Aedes aegypti, the vertical and sexual transmission routes are of significant importance for reproductive health. Sexual transmission demands specific prophylactic interventions, including the use of male or female condoms, especially among couples in a risk situation and planning pregnancy. Vertical transmission is linked to severe structural abnormalities of the central nervous system, and there is still no vaccine or known pharmacological resources that can prevent it. As the disease is predominantly asymptomatic, failure to comply with the basic principles of care and guidelines associated with the spread of the infection transcends the severity of the disease's symptoms.This article addresses the vector, sexual and vertical transmissions of the Zika virus, a topic covered in the Clinical Protocol and Therapeutic Guidelines for Comprehensive Care for People with Sexually Transmitted Infections, published by the Brazilian Ministry of Health in 2020. Although in Brazil Zika virus is transmitted more predominantly by  Aedes aegypti mosquito, vertical and sexual transmission routes are important for reproductive health. Vertical transmission causes severe central nervous system structural abnormalities.Although in Brazil Zika virus is predominantly transmitted by the  This article addresses the chapter on Zika virus in the Clinical Protocol and Therapeutic Guidelines for Comprehensive Care (CPTG) for People with Sexually Transmitted Infections (STI), published by the Health Surveillance Department of the Brazilian Ministry of Health. For the elaboration of the CPTG, a selection analysis of the evidence available in literature was performed, and a panel of specialists discussed it. The CPTG was approved by the National Committee for the Incorporation of Technologies in the Brazilian National Health System (Conitec)Flaviviridae family, genus Flavivirus. It was first isolated in Uganda (Africa) in 1947,,Zika virus belongs to the In April 2015, the Zika virus was first identified in the Americas, with the first case being reported in Bahia, Brazil. By the end of January 2016, its native circulation had already been registered in more than 20 countries or territories in South, Central, and North America, the Caribbean, and Cape Verde, in West Africa-The evolution of Zika virus infection incidence in Brazil is shown in Aedes aegypti being the principal vector in this country. It should be highlighted this is the same mosquito that transmits the dengue, chikungunya, and yellow fever virusesThe three most studied forms of Zika virus transmission are vectorial transmission by mosquito bites, vertical transmission, and sexual transmissionnon-structural, NS1),Zika virus transplacental transmission brings paramount concern in its scenario due to its potential to cause embryonic and fetal central nervous system structural abnormalities. Several mechanisms are evoked for explaining how the virus reaches the embryo and fetus. As the syncytiotrophoblast is resistant to the Zika virus infection-,,Studies have detected Zika virus presence in blood, semen, urine, and saliva, suggesting that it could also be transmitted through these body fluids. However, this kind of transmission is rareZika virus sexual transmission was suggested in 2011 in the United States of America, with the case report of a woman infected with the virus when her partner returned from a trip to Senegal in 2008, when he was infected-,A study conducted in Padova , from January 2016 to January 2017, showed that Zika virus was detected in the semen of five out of ten tested men, eliminating up to 370 days and a mean clearance of 25 days. However, in general, this viral elimination period is highly variable-Zika virus infection is an acute, self-limited, feverish disease lasting from three to seven days, usually without severe complications. Most infections are asymptomatic, but from 20% to 25% of infected people have nonspecific clinical manifestations, giving room to the need for differential laboratory diagnosis regarding chikungunya and dengue-,-,Among all the possible Zika virus infection complications, those with gestational and neurological outcomes stand out,From the male reproductive point of view, in cases where the virus reaches the testicle, Zika virus aggression to testicular tissues is pointed out, with a prognosis that shall depend on the intensity of the immune and inflammatory response, varying from a simple reversible spermatozoon number reduction to testicular atrophyLaboratory diagnosis during acute Zika virus infection is based on detecting viral RNA through the polymerase chain reaction, mediated by reverse transcription polymerase chain reaction (RT-PCR) in serum or blood up to seven days after symptoms or in urine sample up to 14 days. Although there are cases in which viral RNA can be detected for longer, either in serum or urine and semen, this possibility does not contribute to diagnosing the disease's acute phasesth day, and immunoglobulin G (IgG) from the 17th day after the begin of infection. Every serological test must be cautiously interpreted, considering the high number of cross-reactions with other Flavivirus,In cases of clinical manifestations compatible with Zika virus infection, with a negative result on the RT-PCR diagnostic test, or if more than seven days have elapsed since the onset of symptoms, a serological examination must be requested to identify immunoglobulin M (IgM) for Zika virus and dengue. The IgM can be detected, on average, from the 8Flavivirus infection is established, and if it is <10 for both, both infections are dismissedIf the serological result is negative for both viruses, infection by both is dismissed. If either one is positive, the plaque reduction neutralization test must be requested, if available. In cases of the reduction is >10 for dengue virus and <10 for Zika virus, dengue infection is confirmed. If the result is >10 for Zika virus and <10 for dengue virus, Zika virus infection is confirmed. If it is >10 for both viruses, Due to symptoms overlapping, in regions with high arboviruses prevalence, the differential diagnosis of Zika virus infection must be conducted with all exanthematous diseases, including chikungunya, dengue, and measles. Such differential diagnosis must be expanded in pregnant women, considering syphilis, toxoplasmosis, rubella, cytomegalovirus, and herpes (STORCH), all of which can cause fetal malformationsCurrently, there is no specific treatment for Zika virus infections. Management implies symptomatic treatment, which includes hydration, analgesics, and antipyretics. Non-steroidal anti-inflammatory drugs must be avoided until dengue diagnosis is dismissedNotification of Zika virus infection suspected cases is mandatory for all Brazilian states. The measure was published in the Brazilian Official Gazette through Ordinance no. 204, of February 17th, 2016. All suspected cases must also be reported to health authorities weekly. For pregnant women with a suspected virus infection or suspected death, notification is immediate, within 24 hoursAedes aegypti reproduction control and using repellents, and wearing appropriate clothing stand out. It should also be considered that Aedes aegypti mosquitoes have preferentially daytime habits and depend on light and higher temperaturesWolbachia pipiensis bacteriaAedes aegypti reproduction cicle and prevents the eggs laid by infection-free females from hatching when fertilized by a male infected with Wolbachia-One of the factors reinforcing primary prophylaxis measures' role is based on the lack of specific vaccine or treatment for Zika virus infection and secondary prevention methods for vertical transmission,,,Objectively aiming to control the Zika virus sexual dissemination, female or male condoms must be reinforced for possible vectorial or sexual exposure when traveling to high transmission areas and returning to non-endemic areas. The same recommendation should be applied even after the diagnosis of the infectionIn terms of sex partners, it is essential to reduce transmission between infected people and develop strategies to break the transmission chain through identification and adequate management of sex partners. Risk communication