated with greater challenges accessing the radial artery which was highlighted by the longer times to radial puncture and sheath insertion according to lead investigator Giuseppe Ferrante issue of JACC: Cardiovascular Interventions highlights the “current limitations” of the technique which are likely attributable to operators not being completely proficient yet “All the limitations are actionable and may be overcome by a proper learning curve,” Ferrante told TCTMD “It’s not a reason to not develop and implement the technique we think the main issue we have now for not using distal radial access as the default approach is that the evidence from clinical studies doesn’t provide us with clear information about the impact on strong clinical endpoints.” “We don’t have this type of information from randomized clinical studies with the distal radial approach,” said Ferrante said one of the reasons for wanting to avoid radial artery occlusion (RAO) is that many patients are undergoing multiple procedures over a lifetime RAO can limit future percutaneous interventions and may even eliminate the radial artery as a potential conduit for CABG surgery rates of RAO are low with both conventional and distal radial access these days “but it does seem that the radial artery occlusion rates might be less with distal radial access,” he told TCTMD it happens distally so it’s less impactful to the hand.” His own experience also suggests there is a benefit when it comes to reducing the risk of hematomas that I get less calls to the postprocedure unit to evaluate arm or wrist hematomas when I’m doing distal radial [procedures].” that starting with the distal radial approach is a good option for a lot of patients noting that it can be routinely used by operators once they gain some experience “One of the shifts that is essential is that you really need to use ultrasound for every access,” said Korngold “I don’t think a lot of [conventional] radial operators are using ultrasound for their access but if you shift to distal radial you really need to commit to using it A hockey stick probe is great if you have it but you can also get good images if you don’t have one I think there’s certainly a learning curve I’d probably estimate that it takes around 20 to 40 cases in order to get comfortable with it but it’s something that’s learnable and repeatable.” Ferrante agreed that ultrasound may be useful in distal radial cases particularly if the radial artery is very small and tortuous The distal radial technique emerged as an alternative access site to lower the risk of RAO, which one meta-analysis suggested was 7.7% with conventional radial access a puncture is made distal to the superficial palmar arch from the anatomical “snuff box” on the dorsal side of the hand The distal approach preserves anterograde flow in the forearm during compression with the idea being there will be less risk of thrombus formation and RAO the catheters tend to engage very easily from the left subclavian artery and it’s just a nice thing for patient comfort which includes prophylactic ipsilateral ulnar compression during hemostasis and reported radial occlusion rates of less than 1% in both the conventional and distal radial treatment arms To get a better understanding of the overall RAO risk with both access sites the researchers performed a meta-analysis of 6,208 patients undergoing coronary angiography and/or PCI in 14 randomized coronary angiography alone was performed in three studies while PCI was performed in 24% to 100% of patients in the others The proportion of patients with ACS ranged from 14% to 100% Distal radial artery access was associated with a significantly lower risk of RAO at follow-up (risk ratio 0.36; 95% CI 0.23-0.56) in-hospital RAO (RR 0.32; 95% CI 0.19-0.53) and EASY ≥ II hematoma (RR 0.51; 95% CI 0.27-0.96) when compared with conventional radial access the distal approach was associated with longer times to radial artery puncture and for sheath insertion as well as a greater number of puncture attempts access-site crossover was more than threefold higher with distal radial access (12.5% vs 3.8%; P < 0.001) and time to hemostasis did not differ between the two approaches One of the limitations of the meta-analysis is that researchers were unable to perform subgroup analyses to identify patients who might benefit the most from distal radial access the trials were largely conducted in patients with chronic coronary syndrome and the results might not be generalizable to the ACS setting Ferrante noted that the rates of RAO varied widely in the trials with an average pooled crude event rate of 5.5% “It’s probably because there was a lack of systematic implementation of best practices for the prevention of radial arterial occlusion,” he said “I suspect that our finding might suffer from this limitation with some amplification of the true effect of distal radial compared with conventional radial on the incidence of radial artery occlusion.” MD (Icahn School of Medicine at Mount Sinai state that RAO is a common nonbleeding vascular complication with radial access and while it’s seldom symptomatic and does not affect function and ipsilateral compression of the ulnar artery have all been put forth as ways to reduce the risk Distal radial access is another one of the tools noting that it’s been sensationalized a little bit on social media but the meta-analysis does suggest that the risk of RAO is lower with distal radial access The downside is the time required to gain access This might not matter as much in chronic coronary syndromes cases stating that before the distal approach can be endorsed in ACS “The findings of this meta-analysis serve not to dismiss the approach as overly difficult but rather to challenge the interventional community to confront its learning curve,” write Tomey and Tamis-Holland noting that it’s “conceivable” that ultrasound could flatten the learning curve and improve ease of access “A key question is whether the promise of reduced RAO and EASY ≥ grade II hematomas justifies anticipated additions to time and perhaps patient inconvenience as the interventional community climbs the learning curve of distal radial arterial access.” Ferrante said that their high-volume center has adopted the distal radial technique for chronic coronary syndrome cases particularly for interventions done from the left side they will do the case via the conventional radial approach because of the longer time needed for access There are no data yet showing that the extra couple of minutes required to reach the culprit artery with distal radial access doesn’t negatively impact clinical outcomes “This is an issue that should be addressed in future studies,” he said “We need more evidence in order to support [distal radial] arterial access in this specific setting.” While distal radial access might be having a moment Korngold said he believes the