and adequate information for health service users are essential. A gender-specific approach is important, considering that men's and women's prevention responses have shown to be different. Disease awareness is associated with a more preventive and protective attitude by both sexes,According to the guidelines by both the American Centers for Disease Control and Prevention and the World Health Organization, the quarantine of protective sexual measures or sex abstinence when returning from travel to endemic regions is of 90 days for men and 60 days for women. These international organizations also share the guideline for protected sex or even sex abstinence for the remainder of the pregnancy when a pregnant woman's partner returns from a Zika virus endemic region or has been diagnosed with the infection-Zika virus vertical transmission, which can occur at any time during pregnancy, has been associated with serious and harmful pregnancy outcomes. Although Zika virus vertical transmission frequency among asymptomatic pregnant women is difficult to measure, there is confirmation of its occurrence,-,,Embryonic or fetal central nervous system afflicting spectrum causing malformations and its pathogenesis are not yet fully established. It is known that Zika virus presents neural progenitor cells tropism and that, in the embryonic or embryonic/fetal brain, it stops growth, proliferation, migration, and differentiation of neuronal cells, with severe consequences for neurodevelopment,,,When infection occurs during the first and second trimesters of pregnancy, there is an increased risk of an embryonic or fetal central nervous system structural abnormalities. These infections most often present high variation of anatomical changes, which result in ventriculomegaly, intracranial calcifications, and microcephaly,Zika virus infection neonatal changes were grouped under the name of congenital Zika virus syndrome, including microcephaly with the collapse of the skull, thin cerebral cortices with subcortical calcifications, facial disproportion, hypertonia, spasticity, hyperreflexia, seizures, irritability, arthrogryposis, macular scarring, focal pigmentary retinal mottling, blindness, and sensorineural hearing lossThe increased microcephaly frequency as causing pregnancy complications in Brazil from 2015 to 2020 was published in the Epidemiological Bulletin of the Health Surveillance Department 12. The,,For pregnant women at low or normal risk, the most critical strategy regarding the Zika virus is to prevent them from getting infected. Reaffirming preventive measures for vector or sexual infection is the most efficient strategy to prevent the spread of the infectionth week, a morphological ultrasound around the 22nd week, and a third examination around the 32nd week,,From an assistance point of view, after the Zika virus infection epidemic outbreak, the Brazilian Federation of Gynecology and Obstetrics Associations recommends implementing an ultrasound examination around the 12,Universal screening for prior Zika virus infection among "asymptomatic pregnant women", using serological tests, is not indicated. It is essential to consider the tests' low accuracy, the potential aggregate costs, and the scarce benefits obtained with this measure. Given a positive serology exam showing the presence of antibodies to the virus it is necessary to ensure that a false safety impression cannot be communicated, which could result in reducing the pregnant woman's care regarding other arboviruses , diseases that can also present harmful maternal and perinatal outcomesIn cases suggesting Zika virus infection, the pregnant woman must seek medical attention and undergo physical and laboratory examination to guide the diagnosis,A great demand for psychological support marks the prenatal care of pregnant women diagnosed with Zika virus, which is a fundamental intervention, in addition to compliance with basic prenatal guidelines, such as care associated with blood pressure and weight gain, adequate nutrition, laboratory tests, and vaccines,Currently, more than 500 causes are known for microcephaly, in addition to congenital Zika virus infection, with varying severity degrees. Considering that the treatment and pregnancy monitoring assessment, as well as the newborn’s can be influenced by the etiology, the role of conducting diagnostic tests to detect the teratogenic agent is highlighted. In the case of Zika virus infection, the RT-PCR of the amniotic fluid obtained by the amniocentesis may be an alternative for conducting the differential diagnosis,In cases of fetal infection, prenatal service shall require fetal vitality care through cardiotocography and ultrasound. The returning frequency shall depend on each fetal clinical condition, with no requirements to set strict intervals between appointments,In general, even children affected by congenital Zika virus syndrome can survive labor, considering vaginal delivery as preferable for mothers,,,Until now, there have been no reported cases of Zika virus vertical transmission due to pregnancy that have used assisted reproductive techniques, but some care is recommended for couples undergoing infertility treatment. They are: a) presenting negative IgM serology five days before the procedure; b) wait up to 90 days after the appearance of signs and symptoms associated with Zika virus infection when the man was infected or report risky sexual exposure or travel to endemic regions; c) wait up to 60 days after signs/symptoms associated with Zika virus infection when the woman was infected or report risky sexual exposure or travel to regions endemic for this infection


Flaviviridae, including Dengue virus (DENV), Zika virus (ZIKV), Japanese encephalitis virus (JEV) and West Nile virus (WNV) and Togaviridae viruses, such as chikungunya virus (CHIKV). Several factors may have contributed to the recent re-emergence and spread of mosquito-borne viral diseases. Among these important causes are the evolution of mosquito-borne viruses and the genetic mutations that make them more adaptive and virulent, leading to widespread epidemics. RNA viruses tend to acquire genetic diversity due to error-prone RNA-dependent RNA polymerases, thus promoting high mutation rates that support adaptation to environmental changes or host immunity. In this review, we discuss recent findings on the adaptive evolution of mosquito-borne viruses and their impact on viral infectivity, pathogenicity, vector fitness, transmissibility, epidemic potential and disease emergence.Emerging and re-emerging mosquito-borne viral diseases impose a significant burden on global public health. The most common mosquito-borne viruses causing recent epidemics include flaviviruses in the family  Emerging and re-emerging vector-borne diseases are major public health problems worldwide . Today, Flaviviridae, including Dengue virus (DENV), Zika virus (ZIKV), Japanese encephalitis virus (JEV) and West Nile virus (WNV) and Togaviridae viruses, such as chikungunya virus (CHIKV) [The most common mosquito-borne viruses causing recent epidemics are flaviviruses in the family  (CHIKV) . Several (CHIKV) . The com (CHIKV) . Other d (CHIKV) .Nevertheless, the emergence or re-emergence of mosquito-borne viral diseases often involves the evolutionary adaptation of viruses to new amplification hosts or vectors. Here, we review recent findings on the adaptive evolution of mosquito-borne viruses and their impact on viral infectivity, pathogenicity, vector fitness, transmissibility, epidemic potential and disease emergence.Flaviviridae, which is spread by Aedes mosquitoes and is widespread in tropical and subtropical regions [Dengue fever is caused by a virus of the family  regions ,7. The e regions . Accordi regions ,9. China regions . The rep regions . This di regions .Zika virus was first isolated from a Rhesus monkey in the Zika forest of Uganda in 1947 . The firCulex mosquito [Japanese encephalitis virus is one of the leading causes of viral meningoencephalitis worldwide and is mainly transmitted by the mosquito . Pigs armosquito . The Wormosquito . Despitemosquito , while cmosquito , raisingCulex species mosquito. In contrast to most arboviruses, which are partially or fully host specific, WNV is known to have a wide range of mosquito vectors and hosts, including birds, horses and other mammals. West Nile virus was first isolated in 1937 from a febrile patient in the West Nile district of northern Uganda. The epidemiology and ecology of the disease were first described in the early 1950s and early 1960s, when subsequent epidemics occurred in the Mediterranean basin [West Nile virus is mainly transmitted by the an basin . West Nian basin . Studiesan basin .Togaviridae family [Chikungunya is a mosquito-borne viral disease caused by an alphavirus of the e family . The orie family . Chikunge family . Previoue family . Sporadie family . The vire family .An important cause for the re-emergence of viruses is the adaptive evolution and genetic mutations that make them more virulent and allow for widespread epidemics. RNA viruses tend to acquire genetic diversity due to error-prone RNA-dependent RNA polymerases . This prMore sequence and genetic diversity information is available for DENV than other arboviruses, possibly due to its greater impact on human health ,35,36,37Differences in disease severity associated with individual serotypes or specific serotype sequences have been observed, and it remains unknown whether some serotypes are inherently more pathogenic than others. DENV-2 viruses are most frequently associated with Dengue hemorrhagic fever/Dengue shock syndrome (DHF/DSS) ,54,55,56Aedes aegypti than American DENV-2 strains [Several studies have been conducted to infer the role of viral molecular evolution in driving epidemics. Comprehensive sequencing of Asian and American genotypes revealed several key nucleotide differences, particularly at position 390 in protein E and in the 5′ and 3′ untranslated regions (UTRs) . Substit strains ,67. Ther strains . Additio strains .Although increased viral virulence must be considered in the context of host immunity, it is still possible that more virulent Dengue viruses will continue to evolve in Southeast Asia and spread worldwide, replacing more benign genotypes ,41. On tPhylogenetic studies have revealed that ZIKV has evolved into African and Asian/American clusters ,72. OutbA recent study also demonstrated that a mutation in the ZIKV capsid protein (C-T106A) significantly increased the epidemic potential of ZIKV during its transmission cycle by promoting efficient assembly of ZIKV virions. A capsid T106A substitution facilitates ZIKV transmission by the mosquito vector as well as the infection of human cells and immunodeficient mice . AnotherAedes aegypti, competition experiments in cynomolgus macaques showed that this mutation increased fitness for viremia production [Some genetic changes affect virulence, making the virus more contagious or causing more severe symptoms. Mutations in the viral precursor membrane protein (prM) have been shown to exacerbate the symptoms of ZIKV infection. The S139N substitution arose prior to the outbreak in French Polynesia in 2013 and has been present in the subsequently circulating American strains. This mutation may increase the infectivity of neural progenitor cells and promote apoptosis, possibly contributing to microcephaly and other conditions in pregnant women in the recent epidemic . Anotheroduction .Phylogenetic studies suggest that JEV originally occurs in the Indonesia/Malaysia region and then spreads northward, despite its first detection in Japan . Based oIn order to identify the genetic determinants underlying the GI/GIII lineage replacement, the genome and envelope protein sequences of GI and GIII strains were subjected to in silico analysis. Interestingly, GI was shown to be neutral, while GIII was predicted to have a greater positive selection advantage . A possiCulex mosquitoes, contributing to the prevalence of WNV among mosquitoes. These mutations, in combination, may have led to the rapid spread and persistence of WNV in North America [Additional examples of viral genetic variation associated with increased arbovirus infectivity, vector fitness and transmissibility have been reported in West Nile virus. The amino acid substitution T249P in the NS3 helicase of North American WNV increased its virulence in American crow, the main natural reservoir of WNV . On the  America ,91.A. aegypti was the main vector of CHIKV in India and other countries. The substitutions K211E in envelope protein E1 and V264A in E2 have been reported to enhance CHIKV adaptation to A. aegypti [CHIKV has been repeatedly introduced into Asia from Africa since the 18th century, leading to the establishment of the endemic Asian CHIKV genotype and, in 2005, the Indian Ocean lineage (IOL) ,93. Duri aegypti ,95. Duri aegypti .Aedes albopictus via an E1-A226V substitution appears to have contributed, at least in part, to the evolutionary success of this emerging lineage [A. albopictus but has little effect on A. aegypti infection [A. aegypti and A. albopictus are present have not adapted to A. albopictus. Instead, recent outbreaks in Asia are attributed to introduced ECSA strains that are better adapted to A. albopictus [The Indian Ocean lineage originated from an East/Central/South African (ECSA) enzootic genotype that appeared in 2004 in coastal Kenya and subsequently spread to Indian Ocean islands, India, Southeast Asia and Europe ,97. The  lineage . This E1nfection ,99. Epidbopictus ,101.A. albopictus appears to be a multistep process. Several second-stage adaptive mutations have been identified that also increase CHIKV fitness in this vector [A. albopictus by a factor of 4 to 5 [A. albopictus, a vector that inhabits Southeast Asia, and by facilitating the spread of the virus to urban centers and areas with cooler climates.The adaptation of CHIKV to s vector . The E2-f 4 to 5 ,103. TogVector-borne infectious diseases impose a significant burden on global public health. It is extremely difficult to predict which mosquito-borne virus will be affected, as well as the time and location of the next emerging epidemic, because outbreaks depend on a variety of factors. While factors such as climate, transportation, human and vector population density and vector capacity are important, genetic variations in the virus are the least predictable. Genetic studies of viruses isolated from mosquitoes and patients have made great progress in understanding the patterns of transmission and disease. Continued advances in the efficiency, speed and cost of DNA sequencing now provide new opportunities to revisit many aspects of viral epidemiology and evolution. For example, next-generation sequencing technologies can efficiently sequence large numbers of RNA virus genomes from a single host to provide more complete information about quasispecies, rather than just identifying consensus sequences from RT–PCR amplicons. This will provide a more thorough understanding of the population dynamics and size of the virus at different stages of infection and transmission and may also lead to the identification of sequence variants that exist as minority groups.Understanding the forces that shaped the evolution of mosquito-borne viruses and the role these forces play in shifting infection to higher virulence is important for developing effective countermeasures, especially in the absence of licensed vaccines or antiviral therapies to control the spread of viral pandemics. Undoubtedly, there are as yet undiscovered mosquito-borne viruses that have the potential to emerge, and recent advances in deep sequencing offer new opportunities to identify them based on surveillance activities, especially in tropical regions with the highest viral diversity. The ability of RNA viruses to rapidly mutate and exploit new ecological opportunities highlights the threat of emerging or re-emerging mosquito-borne viral diseases. As humans continue to invade and alter habitats where mosquito-borne viruses spread, especially through deforestation and urbanization, there will be increasing selection pressure for the continued adaption of these viruses. Thus, retrospective and experimental studies of viral evolution, host range and adaptation are needed to improve our ability to predict disease emergence and to develop new intervention strategies.