approach is truly useful in clinical practice adding that anything that increases radial adoption over femoral access is good for patient outcomes He added that the distal radial approach is easier for the patient and operator if doing the procedure from the left side we’re doing left radial access in those who have had a previous [left internal mammary artery graft] and this makes cannulation of the LIMA very easy and straightforward,” said Korngold “I’ve been doing left distal radial as my primary access for most patients coming to the cath lab and it’s just a nice thing for patient comfort.” Michael O’Riordan is the Managing Editor for TCTMD He completed his undergraduate degrees at Queen’s University in Kingston Ferrante G, Condello F, Rao SV, et al. Distal vs conventional radial access for coronary angiography and/or intervention: a meta-analysis of randomized trials Tomey MI, Tamis-Holland JE. Distal radial artery access: fad or new frontier? J Am Coll Cardiol Intv and topical videos covering the spectrum of CVD and presentations from major meetings right to your inbox TCTMD ® is produced by the Cardiovascular Research Foundation ® (CRF) CRF ® is committed to igniting the next wave of innovation in research and education that will help doctors save and improve the quality of their patients’ lives New at TCTMD? Register today! Forgot Password Enter the email you used to register to reset your password. Sign up to receive the most important cardiovascular news, research, and major meeting presentations. This content is available for meeting attendees and/or Platinum Members The Court of Milan has placed Giorgio Armani Operations Spa, a wholly owned subsidiary of the Armani Group, into receivership for facilitating the exploitation of illegal foreign labor from Chinese workshops in the province of Milan. An official Italian supplier of Armani (Manifatture Lombarde Srl) subcontracted the production of authentic Armani branded bags, leather goods and accessories to other companies. This is what the Italian daily newspaper "Corriere della Sera" reports, explaining that, for example, authentic Giorgio Armani leather handbags were allegedly produced by Chinese workers exploited in dormitory-sheds. Moreover, although the fashion house knew this, it ignored the fact for its own convenience. Giorgio Armani Operations Spa is not under investigation, nor is the 89-year-old designer, Italy's third-richest man whose capital is estimated by Forbes to be over €11 billion. No criminal measures have been put in place, but preventive ones. Manifatture Lombarde Srl has no production department, no staff and no machinery. To comply with the order with Armani, it had to outsource all stages of mass production. $(document).ready(function() { adition.srq.push(function(api) { api.renderSlot("renderSlot_Rectangle-2"); }); }); READ ALSO: The Brands The aim of this study is to assess whether restaging transurethral resection (ReTUR) could be safely replaced with urine cytology (UC) and in-office fiexible cystoscopy in selected T1 non-muscle-invasive bladder cancer (NMIBC). The preliminary results of our trial suggested that ReTUR might be safely avoided in highly selected T1 BC patients with a complete resection at first TUR. Longer follow-up and larger sample size are needed to investigate the long-term oncological outcomes of this alternative approach. Volume 12 - 2022 | https://doi.org/10.3389/fonc.2022.879399 Objectives: The aim of this study is to assess whether restaging transurethral resection (ReTUR) could be safely replaced with urine cytology (UC) and in-office fiexible cystoscopy in selected T1 non-muscle-invasive bladder cancer (NMIBC) Materials and Methods: This is an ongoing prospective multicenter trial enrolling patients diagnosed with T1 BC from 5 Italian centers Patients with a macroscopically incomplete initial resection or absence of detrusor muscle were subjected to ReTUR according to European Association of Urology (EAU) guidelines those with a complete tumor resection at initial TUR underwent UC at 3–4 weeks and in-office fiexible white-light and narrow-band cystoscopy at 4–6 weeks patients started Bacillus Calmette–Guérin (BCG) induction course without ReTUR The primary endpoint was to determine the feasibility and the clinical utility of not performing ReTUR in selected T1 NMIBC patients The secondary endpoint was to perform a cost–benefit analysis of this alternative approach Nineteen (25%) patients underwent standard ReTUR after initial resection 10 (13.2%) due to the absence of the detrusor muscle and 9 (11.8%) due to a macroscopically incomplete initial TUR 57 (75%) patients initially avoided immediate ReTUR and underwent UC plus in-office flexible cystoscopy 38 (66.7%) had no evidence of residual disease and immediately started the BCG induction course Nineteen patients (33.3%) underwent “salvage” ReTUR due to either positive UC (7; 12.3%) or suspicious cystoscopy (12; 21%) Considering only the patients who initially avoided the ReTUR The saving of resource for each safely avoided ReTUR was estimated to be 1,759 € we estimated a saving of 855 € per patient if compared with the EAU guideline approach Conclusion: The preliminary results of our trial suggested that ReTUR might be safely avoided in highly selected T1 BC patients with a complete resection at first TUR Longer follow-up and larger sample size are needed to investigate the long-term oncological outcomes of this alternative approach Finally, BC is defined as having the highest resource consumption on the health system per patient (8). Rationalizing the cost of NMIBC treatment and follow-up may offer the chances to save money and resources (9) there is an unmet clinical need to avoid potentially unnecessary endoscopic procedures and save resources without affecting oncological outcomes The “HuNIRe” trial tested the hypothesis that avoiding immediate ReTUR in selected patients with T1 NMIBC might be feasible Data were extracted by a prospective observational multicenter trial enrolling patients diagnosed with T1 NMIBC from a tertiary university hospital as a reference center and 4 additional hospitals of Humanitas Group [HUmanitas New Indication for ReTUR (HuNIRe) trial] The HuNIRe protocol was approved by the local ethics committees after the approval of the reference center ethics committee (n Patients with a macroscopically incomplete initial resection or in the absence of DM in the histological specimen of primary TUR underwent ReTUR within 2–6 weeks according to EAU guidelines T1 patients with a macroscopically complete tumor resection at initial TUR underwent urine cytology (UC) after 3–4 weeks and in-office flexible white-light and narrow-band imaging (NBI)-enhanced cystoscopy after 4–6 weeks Follow-up consisted of cystoscopy and urinary cytology at 3 months followed by cystoscopy and cytology every 3 months for a period of 2 years and every 6 months thereafter. All patients underwent computed tomography of the upper urinary tract after the diagnosis and yearly thereafter (1). UC was considered positive when included in diagnostic categories 3–6 of The Paris System for Reporting Urinary Cytology (11) All pathology specimens from TUR were reviewed by a genitourinary pathologist at the reference institution (PC) The primary endpoint was to determine the feasibility and the clinical utility of avoiding ReTUR in selected T1 NMIBC patients Clinical utility was defined as the rate of unnecessary ReTUR avoided while recurrence is considered as the presence of any bladder tumor during the follow-up Resource consumption analysis was based on the impact on the direct use of resources per patient No overhead or indirect costs were considered The average time of use for the operating room including specialist visits before and after admission were estimated from 150 TURs performed in the reference center from December 2019 to May 2020 Categorical variables were reported as frequencies and proportions; continuous variables were reported as medians and interquartile ranges (IQRs) For distribution analysis of categorical variables chi-square test or Pearson’s exact test was used Mann–Whitney test was used to compare the median of continuous variables with nonparametric distribution Kaplan–Meier method was used to estimate recurrence-free survival (RFS) All statistical analyses were performed with the Stata/SE Table 1 Characteristics of the patients Table 2 Characteristics of the patients stratified by prior recurrence status (primary vs Table 3 Histopathology result at ReTUR for the 19 patients who underwent a second resection because of either positive UC or cystoscopy and for the 10 patients who had recurrence during the follow-up Figure 1 Flow of patients through the study RFS rates were 95.2% and 74.3% at 6 and 12 months The mean cost of ReTUR was estimated at 1,854 € per patient, while the mean cost of conservative approach (UC and outpatient cystoscopy) was estimated at 95 € per patient. Resource consumption and related cost analysis are shown in Table 4 The estimated resource saving for each avoided ReTUR was 1,759 € Considering a ReTUR rate of 50% (38/76) in the whole sample savings of 48.6% per patient were estimated when compared with the EAU guideline approach Table 4 Resource consumption and related cost analysis Our preliminary results show that ReTUR might be avoided in selected T1 BC patients turning into an estimated savings of about 855.6 € per patient diagnosed with pT1 BC we present the preliminary results of HuNIRe trial; the study was designed to evaluate the possibility of identifying those T1 NMIBC patients who could avoid a second resection and directly begin the BCG induction course this is the first study investigating an alternative approach to standard ReTUR in this subset of patients ReTUR may be spared in a substantial proportion of appropriately selected patients and this approach may be effective both from an oncological and from a resource–consumption perspective we avoided 66% of ReTUR in patients with a complete primary resection and A recent randomized trial showed that patients subjected to a second TUR had significantly higher recurrence-free, progression-free, and overall survival (13). However, this study included only the use of intravesical chemotherapy as adjuvant therapy, whereas adjuvant BCG instillations are known to be superior for preventing recurrence and progression in NMIBC and are the current standard of care according to EAU guidelines (14, 15) Although there has been a softening of the European guideline position regarding ReTUR, which is no longer indicated for HG Ta NMIBC patients, there is still an open debate about its clinical usefulness in every patient with a T1 BC (16) only in case of the absence of DM in the surgical specimen these results were limited by the retrospective design of the study and the low rate of ReTUR performed Another debated issue concerns the risk of upstaging to MIBC at ReTUR that ranges from 0% to 45% (19). A recent systematic review of the literature found a negligible risk of upstaging in many series (1−4%), thus underscoring a possible effect of surgeons’ experience on primary TUR outcomes (20) Although the risk of upstaging is non-negligible, the rationale of the study is based on the strong belief that a “good quality” TUR could minimize this risk. Herr et al. (21) stated that a well-performed TUR is one of the most effective and powerful procedures at the disposal of the urologist. In this regard, Mostafid et al. (22) reported a list of optimal best practices to adopt to optimize quality and outcomes of TUR While the presence of DM in the pathological specimen is considered as a surrogate of TUR quality and is related to a lower residual disease rate at ReTUR (19, 23) this factor alone is probably not enough to guide clinical decisions both cystoscopy and UC were also included in the study workflow Cystoscopy was performed from 4 to 6 weeks after TUR to detect any residual disease; a controversial point may be the presence of fibrin covering the resection scar, although after this time, it should not prevent residual disease from being visualized. Furthermore, all cystoscopies were performed with NBI, which was shown to be superior to white light alone in terms of BC detection (24) while NBI represents a useful tool in the diagnosis of BC could be used in the future to improve the identification of those patients who can avoid ReTUR One of the strengths of our study is the analysis of the impact that avoiding a ReTUR in selected T1 NMIBC patients might have on hospital resource However, the impact of an NMIBC diagnosis extends beyond quantifiable factors. Indirect costs, such as days of work lost by the patient and his/her caregivers, are difficult to estimate and would deserve a detailed analysis (8). Indeed, our analysis only considers resource consumption, which is a “direct” and immediate measure of saving for the hospital. Nevertheless, according to Value-Based Healthcare logic (28) the hospital can invest the saved resources in new therapies or to treat other patients Lastly, Ferro et al. (29) reported in a recent study that the time to ReTUR was significantly increased during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic; this finding suggest that an outpatient management which in many cases was preserved during the pandemic would not have resulted in delayed treatment Our study is not devoid of limitations mainly due to the lack of a control group We also acknowledge that the small sample size could have limited the strength and reproducibility of our results the median follow-up was limited to 11 months therefore being too short to provide an accurate estimate of oncological outcomes a comparison of long-term oncological outcomes between patients enrolled