Few studies have reported a structured cost analysis of robotic distal pancreatectomy (RDP), and none have compared the relative costs between the robotic-assisted surgery (RAS) and the direct manual laparoscopy (DML) in this setting. The aim of the present study is to address this issue by comparing surgical outcomes and costs of RDP and laparoscopic distal pancreatectomies (LDP).Eighty-eight RDP and 47 LDP performed between January 2008 and January 2020 were retrospectively analyzed. Three comparable groups of 35 patients each  were obtained matching 1:1 the RDP-groups with the LDP-group. Overall costs, including overall variable costs (OVC) and fixed costs were compared using generalized linear regression model adjusting for covariates.p = 0.045). Although not statistically significant, the mean operative time was lower in Xi-RDP-group: 226 min versus 262 min for Si-RDP-group and 247 min for LDP-group. The overall post-operative complications rate and the length of hospital stay (LOS) were not significantly different between the three groups. In LDP-group, the LOS of converted cases was significantly longer: 15.6 versus 9.8 days (p = 0.039). Overall costs of LDP-group were significantly lower than RDP-groups, (p < 0.001). At multivariate analysis OVC resulted no longer statistically significantly different between LDP-group and Xi-RDP-group (p = 0.099), and between LDP-group and the RDP-groups when the spleen preservation was indicated .The conversion rate was significantly lower in the Si-RDP-group and Xi-RDP-group: 2.9% and 0%, respectively, versus 14.3% in the LDP-group (RAS is more expensive than DML for DP because of higher acquisition and maintenance costs. The flattening of these differences considering only the variable costs, in a high-volume multidisciplinary center for RAS, suggests a possible optimization of the costs in this setting. RAS might be particularly indicated for minimally invasive DP when the spleen preservation is scheduled. Since the description of the first minimally invasive distal pancreatectomy (MIDP) in 1994 . MoreoveRobotic distal pancreatectomy (RDP) seems also to be associated with an additional positive impact on the clinical outcomes as well, with a reduction of conversion rates, higher spleen preservation rates, and a shorter LOS , 6, 7. AFrom January 2008 to January 2020, 88 patients underwent RDP at the Multidisciplinary Center of Robotic Surgery of Pisa, performed by the 1st General Surgery Unit, and were included in the present study. All patients were operated by two surgeons (AP and LM), both with high experience of pancreatic surgery (> 300 procedures each) and minimally invasive surgery , and both trained in the high-volume center of Pisa (> 100 pancreatic resections/year).The choice of the operative technique (laparoscopic or robot-assisted) was at the discretion of the operating surgeon and based on the robotic platform availability, being that the second one has been the preferred approach in the last 8 years.n = 35), Xi-RDP group (n = 35), and LDP-group (n = 35).The RDPs were performed with the da Vinci Si platform until December 2014. Since the introduction of the da Vinci Xi at our center, in January 2015, the choice of the platform of da Vinci Surgical System (da Vinci Si or da Vinci Xi) depended on their availability. In detail, 47 patients underwent RDP with the da Vinci Si (Si-RDP-group) and 41 patients with the da Vinci Xi (Xi-RDP-group). In the same period 47 patients underwent laparoscopic distal pancreatectomy (LDP-group) for the same indications by the same two surgeons (AP and LM). In order to compare outcomes and costs among the three groups minimizing possible biases deriving from treatment allocation, three comparable groups were obtained matching 1:1 the two robotic groups with the LDP-group. The following patients’ characteristics were considered for the matching: age, gender, Body Mass Index (BMI), and American Society of Anesthesiology (ASA) score. After matching, the final population included 105 patients, equally divided between each group: Si-RDP-group  were retrospectively reviewed and analyzed, from a prospectively collected database.The preoperative workup included abdominal ultrasonography, abdomen CT and/or MRI. Indications for minimally invasive approach were neoplasms < 10 cm with benign or borderline features on cross-sectional imaging or adenocarcinomas, similarly to other teams , 16.Laparoscopic and robotic distal pancreatectomies were performed as already described . SplenicLaparoscopic DP The patient is placed in the supine or left sided position, dependent upon the tumor site, with both arms along the sides of the body, and tilted in partial reverse Trendelenburg position. Four/five ports are used . After the establishment of pneumoperitoneum and the ports placement, an abdominal exploration is performed. The lesser sac is then entered through the greater gastrocolic omentum. The splenic flexure of the colon is mobilized, if necessary. An intra-operative diagnostic ultrasound with a laparoscopic probe is always performed to evaluate the pancreatic lesion and its correct position. The superior and inferior borders of the pancreas are defined and the pancreas is transected using a stapler . The distal transected pancreas is gently lifted, and a medial-to- lateral dissection is started. In case of splenic conservation, the splenic vein and artery are skeletonized from the isthmus toward the splenic hilum. This manoeuvre allows both the lymphadenectomy and a step-by-step division of all the branches coming from the splenic vessels. In case of DP with splenectomy, first the splenic artery and then the vein are divided after the transection of the pancreas. This step is followed by a medial-to-lateral dissection posterior to the splenic vein along the retroperitoneal plane. Two drains are left near the pancreatic stump.Robotic DP Patient position is similar to that of laparoscopic DP. For this approach, a five-port technique is adopted. The trocars disposition and the robot chart position change according to the type of robot used , American Society of Anesthesiology (ASA) score, preoperative diagnosis, intention to spleen preservation, and radiologic tumor size. Operative data included type of surgical procedure, operative time (OT), conversion rate, spleen preservation rate , any additional organ resection (beyond splenectomy), pancreatic stump management (handsewn or stapler and number of charges used), and intraoperative complications. Postoperative data included LOS, both considering intensive care unit (ICU) and general ward, complications (according to the Clavien-Dindo Classification ), re-opeCosts were valued using a micro-costing approach and expressed in euros and referred to 2020. Unit costs were collected from the accounting department of the hospital and divided in fixed costs and variable costs. In detail, fixed costs included the purchase and maintenance costs of the technology and the proportion of fixed costs attributable to a single intervention was estimated firstly deriving a cost per year on the basis of acquisition costs, the amortization period and annual maintenance