in the current protocol and those subjected to the standard of care is warranted we demonstrated that avoiding ReTUR in appropriately selected patients with T1 NMIBC is feasible and safe This approach may limit the psychological impact and potential morbidities of a second surgery while providing significant resource savings the findings are preliminary and internally validated; furthermore the study design does not permit to conclude on the oncological safety of this approach in order to confirm our preliminary results randomized controlled trials are mandatory extended follow-up and a larger sample size as well as further studies on novel diagnostic tools are needed to obtain a better patient selection and a safer therapeutic strategy balancing risks The original contributions presented in the study are included in the article/Supplementary Material Further inquiries can be directed to the corresponding author The studies involving human participants were reviewed and approved by Comitato etico IRCCS Humanitas Research Hospital The patients/participants provided their written informed consent to participate in this study Department of Biomedical Sciences,Humanitas University Pieve Emanuele SC Urology and Reconstructive Andrology PO Humanitas Gradenigo and GG contributed to conception and design of the study RC and GL performed the statistical analysis All authors contributed to article revision and read and approved the submitted version The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher We would like to thank Nadia Lo Iacono and Francesca Bertuzzi for their valuable technical support The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fonc.2022.879399/full#supplementary-material European Association of Urology Guidelines on Non-Muscle-Invasive Bladder Cancer (Ta Transurethral Resection of Bladder Tumor and the Need for Re-Transurethral Resection of Bladder Tumor: Time to Change Our Practice Impact of Routine Second Transurethral Resection on the Long-Term Outcome of Patients With Newly Diagnosed Pt1 Urothelial Carcinoma With Respect to Recurrence and Disease-Specific Survival: A Prospective Randomised Clinical Trial The Impact of Restaging Transurethral Resection of Bladder Tumor on Survival Parameters in T1 Nonmuscle-Invasive Bladder Cancer: Systematic Review and Meta-Analysis The Impact of Re-Transurethral Resection on Clinical Outcomes in a Large Multicentre Cohort of Patients With T1 High-Grade/Grade 3 Bladder Cancer Treated With Bacille Calmette-Guérin The Perioperative Morbidity of Transurethral Resection of Bladder Tumor: Implications for Quality Improvement Quality of Life in Patients Undergoing Surveillance for Non-Muscle Invasive Bladder Cancer-a Systematic Review Transl Androl Urol (2021) 10(6):2737–49 The Burden of Bladder Cancer Care: Direct 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Transurethral Resection of Bladder Tumours Apparently Complete Transurethral Resection of Bladder Tumour Specimen Is a Surrogate Marker of Resection Quality Performance of Narrow Band Imaging (NBI) and Photodynamic Diagnosis (PDD) Fluorescence Imaging Compared to White Light Cystoscopy (WLC) in Detecting Non-Muscle Invasive Bladder Cancer: A Systematic Review and Lesion-Level Diagnostic Meta-Analysis Reclassification of Urinary Cytology Regarding The Paris System for Reporting Urinary Cytology With Cytohistological Correlation Demonstrates High Sensitivity for High-Grade Urothelial Carcinoma Diagn Cytopathol (2020) 48(5):446–52 Xpert Bladder Cancer Monitor May Avoid Cystoscopies in Patients Under “Active Surveillance” for Recurrent Bladder Cancer (BIAS Project): Longitudinal Cohort Study Urinary Markers in Bladder Cancer: An Update PubMed Abstract | CrossRef Full Text | Google Scholar N Engl J Med (2010) 363(26):2477–81 PubMed Abstract | CrossRef Full Text | Google Scholar The Impact of SARS-CoV-2 Pandemic on Time to Primary Secondary Resection and Adjuvant Intravesical Therapy in Patients With High-Risk Non-Muscle Invasive Bladder Cancer: A Retrospective Multi-Institutional Cohort Analysis Hurle R and HuNIRe Study Group (2022) Could We Safely Avoid a Second Resection in Selected Patients With T1 Non-Muscle-Invasive Bladder Cancer Preliminary Results of Cost-Effectiveness Study From HUmanitas New Indications for ReTUR (HuNIRe) Multicenter Prospective Trial Received: 19 February 2022; Accepted: 11 April 2022;Published: 18 May 2022 Copyright © 2022 Contieri, Lughezzani, Buffi, Taverna, Giacobbe, Micheli, Barra, Colombo, Vanni, Guazzoni, Lazzeri, Hurle and HuNIRe Study Group. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) distribution or reproduction in other forums is permitted provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited in accordance with accepted academic practice distribution or reproduction is permitted which does not comply with these terms *Correspondence: Massimo Lazzeri, bGF6emVyaS5tYXhpbXVzQGdtYWlsLmNvbQ== Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher 94% of researchers rate our articles as excellent or goodLearn more about the work of our research integrity team to safeguard the quality of each article we publish Metrics details The impact of active cancer in COVID-19 patients is poorly defined; however most studies showed a poorer outcome in cancer patients compared to the general population We analysed clinical data from 557 consecutive COVID-19 patients Uni-multivariable analysis was performed to identify prognostic factors of COVID-19 survival; propensity score matching was used to estimate the impact of cancer Oncologic patients were older (mean age 71 vs 65 with higher neutrophil-to-lymphocyte ratio (13.3 vs 8.2 Fatality rate was 50% (CI 95%: 34.9;65.1) in cancer patients and 20.2% (CI 95%: 16.8;23.9) in the non-oncologic population Multivariable analysis showed active cancer (HRactive: 2.26 as well as lactate dehydrogenase (HRLDH>248mU/mL: 2.42 p = 0.041) to be independent statistically significant predictors of outcome Propensity score matching showed a 1.92× risk of death in active cancer patients compared to non-oncologic patients (p = 0.013) We observed a median OS of 14 days for cancer patients vs 35 days for other patients A near-doubled death rate between cancer and non-cancer COVID-19 patients was reported Active cancer has a negative impact on clinical outcome regardless of pre-existing clinical comorbidities We retrospectively reviewed the medical records of all consecutive adult patients admitted for COVID-19 at our Institution (a tertiary cancer centre with 662 beds including 42 ICU beds) between February 27 and May 20 The diagnosis of Sars-CoV-2 infection was confirmed by a reverse-transcriptase polymerase chain reaction (RT-PCR) of nasopharyngeal swab or bronchoalveolar lavage (BAL) We collected also the clinical characteristics of Sars-CoV-2 at presentation the ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2) laboratory