costs, then dividing these costs for the overall number of interventions for which each technology was used. Overall variable costs (OVC) included items related to disposable instruments used within each intervention , operating room personnel , and length of stay, both ICU and general ward . For each intervention variable costs associated with the specific intervention were then estimated valuing resources used according to unit costs collected. Details about resources use and related costs are reported in Tables Robotic staplers’ costs were excluded from the consumable cost analysis to avoid bias, as they were introduced only since 2016, and the choice to use them just depends on surgeon’s preference. In order to have three homogeneous groups, when the robotic staplers were used in the Xi-RDP-group, we considered the costs of the corresponding laparoscopic staplers and charges.The study was approved by the Institutional review board.T-test or Mann–Whitney test and multiple comparisons were performed by means of ANalysis Of Variance (ANOVA) or Kruskall-Wallis test. Post hoc comparisons were performed using Bonferroni or Mann–Whitney test with Bonferroni correction for p-value as appropriate.Categorical variables were depicted as number of cases and percentages, while continuous variables were expressed as mean ± (standard deviation) or median [25–75 percentile], depending on their distribution. Chi-square test and Fisher test were used to compare the distribution of categorical variables. For continuous variables, comparisons were made using independent p value < 0.10 at univariate analysis. In the multivariate analysis patients’ age was forced to enter while variables creating collinearity (on the basis of the variance inflation factor) were excluded. A p-value < 0.05 was considered statistically significant. All analyses were performed using Stata version 14.Generalized linear models were used to evaluate the impact of the different surgical techniques on costs. In details, in addition to univariate analysis, multivariate models were developed including those variables whose Preoperative data are summarized in Table p = 0.155). Regarding the intraoperative variables, the conversion rate was significantly lower in the Si-RDP-group and Xi-RDP-group: 1/35 case (2.9%) and 0/35 cases (0%), respectively, versus 5/35 cases (14.3%) in the LDP-group (p = 0.045). The spleen preservation rate was higher in the RDP-groups, even if it did not reach a statistical significance . In the RDP subgroups, the number of robotic instruments used was 4 in case of hand sewn closure of the pancreatic stump or 3 in case of the section of the pancreas with a stapler, with a mean number of robotic instruments used for each RDP of 3.3. No differences were reported in terms of overall post-operative complications rate between the three groups: 48.6% in the LDP-group, 57.1% in the Si-RDP-group and 48.6% in the Xi-RDP-group (p = 0.710). The incidence of complications with Clavien-Dindo ≥ III was similar between the three groups: 5.7% in the LDP-group, 2.9% in the Si-RDP-group and 8.6% in the Xi-RDP-group (p = 0.588). The length of hospital stay was nearly 1 day shorter in the RDP groups than the LDP group even if not statistically significant different: 11.1 ± 6.9 days in the LDP-group versus 9.5 ± 5.9 days in the Si-RDP-group and 9.3 ± 4.9 days in the Xi-RDP-group (p = 0.424). In the LDP-group, the length of hospital stay of converted cases was significantly longer than the cases treated with a minimally invasive approach: 15.6 ± 10.6 versus 9.8 ± 5.7 days, respectively (p = 0.039).Perioperative data are summarized in Table p = 0.001).Analyzing the pathological data, no differences were detected between the pathological diagnoses Table . A signip-value = 0.132 and p = 0.069, respectively). The comparison of the consumable costs showed significant higher costs of the Si-RDP-group and the Xi-RDP-group respect to the LPD-group . Overall variable costs and overall costs including fixed costs of the Si-RDP-group and the Xi-RDP-group resulted significantly higher respect to the LPD group: median values being €7856 and €7981 versus €6968, and €9440 and €9809 versus €7002, respectively (p < 0.05). However, at multivariate analysis, adjusting for age, ASA risk score and spleen preservation, overall variable costs were no more significantly different between the LPD-group and the Xi-RPD-group (p = 0.099)   Tables  and 11. The economic impact of the robotic approach on pancreatic surgery, and particularly on distal pancreatectomy, is still under debate, with controversial published studies , 9–14. ITherefore, as from a clinical point of view RDP seems to be associated with some positive impact on the outcomes with respect to the LDP, it is still a matter of debate whether the use of the da Vinci is sustainable, and whether the advantages of the da Vinci Surgical System can justify its use for distal pancreatectomy.For these reasons, to evaluate the costs-effectiveness of RAS and DML in this setting, different factors to be evaluated comprise both those strictly related to the instrumentation and its use and those referring to the clinical outcomes. Thus, to perform our structured cost-analysis, we divided the costs in fixed and variable costs, including in the first the purchase and maintenance of the technology, and in the latter the disposable instruments (consumable costs), the length of stay and the post-operative course , and the operating room personnel costs (personnel costs) which are associated to the OT.Interestingly, despite our costs’ analysis confirmed that the overall cost including fixed costs and overall variable costs of RDP resulted higher compared with that of the LDP, at univariate and multivariate analysis, the overall variable costs were no longer significantly different between the LPD-group and the Xi-RPD-group. In our opinion, this data can be explained by the standardization of the technique, the perioperative outcomes, and by a discount of robotic instruments’ purchase costs coming from the multidisciplinary high-volume center setting as well.In fact, the standardization of the technique with the improvement in robotic expertise, allows to optimize the use of instruments, by performing all phases of the surgical operation with an average of only 3.3 robotic instruments, therefore contributing to minimize the CCs . Indeed,Among the perioperative outcomes, OT, conversion rate, and LOS are the main key factors that might have had a major impact on costs. Indeed, in our series, the reported shorter mean operative time of the Xi-RDP-group with respect to Si-RDP-group and LDP-group, even if not statistically significant, has played a role in reducing the PCs, in line with similar works already reported also for other indications . In factOther important perioperative factors influencing costs in our series, as well as in previous papers , 26–30, In this respect, it has also to be noticed that, despite the minimally invasive approach and the relatively low incidence of complications, we reported a mean LOS longer as compared with other robotic and laparoscopic case series of international literature. However, our data are comparable with the analysis conducted in an Italian multicenter cohort of 236 patients that had undergone RDP , and thiAnother aspect which deserves to be highlighted among the positive impact of the RAS versus the DML on the outcomes of the distal pancreatectomy, although difficult to quantify within a cost analysis, is the higher spleen preservation rate. In this regard, our data are in line with literature , 17, 33,Interestingly, in this regard, the multivariate analysis of our costs’ analysis revealed that the overall variable costs were no longer significantly different between LPD and RPD, both for the da Vinci Si and the da Vinci Xi, in the subgroup of patients in which the spleen preservation was indicated on the basis of the preoperative diagnosis. These data suggest that the use of the da Vinci Surgical System, both Si and Xi, could be particularly indicated in those cases in which the spleen preservation is scheduled.From a histological standpoint, we reported a higher percentage of cystic lesions in the Si-RDP-group, while on the contrary a higher percentage of pancreatic carcinoma was reported in the Xi-RDP-group, explaining also the higher number of lymph nodes harvest in the Xi-RDP-group. In fact, while in the initial experience with RAS we preferred to treat benign lesions, with the overcoming of the learning phase with the robotic technology, more and more complex cases were treated with RDP, particularly since the introduction of the da Vinci Xi. We acknowledge that this aspect could introduce a bias, but it is interesting to note that although the complexity of cases has increased over time within the RDP whole group, the outcomes of patients belonging to the Xi-RDP-group were not worse respect to those of the Si-RDP-group and, in some cases, resulted even better. Furthermore, although the number of pancreatic malignant tumors was similar between LDP-group and Xi-RDP-group, the number of harvested lymph nodes was significantly higher in the latter, probably as a consequence that, because of increasing confidence with the robotic system acquired over time, as well as the improvement offered by the Xi version, more complex cases of malignant tumors located in the isthmus or central part of the body of the pancreas needing a more extended lymphadenectomy, were treated with a minimally invasive technique. This is a crucial aspect, to encourage the use of robot, particularly if included in a setting of possible optimization of costs. Indeed, even though the use of robotic technology to perform a robotic DP was first reported by Melvin in 2003 , so far Our study has some limitations. First of all, its retrospective nature, the heterogeneity of the sample and the not standardized choice of the laparoscopic versus robotic approach. However, using a case–control matching analysis we tried to mitigate these issues by obtaining three comparable groups. Another criticism might be the exclusion of robotic staplers’ costs to avoid bias in the analysis of consumable costs. Indeed, as previously declared, at the time our Si interventions were performed, they were not available for that robotic platform. Furthermore, so far there is no evidence in literature of the superiority of the endo-wristed staplers respect to the laparoscopic ones, and the use of anyone of them during an RDP is merely a surgeon’s choice. Therefore, considering the costs of endo-wristed staplers during the analysis would have introduced a bias. For this reason, in order to have three homogeneous groups, when the robotic staplers were used in the Xi-RDP-group we considered the costs of the corresponding laparoscopic staplers and charges, as they were always usable in all cases. Moreover, since this study comes from a high-volume center for pancreatic surgery and also for RAS, the results of the analysis may not be applicable to all centers, also because the cost-analysis was performed using specific resources use and economic data of the accounting department of our hospital and it could be difficult to generalize these data to other parts of the world. In this regard, although currently difficult to define a threshold, the use of the da Vinci Surgical System in a high-volume RAS center, can contribute itself to the reduction of the fixed costs, by reducing the depreciation charge, and of each operation OVCs of RDP thanks to reduction of the CCs. Indeed, in our experience, thanks to the high number of robotic operations performed each year at the Multidisciplinary Center of Robotic Surgery at Cisanello Hospital in Pisa, we obtained a 2% discount of robotic instruments’ purchase costs, partially contributing to reduce the gap of CCs between the LDP and RDP. Moreover, performing even more than a thousand robotic interventions per year, as we have experienced at our Centre, thanks to the purchase of a large number of robotic instruments it is possible to obtain a further bulk discount, thus reducing the average cost of robotic instruments for each robotic intervention, with the possibility to obtain a further reduction of CCs of RDP. This represents another reason, in addition to those mentioned above, for further encourage the wide spreading of robotic technologies in the field of pancreatic surgery. Therefore, it may well be crucial to encourage the spread of multidisciplinary high-volume centers, in which surgeons coming from different hospitals can have access with the opportunity to operate on their own patients, benefiting from the most advanced technologies and also reducing costs at the same time. This could be one of the key points to make sustainable the use of robots for surgical operation, particularly for more complex cases, such as those involving pancreatic surgery. Furthermore, of note that according to accounting standards fixed costs attributable to the single intervention were estimated considering the 5-year amortization period of the instruments. This period is obviously limited when compared to the actual period of use of the technologies, thus spreading costs over the entire product life cycle can give a more realistic picture of the economic impact and in this case the gap in fixed costs between LDP and RDP would be reduced. Finally, this study is a cost analysis and further studies properly evaluating the cost-effectiveness of RDP, also including an assessment of the quality of life and the impact of the procedure on long-term outcomes, would shed light on the cost-effectiveness of RDP vs LDP.In conclusion, RAS is more expensive than DML for DP because of higher acquisition and maintenance costs. The flattening of these differences considering only the variable costs suggests a possible optimization of the cost-effectives of RAS, particularly in high-volume centers. As a result, the advantages of robotic technology could be encouraged in this setting, as it can favor the use of minimally invasive approach for DP by a larger cohort of pancreatic surgeons and expand the field of this approach to more complex pancreatic lesions, so far treated by open surgery. Moreover, RAS might be particularly indicated for MIDP when the spleen preservation is scheduled.