findings including full blood count (FBC) lactate dehydrogenase (LDH) and radiological CT findings We analysed SARS-CoV-2 active cancer patients focusing on the type of malignancy (solid tumour vs haematologic disease) the extent (localised vs metastatic) and the status of disease at the COVID-19 diagnosis progressive disease (PD) vs non-PD (CR/PR/SD/NED) Active cancer was defined by the presence of localised or metastatic disease at the time of the viral infection despite the received oncological treatment Patients undergoing radical surgery or radical radio-chemotherapy within 4 weeks from COVID-19 diagnosis were also included in the analysis patients with a history of cancer or on adjuvant hormonal treatment were not considered in the cancer subgroup Surrogate endpoints for COVID-19 survival included the length of hospitalisation the ICU admission and the in-hospital fatality rate The absence of prospective informed consent was waived by the Ethics Committee due to the emergency situation of the clinical scenario of the current pandemic Demographic and clinical characteristics were summarised as number and percentage or as median and range Differences in distribution were estimated using the Chi-square or the Fisher exact test (when appropriate) Patients survival was calculated from the hospitalisation until death or discharge Survival curves were generated using the Kaplan–Meier method Median follow-up was estimated using the inverse Kaplan–Meier method Differences between groups were evaluated using the log-rank test The Cox proportional hazard regression model was used to calculate the hazard ratios (HRs) and their 95% confidence intervals (CI) in univariate and multivariate analysis ICU was included in the model as a time-dependent variable starting from the first day of ICU admission A propensity score matching was performed to estimate the effect of cancer by accounting for the covariates statistically significant in the multivariable model four comparable patients were selected in the non-cancer population (1:4 ratio) All analyses were carried out with the SAS software v Cancer patients showed a poorer COVID-19 survival (HR: 2.26; CI 95%: 1.39;3.66, p = 0.001). a solid cancer vs haematologic cancer; b tumour type (lung vs other); c localised vs metastatic disease; d disease status at COVID-19 diagnosis (PD vs non-PD cancer patients) Clinical characteristics of COVID-19-infected cancer patients: a retrospective case study in three hospitals within Wuhan A war on two fronts: cancer care in the time of COVID-19 COVID-19 mortality in patients with cancer on chemotherapy or other anticancer treatments: a prospective cohort study Cancer is associated with severe disease in COVID-19 patients: a systematic review and meta-analysis and risk factors for mortality in patients with cancer and COVID-19 in Hubei Managing patients with cancer during the COVID-19 pandemic: frontline experience from Wuhan Low incidence of SARS-CoV-2 in patients with solid tumours on active treatment: an observational study at a Tertiary Cancer Centre in Lombardy Clinical impact of COVID-19 on patients with cancer (CCC19): a cohort study The risk and prognosis of COVID-19 infection in cancer patients: a systematic review and meta-analysis ASCO Statement on Novel Coronavirus (COVID-19). ASCO Annual Meeting. https://meetings.asco.org/am/asco-statement-novel-coronavirus-covid-19 (2020) COVID-19 and Cancer. ESMO. https://www.esmo.org/covid-19-and-cancer (2020) Cancer guidelines during the COVID-19 pandemic Cancer prevales on COVID-19: To maintain high quality standard concerning diagnosis and oncological care even during a pandemic Impact of the coronavirus disease 2019 pandemic on cancer treatment: the patients’ perspective The impact of the COVID-19 pandemic on cancer patients Quality of life of cancer patients during coronavirus disease (COVID-19) pandemic The impact of the COVID-19 pandemic on cancer care Cancer treatment during the coronavirus disease 2019 pandemic: do not postpone COVID-19 infection in cancer patients: early observations and unanswered questions Cancer and COVID-19: what do we really know Cancer and SARS-CoV-2 infection: diagnostic and therapeutic challenges A systematic review and meta-analysis of cancer patients affected by a novel coronavirus Cancer increases risk of in-hospital death from COVID-19 in persons <65 years and those not in complete remission The impact of COVID-19 on cancer risk and treatment Obesity in patients with COVID-19: a systematic review and meta-analysis Sex differences in immune responses that underlie COVID-19 disease outcomes Cancer patients and risk of mortality for COVID-19 Baseline characteristics and outcomes of 1591 patients infected with SARS-CoV-2 admitted to ICUs of the Lombardy Region Clinical portrait of the SARS-CoV-2 epidemic in European cancer patients Venous and arterial thromboembolic complications in COVID-19 patients admitted to an academic hospital in Milan Current overview on hypercoagulability in COVID-19 The hypercoagulable state in COVID-19: Incidence Co-infections in people with COVID-19: a systematic review and meta-analysis The blurred line between the art and science of medicine Engaging multidisciplinary stakeholders to drive shared decision-making in oncology Download references These authors contributed equally: Alexia F Humanitas Clinical and Research Center—IRCCS Data collection; L.G.—Drafting of manuscript Ethics approval was provided by the local ethics committee of Humanitas Clinical and Research Center; the study was performed in accordance with the Declaration of Helsinki Consent to participate was obtained from the patients involved in the study Consent for publication have be obtained from the patients involved in the study The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request The authors declare no competing interests The authors received no specific funding for this work Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations Download citation DOI: https://doi.org/10.1038/s41416-021-01396-9 Anyone you share the following link with will be able to read this content: a shareable link is not currently available for this article Clinical and Translational Oncology (2024) Metrics details Although there are reports of otolaryngological symptoms and manifestations of CoronaVirus Disease 19 (COVID-19) there have been no documented cases of sudden neck swelling with rash in patients with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection described in literature We report a case of a sudden neck swelling and rash likely due to late SARS-CoV-2 in a 64-year-old woman The patient reported COVID-19 symptoms over the previous three weeks Computed Tomography (CT) revealed a diffuse soft-tissue swelling and edema of subcutaneous tissue All the differential diagnoses were ruled out Both the anamnestic history of the patient’s husband who had died of