Emaravirus of the family Fimoviridae. Moreover, when GEVA was graft-transmitted to SJ and “Beta” grapevines, all grafted plants showed the same symptoms, similar to those observed in the source of the inoculum. This is the first report to our knowledge of an emaravirus infecting grapevine and its possible association with chlorotic mottling symptoms.A novel negative-sense, single-stranded (ss) RNA virus was identified in a “Shennong Jinhuanghou” (SJ) grapevine showing severe chlorotic mottling symptoms by integrating high-throughput sequencing (HTS) and conventional Sanger sequencing of reverse transcription polymerase chain reaction (RT-PCR) products. The virus was provisionally named as “grapevine emaravirus A” (GEVA). GEVA had a genome comprising five genomic RNA segments, each containing a single open reading frame on the viral complementary strand and two untranslated regions with complementary 13- nt stretches at the 5′ and 3′ terminal ends. RNA1 , RNA2 , RNA3 , and RNA4  encoded putative proteins P1–P4 that, based on their conserved motifs, were identified as the RNA-dependent RNA polymerase, glycoprotein, nucleocapsid protein, and movement protein, respectively. However, the functional role of protein P5 encoded by RNA5  could not be determined. Phylogenetic trees constructed based on amino acids of P1 to P4, allocated GEVA in clade I, together with other species-related emaraviruses. These data support the proposal that GEVA is a representative member of a novel species in the genus  Emaravirus is the sole genus in the family Fimoviridae and encompasses plant viruses with multiple, negative-sense, single-stranded (ss) RNA genomes (Emaravirus: Actinidia chlorotic ringspot-associated virus (AcCRaV) (Emaravirus) , they have not been reported in grapevines. genomes . Viruses(AcCRaV) , blackbe(AcCRaV) , Europearavirus) , fig mosravirus) , High Plravirus) , pigeonpravirus) , PPSMV-2ravirus) , Pistaciravirus) , raspberravirus) , redbud ravirus) , rose roravirus) , Actinidravirus) , aspen pravirus) , lilac cravirus) , blue paravirus) , pear chravirus) , ti ringravirus) , Camelliravirus) , jujube ravirus) , and Perravirus) . Other travirus) , common ravirus) , and Chrravirus) . AlthougEmaraviruses consist of 4–8 RNA segments in their genomes. Each segment contains a single open reading frame (ORF) on the strand of complementary RNA. The RNA1, RNA2, RNA3, and RNA4 segments of emaraviruses encode an RNA-dependent RNA polymerase (RdRp), a glycoprotein (GP) precursor, a nucleocapsid protein (NP), and a non-structural movement protein (MP), respectively, as core elements . The proChina is one of the world’s leading grape-production areas . Grapevine virus diseases are major threats to grape production, with 21 species of grapevine viruses reported in China . ChlorotDuring a field investigation in 2016, the obvious symptoms of chlorotic mottling on the leaves of a “Shennong Jinhuanghou” (SJ) grapevine cultivar were observed. A preliminary investigation conducted using reverse-transcription polymerase chain reaction (RT-PCR) assay showed that the SJ grapevine did not harbor common viruses identified previously in China. To identify possible virus infections in the diseased-grapevine sample, small RNA sequencing (sRNA-seq) and RNA sequencing (RNA-seq) were used to identify viruses in diseased grapevine samples in 2018.Vitis vinifera L.), showing systemic symptoms of chlorotic mottling , as reported previously DNA library of sRNAs. sRNA-seq was carried out using an Illumina HiSeqeviously . “Clean”ously  according to the manufacturer’s instructions. Primers 5H/3C usually allow full-length amplification of emaravirus RNAs (expect for RNA1) by RT-PCR  7.03. Protein analyses for prediction of the transmembrane domains of proteins were conducted using TMHMM4  was used to search for potential ORFs in the genomic and anti-genomic RNAs of the virus. Nucleotide (nt) and amino acid (aa) sequences were compared with those of other emaraviruses using ClustalW2g TMHMM4 . PredictalP 3.06 .Graft transmissibility was assessed by grafting GEVA-infected grapevine buds onto SJ seedlings and “Beta” grapevine seedlings (2 years of age) in four replicates in July 2020. These seedlings had tested negative for GEVA and other major viruses reported in China: grapevine leafroll-associated virus-1 (GLRaV-1), GLRaV-2, GLRaV-3, GLRaV-4, GLRaV-7, GLRaV-13, grapevine rupestris stem pitting-associated virus (GRSPaV), grapevine fleck virus (GFkV), grapevine fanleaf virus (GFLV), grapevine virus A (GVA), grapevine virus B (GVB), grapevine virus E (GVE), grapevine Pinot gris virus (GPGV), grapevine berry inner necrosis virus (GINV), grapevine fabavirus (GFabV), grapevine rupestris vein feathering virus (GRVFV), grapevine geminivirus A (GGVA), grapevine Syrah virus-1 (GSyV-1), and grapevine red globe virus (GRGV). Inoculated seedlings were maintained in a greenhouse under natural conditions for symptom development. Grafted grapevines were observed continuously for symptoms after inoculation. After 2 months, total RNAs were extracted from the leaves of the grafted SJ grapevine and Beta grapevine using the method described by To survey GEVA prevalence, 473 grapevine samples of 71 cultivars were collected from 21 provinces in China during 2018–2020. These samples were tested for GEVA by RT-PCR using the primers P3-1a/1b and P4-1a/1b. Amplification products from positive samples were cloned and sequenced as described above.Sequencing of a cDNA library of sRNAs from symptomatic leaves of the SJ grapevine  resultedRNA1, RNA2, RNA3, RNA4, and RNA5 had lengths of 7,090, 2,097, 1,615, 1,640, and 1,308 nt, respectively . The fir1132–1138) and C (HSDDS1257–1261) are part of the palm domain of the replicase, and are involved in the binding of divalent metal cations (1217–1225) is thought to be involved in RNA binding with the Gly residue, which allows for mobility in the peptide backbone; motif D (KKTY1308–1311) has a strictly conserved Lys residue, and is proximal to the Asp of motif A (1317–1322) is likely to be involved in “cap-snatching” in bunyaviruses as well as in possible endonuclease activity (95–97–PD134–135–EIK148–150), which is deemed to be involved in cap-snatching of viral mRNAs during genome expression  encoding a putative protein (P1) of 2,300 aa with a predicted molecular mass of 268 kDa. The sequence identity between GEVA P1 and RdRps of other emaraviruses ranged from 27.8 to 49.8% . P1 of G cations . Motif B motif A . Motif Eactivity . P1 alsopression . Such reIn silico analyses predicted four transmembrane helices  and four N-glycosylation sites  (28L/VNV and K192A/DDN) that would process the GP precursor into the C-terminal GP  and two N-terminal GPs, a larger Gn (19 kDa) and a smaller Gs (3 kDa)  encoding P2, a putative GP of 638 aa with a predicted molecular mass of 73 kDa. GEVA P2 shared identity of 19.0–43.1% at the aa level with GPs of the other emaraviruses. N439STI) . Two cle (3 kDa) , were al136–145, NRLA184–187, and GXEF205–208) similar to the NP motifs reported in other emaraviruses  encoding P3, a putative NP of 313 aa with a predicted molecular mass of 35 kDa. It shared aa-sequence identity of 18.5 to 43.5% with NPs of the other emaraviruses. Sequence alignment of P3 identified three conserved aa blocks  encoding P4, a putative protein of 363 aa with a predicted molecular mass of 41 kDa. It shared aa-sequence identity of 11.2–34.7% with the NPs of the other emaraviruses. We identified a signal peptide with a cleavage site (VKA23DD) using SignalP . SMART aRNA5 was of length 1,308 nt and had one ORF  encoding the P5 protein consisting of 255 aa with a molecular mass of 29 kDa. A BLASTp search against the GenBank database of NCBI indicated that GEVA P5 shared a limited aa-sequence identity of 25.8% with PiVB P6, but did not display significant sequence identity with proteins encoded by other emaraviruses or the proteins available in GenBank. Moreover, we did not identify a conserved domain in P5 through CDD analysis. Thus, we could not ascertain the function of this viral protein.Mapping results showed that 23,829 (0.17%), 61,088 (0.43%), 52,943 (0.37%), 86,093 (0.60%), and 79,211 (0.55%) of 14,348,642 clean reads were derived from RNA1, RNA2, RNA3, RNA4, and RNA5, respectively . The sRNPhlebovirus, Tenuivirus, Coguvirus, and Rubodvirus in the family Phenuiviridae, the genus Orthotospovirus in the family Tospoviridae, and the genus Orthobunyavirus in the family Bunyaviridae were used in the tree reconstruction. Regardless of the proteins under consideration, GEVA clustered together with emaraviruses with high bootstrap values, and was clearly separated from other viruses in several genera in the order Bunyavirales, thereby confirming a close phylogenetic relationship of GEVA with members of the genus Emaravirus  has become very popular in recent years for identification of potentially novel viruses associated with fruit disease . SeveralEmaravirus, as reported by Emaravirus. To ascertain if GEVA had more than five types of RNA, we used the primers 5H/3C to amplify the full-length of emaravirus RNA according to the method described by Five genomic components of GEVA from a SJ grapevine sample were determined by integrating data from sRNA-seq, RNA-seq, and conventional Sanger-seq. Each genomic RNA of GEVA possessed a single ORF on its complementary strand and 13-nt stretches with complementary sequences at its 5′ and 3′ termini, similar to those of other emaraviruses . The P1–Emaravirus. Analyses of the sRNAs derived from the GEVA genome revealed that most were 21 nt in length, suggesting that DICER-like (DCL) enzyme-4 had a major role in siRNA production , accession number were MW888853–MW888857.The data presented in the study are deposited in the NCBI repository (XF and YD conceived and designed the experiments. XF, ZZ, and HS collected the samples. XF, CL, FR, GH, BZ, and YD conducted the experiments and analyzed data. XF, CL, and YD discussed the results and drafted and revised the manuscript. All authors approved the final draft of the manuscript.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.