COVID-19 with and the collateral findings of pneumonia and esophageal wall edema suggested the association with COVID-19 This was confirmed by nasopharyngeal swab polymerase chain reaction The patient was treated with lopinavir/ritonavir hydroxychloroquine and piperacillin/tazobactam for 7 days The neck swelling resolved in less than 24 h while the erythema was still present up to two days later The patient was discharged after seven days in good clinical condition and with a negative swab Sudden neck swelling with rash may be a coincidental presentation it is most likely a direct or indirect complication of COVID-19 To our knowledge, COVID-19 presenting with primary unilateral sudden neck swelling and rash due to edema of subcutaneous tissue, hypodermis, and muscular and deep fascial planes changes is unreported in the literature. We report our case highlighting this unusual presentation occurring in the context of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. A 64-year-old woman with a sudden left lateral cervical swelling (A) and the corresponding coronal multiplanar reconstruction (MPR) contrast-enhanced CT images at the admission (B) showing the soft-tissue swelling (white arrows) Laboratory tests showed C reactive protein of 0.43 mg/dL (normal value < 0.50 mg/dL), white blood cells count of 11, 39 × 10^3/mm^3, neutrophils 71%, eosinophils 2%, D-Dimer 750 ng/mL (normal value 200–350 mg/dL); the remaining values were unremarkable. Axial contrast-enhanced and non-contrast neck CT images on the admission and discharge (A,B) showed soft-tissue swelling and diffuse reticulation of subcutaneous fat with edema around vessels (arrows in A) with a complete resolution in few days (arrows in B) Axial contrast-enhanced and non-contrast chest Computed Tomography images on the admission and discharge (C,D) documented esophageal wall edema with adjacent effusion (arrows in C) with a complete resolution in few days (arrows in D) The patient was discharged after seven days in good clinical condition and PCR test was negative for SARS-CoV-2 on the twenty-first day This case shows that SARS-CoV-2 infection could present with a sudden neck swelling associated with pneumonia and rash highlighting the need of an appropriate differential diagnosis in sudden lateral swelling of the neck in a pandemic context. Lymph-nodes and salivary glands were not enlarged In consideration of the clinical presentation of rubor (redness) and vasculitis were first considered in the differential diagnosis Oro-dental and oropharyngeal causes of infection were also excluded Both the anamnestic history of the patient’s husband who had died of COVID-19 and the collateral findings of pneumonia and esophageal wall edema suggested the possible association with COVID-19 disease This was confirmed by nasopharyngeal swab PCR the rapid resolution of the swelling did not allow biological sampling for virus isolation and citology characterization Despite the absence of a definitive causal relationship this interaction could explain COVID-19-endothelitis with systemic impaired microcirculatory function in different vascular beds which could be the cause of the neck swelling and esophageal wall edema reported in our case Most Sars-CoV-2 infected patients arrived at respiratory clinic or emergency clinic A patient arriving at an emergency department with an unusual symptoms such as the presentation of a sudden neck swelling may not receive the prompt diagnosis and therapy they required thereby also increasing the medical staff’s exposure to Sars-Cov-2 Although further studies on the association between neck swelling and SARS-CoV-2 are needed our observation could help emergency physicians to avoid misdiagnosis by considering sudden neck swelling with a rash as a possible sign of COVID-19 when all the other differential diagnoses have been ruled out in a pandemic context Severe Acute Respiratory Syndrome Coronavirus 2 Epidemiological profile of non-traumatic emergencies of the neck in CT imaging: our experience Fisher J, Monette DL, Patel KR, Kelley BP, Kennedy M. COVID-19 associated parotitis. Am J Emerg Med. 2021; 39: 254.e1–254.e3. doi: https://doi.org/10.1016/j.ajem.2020.06.059 Chern A, Famuyide AO, Moonis G, Lalwani AK. Sialadenitis: a possible early manifestation of COVID-19. Laryngoscope. 2020;130(11):2595–7. https://doi.org/10.1002/lary.29083 Prevalence of Taste and Smell Dysfunction in Coronavirus Disease 2019 [published online ahead of print Steehler AJ, Ballestas SA, Scarola D, Henriquez OA, Moore CE. Observation of retropharyngeal fluid collection in 2 COVID-19 positive patients. Ear Nose Throat J. 2020;6:145561320971370. https://doi.org/10.1177/0145561320971370 Sideris AW, Ghosh N, Lam ME, Mackay SG. Peritonsillar abscess and concomitant COVID-19 in a 21-year-old male. BMJ Case Rep. 2020;13(9):e238104. https://doi.org/10.1136/bcr-2020-238104 Ajeigbe T, Ria B, Wates E, Mattine S. Severe parapharyngeal abscess that developed significant complications: management during the COVID-19 pandemic. BMJ Case Rep. 2020 22;13(12):e236449. doi: https://doi.org/10.1136/bcr-2020-236449 Novak N, Peng WM, Naegeli MC, et al. SARS-CoV-2, COVID-19, skin and immunology - what do we know so far? Allergy. 2020. https://doi.org/10.1111/all.14498 Gianotti R, Barberis M, Fellegara G, et al. COVID-19 related dermatosis in November 2019. Could this case be Italy's patient zero? Br J Dermatol 2021; https://doi.org/10.1111/bjd.19804 Download references Humanitas Clinical and Research Center IRCCS Letterio Salvatore Politi & Luca Balzarini Humanitas Clinical and Research Centre – IRCCS Armando De Virgilio & Giuseppe Spriano Enrico Heffler & Letterio Salvatore Politi Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations unless otherwise stated in a credit line to the data Download citation DOI: https://doi.org/10.1186/s12879-021-05911-4 The five monuments of cycling can also be followed by amateur athletes in special cyclosportives and events Alpecin Cycling has compiled them for the 2024 season: 2024 – tentativeStart-Finish: Milan Sanremo/ItalyRoute: approx The “Primavera” amateur event is more than 50 years old Hobby athletes also need a long breath for the approximately 300-kilometer ride from the capital of Lombardy across the Piedmont plain down to the Ligurian coast The many consecutive climbs on the final 50 kilometers including well-known names like Capo Berta and of course the Cipressa shortly before the end of the race While the professionals start in front of Milan Cathedral the hobby athletes set off on the long journey in a suburb outside Milan – Pieve Emanuele the date of the event at the beginning of June is chosen so that snow and cold can be completely ruled out more info 2024Start-Finish: Oudenaarde- Oudenaarde/Belgium Oudenaarde-Antwerp/ all Belgium (217 km)Routes: 75 km Anyone who wants to experience what it feels like for the pros at the “Ronde van Vlaanderen” to bolt over the cobbles because at the famous and race-deciding climbs Oude Kwaremont there are also an incredible number of spectators at the everyone’s race the pros are cheered on at the “Ronde” just one day later you can choose from four different routes: 75 Because at the famous and race-deciding climbs Oude Kwaremont Anyone who also wants to ride over the famous Muur van Geraardsbergen – it’s worth it – must sign up for the 177 or 242-kilometer route For the participants of the long-distance route there is an early morning shuttle bus from Oudenaarde to the Belgian port city on race day more info Busigny–Roubaix/France (170 km)Routes: 70 km Even suffering and pain-tolerant hobby athletes can venture into the “Hell of the North” One day before the professional peloton and just a few hours before the women they have the chance at the 12th edition of this everyone’s event to “iron” over 54 kilometers of the toughest cobblestones and 19 sectors Those who want to minimize the vibrations on the Paves with the sonorous names like Forest of Arenberg or Carrefour de l’Abre should either drive on the right or left at the edge of the road or in the middle of the road – on the dam everyone is allowed to do an honorary lap in the famous velodrome in Roubaix at the end must hurry and reach the velodrome by 4 p.m. as shortly afterwards the winner of the professional women’s race arrives more info Bohain En Vermandois-Roubaix (210 km)/ all FranceRoutes: 70 km Great fun for comparatively little money awaits the participants at Paris Roubaix Cyclo there are usually pleasant temperatures when the local cycling club VC Roubaix organizes its own Hell of the North here almost two months after the professional race All three have the finish in the velodrome in Roubaix and the shower in the legendary catacombs in common; a pleasure that participants in the official “Challenge” do not get more info 2024Start-Finish: Ans – Liège/BelgiumRoutes: 66 km/1292 hm Those who want to ride the oldest classic in its everyone’s version do not have to decide months in advance to start short-term decision-makers can still register on site and tackle one of the three routes The ultimate challenge is to ride the same route as the pros at “La Doyenne” That would then be 257 kilometers and a good dozen so-called Côtes – the majestic name of the short Among them are well-sounding names like Côte de La Roche-aux-Faucons and of course the Côte de La Redoute But the other two routes (66 km and 142 km) also offer plenty of opportunities to experience and feel the fascination and hardness of the “Ardennes roller coaster” with its legendary climbs more info 2024Start-Finish: Cantù/ItalyRoute: 109 kilometers / 1700 altitude meters “Madonna del Ghisallo” and “Muro di Surmano” the eyes of cycling connoisseurs and fans light up and they know what it’s all about – the Tour of Lombardy It is a pilgrimage on wheels – for professionals and hobby athletes alike The race of the “falling leaves” is not only the last of the five monuments in cycling An enthusiastic knowledgeable audience that cheers on the pros; a grandiose scenic backdrop but just as imposing is the everyone’s version of the Tour of Lombardy hobby athletes can hit the road at the Gran Fondo Il Lombardia and pay their respects to the cycling pilgrimage site Although the route passes the lovely Lake Como several times – but the detours up to the Madonna del Ghisallo and the Muro di Surmano let even well-trained hobby athletes feel why this race belongs to the monuments of cycling Steep ramps with up to 27 percent gradient are not uncommon more info Cylcosportive Events 2025: The Most Beautiful Marathons in the Alps Ride like a pro: Tour de France Gran Fondos 2024 Gravel-Worldchampionships 2024: Qualifyings for Hobby Cyclists Events 2024: Cyclosportives with 300 and more Kilometers The five monuments of cycling can also be ridden by hobby athletes in special amateur races and events Please find below an overview Alpecin Cycling created for the 2022 season: Date: 5 June 2022Start-finish: Milan-Sanremo/ItalyDistance: approx The “Primavera” amateur event celebrates its 52nd anniversary in 2022 Long staying power will also be required from amateur athletes tackling the approximately 300-kilometre long ride from the capital of Lombardy across the Piedmont plain and the Turchino Pass down to the Ligurian coast On the final 50 kilometres an array of climbs including illustrious names such as Capo Berta the Cipressa shortly before the end of the race awaits the riders and will soak any energy left out of the athletes’ legs What sounds like a picturesque setting starts quite dull While the professionals start in front of Milan’s cathedral amateur athletes set off on their long journey in a suburb just outside Milan – Pieve Emanuele But the event date at the beginning of June at least makes sure there won’t be neither snow nor cold more info Date: 2 April 2022Start-finish: Oudenaarde-Oudenaarde/Belgium Oudenaarde-Antwerp/all Belgium (217 km)Distances: 72 km This amateur race is a must if you want to experience first-hand what it feels like for the pros to ride the “Ronde van Vlaanderen” with its Kasseien because also at the amateur race a huge crowd of spectators will be cheering on amateur athletes at the famous and race-deciding climbs Oude Kwaremont Koppenberg and Paterberg – only one day before the pro riders are cheered on at their “Ronde” you can choose from four different distances: 72 The famous Muur van Geraardsbergen – which is definitely worth riding – is only part of the 177- and the 217-kilometre course the finish in Oudenaarde is quite unspectacular Only one day after amateur athletes completed their race pros will go on the course for the “Ronde” The longest distance is the only one that starts in Antwerp there will be a shuttle bus for participants from Oudenaarde to the Belgian port city early in the morning on race day more info Date: 16 April 2022Start/Finish: Roubaix-Roubaix/France Busigny-Roubaix/France (172 km)Distances: 70 km Amateur athletes who are willing to suffer and tolerate some pain are given the chance to ride the “Hell of the North” One day before the pro race and only a few hours before the women’s race hobby cyclists will be given the opportunity to ride over 54 kilometres of hardest cobblestone and 19 sectors at the 12th edition of this amateur event Those who want to minimise the vibrations on the pave sections with illustrious names like Forest of Arenberg or Carrefour de l’Abre are recommended to either ride on the right or left side of the road or in the middle of the lane – on the raise The reward for the suffering will be a lap of honour in the famous velodrome in Roubaix at the end which is the only one that starts in Busigny as the winner of the professional women’s race will arrive shortly afterwards more info Date: 5 June 2022Start/Finish: Roubaix-Roubaix (70 km) Bohain En Vermandois-Roubaix (210 km)/all FranceDistances: 70 km Participants of Paris-Roubaix Cyclo get big fun for rather little money On top of that temperatures are usually quite pleasant when about two months after the pros’ Hell of the North the local cycling club VC Roubaix organises their own edition There are three distances to choose from with 11 All three will finish in the Roubaix velodrome where participants can take a shower in the legendary catacombs; a bonus that participants in the official “Challenge” do not get to enjoy more info Date: 23 April 2022Start-finish: Ans-Liège/BelgiumDistances: 66 km/1292 vertical metres (vm) If you want to ride the amateur version of the oldest cycling classic you don’t need to register months in advance late entries for one of the three course options are offered The ultimate challenge is to ride the same course as the pros at “La Doyenne” 257 kilometres and a good dozen so-called Côtes – the majestic name of the short Among them are illustrious names like Côte de La Roche-aux-Faucons and But also the other routes (66 km and 142 km) offer plenty of opportunities to experience the fascination and toughness of the “roller coaster of the Ardennes” with its legendary climbs more info Date: October 2022Start-finish: Cantù/ItalyDistance: 109 kilometres/1700 vm “Madonna del Ghisallo” and “Muro di Surmano” are names that make eyes of cycling entusiasts light up and leave only one option which race this could be about – the Tour of Lombardy It is a pilgrimage on wheels – for professionals and amateur athletes alike The race of the “falling leaves” is not only the last of the five cycling monuments but also an extremely attractive event featuring an enthusiastic crowd with lots of cycling experience that is cheering on the pros; a very scenic setting The professional race will take place for the 115th time on 8 October 2022 is the amateur version of the Tour of Lombardy amateur athletes tackle the course at the Gran Fondo Il Lombardia and pay their respects to the cycling pilgrimage site Although the course passes by the lovely Lake Como several times the detours up to Madonna del Ghisallo and Muro di Sormano make even well-trained amateur athletes feel why this race is one of the monuments of cycling Steep ramps with gradients of up to 27 percent are not uncommon more info Events 2024: The five cycling monuments for amateurs and hobby cyclists ITALY: Vitamin D is a good predictor of clinical and radiological severity of bronchiectasis according to a recent study published in the journal Respiratory Medicine Vitamin D is a hormone synthesized in the skin in the presence of sunlight vitamin D plays a role in a wide range of processes in the body Oral intake from natural and fortified foodstuffs adds to vitamin D levels in the individual Sufficient vitamin D levels are important not only for a healthy skeleton but also for a healthy immune system Bronchiectasis is a complex respiratory disease characterized by damaging of the lungs' airways Vitamin D plays a role in the infective disease by modulating the inflammation Bronchiectasis patients are frequently deficient in vitamin D which is related to a decline in lung function the researchers analyzed 57 patients consisting of 17 males and 40 females between October 2017 and March 2018 traction bronchiectasis and reporting Vitamin D supplementation were excluded They then calculated the Bronchiectasis severity index (BSI) and Bhalla score D was measured and lung function tests were performed "We consider Vitamin D as a good predictor of clinical-radiological severity of bronchiectasis irrespective of the underlying etiology," the authors concluded based on the findings For detailed study log on to https://doi.org/10.1016/j.rmed.2019.01.009 • Email: info@medicaldialogues.in • Phone: 011 - 4372 0751 Fourth edition of the survey by the Confcommercio Research Office of Milan Monza and Brianza with the Tax Services: a detailed analysis of the Tari for non-domestic users in 226 municipalities - excluding that of Milan which is not comparable with the others by population and influx of non-residents - classified into large medium and small (from over 30 thousand inhabitants to less than 5 thousand) with a reference benchmark of the average Tari tariff and identifying deviations / anomalies Rozzano and Sesto San Giovanni have the most difficult situation the Tari tariff is double (31,2 against 15,6) of the benchmark for commercial activities classified as highly taxed for the production of waste (bars flowers and plants) and is close to triple (18,3 versus 7) for medium and large retail surfaces (supermarkets Rozzano is a "black jersey" for the waste tax with increased rates in all areas of non-domestic users: over double (32,7 against 15,6 of the benchmark) in highly taxed businesses and in medium / large retail areas (14,4 versus 7) Criticalities in Bresso for high taxation activities (23,9 against 15,6) and in Paullo (15,2 against 7) ​​and Pieve Emanuele (19,2 against 7) ​​where the Tari rate for medium and large companies is more than double sales areas as it has a higher waste tax rate level in all categories: in particular in highly taxed companies 21,8 against the benchmark of 10,4 and in medium / large surfaces 11,6 against 5,3 higher rates in all reference values ​​(especially for highly taxed companies: 24,4 against 11,8) Higher rates are also found in Mulazzano (Lodi): 21,6 against 11,8 for highly taxed companies and 12,5 against 6,2 in medium / large surfaces The "black jersey" goes to Boffalora Sopra Ticino in Magentino: more than double (37 against 10) for highly taxed commercial activities and in medium / large retail areas (16,2 against 5,1) but with tariff values also high in all other categories of companies each percentage increase in separate waste collection leads to an average saving in the rates of the waste tax of 0,56 euros per square meter the increase in the share of separate waste collection leads to an increase in the tariff cost of 0,36 euros per square meter In large municipalities below the reference percentage for separate waste collection (71 per cent) is Rozzano in particular (51 per cent) Slightly lower values ​​for Segrate (67 percent but with an average rate that remains below the benchmark) and Sesto San Giovanni (69 percent) In the medium-sized municipalities "virtuous" in separate collection is Pogliano Milanese (83 percent against an average of 74 percent) but the rates of Tari are on average higher than the benchmark Pieve Emanuele has a low separate waste collection (57 percent) and on average higher rates It is Assago that has the lowest percentage of separate waste collection (54 percent) with rates the highest percentage of separate waste collection is in Colturano (Melegnanese) with 90 percent against an average of 76 percent The lowest in Montanaso Lombardo (Lodi): 52 percent