Mental disorders are related to high individual suffering and significant socio-economic burdens. However, it remains unclear to what extent self-reported mental distress is related to individuals’ days of incapacity to work and their medical costs. This study aims to investigate the impact of self-reported mental distress for specific and non-specific days of incapacity to work and specific and non-specific medical costs over a two-year span.Within a longitudinal research design, 2287 study participants’ mental distress was assessed using the Hospital Anxiety and Depression Scale (HADS). HADS scores were included as predictors in generalized linear models with a Tweedie distribution with log link function to predict participants’ days of incapacity to work and medical costs retrieved from their health insurance routine data during the following two-year period.Current mental distress was found to be significantly related to the number of specific days absent from work and medical costs. Compared to participants classified as no cases by the HADS (2.6 days), severe case participants showed 27.3-times as many specific days of incapacity to work in the first year (72 days) and 10.3-times as many days in the second year (44 days), and resulted in 11.4-times more medical costs in the first year (2272 EUR) and 6.2-times more in the second year (1319 EUR). The relationship of mental distress to non-specific days of incapacity to work and non-specific medical costs was also significant, but mainly driven from specific absent days and specific medical costs. Our results also indicate that the prevalence of presenteeism is considerably high: 42% of individuals continued to go to work despite severe mental distress.Our results show that self-reported mental distress, assessed by the HADS, is highly related to the days of incapacity to work and medical costs in the two-year period. Reducing mental distress by improving preventive structures for at-risk populations and increasing access to evidence-based treatments for individuals with mental disorders might, therefore, pay for itself and could help to reduce public costs. Mental disorders are related to high individual suffering and a significantly reduced quality of life for those affected , 2. In aTherefore, recognizing and reducing mental distress is of central importance to society to reduce individual suffering and socio-economic burdens . For doiCreating a low-threshold and rapid access to professional help requires financial investment. At the same time, when considering the reduction of days of incapacity to work and productivity losses, it could save money. Results from the English Improving Access to Psychological Therapies  serviceThis study aims to examine the impact of different degrees of self-reported mental distress as expressed in terms of subclinical anxiety and depression levels on the number of specific  and non-specific (due to any diagnosis) days of incapacity to work (DIW) as well as specific and non-specific medical costs in a two-year period in Germany.Data from a passive control cohort of a large health promotion intervention study were used, which was conducted in 2013 and 2014 in 43 locations in Southern Germany –37. The n = 808), (ii) consent to participate in the study was withdrawn (n = 20), or (iii) the questionnaire was sent out twice (n = 23). The education variable “still in school” (n = 10) was excluded because the incomplete educational status could not be included in the ranking of the education factor. Of the remaining 4688 insured persons, 1329 insured persons were not included because they were not entitled to sickness benefits , and 1072 because they belonged to the experimental group in the initial study. Finally, a total sample of 2287 study participants were included in the analyses. For details, see Lyssenko et al.  = 2.60, p = .107) in the first year and 1.4-times as many specific medical costs  in the second year.Gender revealed no significant differences in non-specific and specific DIW in the first and second years Tables  and 3. Aχ2[2] = 22.54, p < .001, factor 1.2 to 1.5) and the second year . This increase of non-specific DIW was not driven by higher specific DIW . Accordingly, older participants showed significantly higher non-specific medical costs in the first year (χ2[2]) = 11.68, p = .003) and second year , but no significant differences in specific medical costs.Compared to 18–33-year-old participants, older participants showed significantly increased non-specific DIW in the first year  and the second year .Marital status revealed no significant differences in non-specific and specific DIW in the first or second years. Accordingly, no differences in non-specific medical costs were obtained between married and unmarried participants. The specific medical costs, however, were significantly increased in unmarried participants both in the first year  and in the second year . The number of specific DIW was also increased for lower educated participants, however, this only yielding significance in the second year. Lower educated participants showed in the first year 1.2 to 2.0 as many specific DIW  and in the second year 1.4 to 3.3 as many specific DIW . Regarding the medical costs, no differences were obtained on non-specific costs in the first year, but an increase was shown in non-specific medical costs for lower educated participants in the second year . An opposite pattern was found concerning specific costs. Here, lower educated participants showed increased costs in the first year  but not in the second year.Lower educated participants showed a significant increase in non-specific DIW. Compared to participants holding an A-Level degree, lower educated participants showed 1.2 to 2.2 as many non-specific DIW in the first  in the first year and 1.7-times as many non-specific medical costs  in the second year. Specific medical costs of unemployed participants were descriptively increased (1.3 to 1.5), but this was not significant.Employment status revealed no significant differences in non-specific and specific DIW in the first and second years. However, the non-specific costs of unemployed participants were significantly increased. Compared to employed participants, unemployed participants showed 2.0-times as many non-specific medical costs . The number of non-specific DIW increased continuously with the degree of mental distress. While participants classified as no cases averaged 15.8 non-specific DIW in the first year (13.1 in the second year), mild case participants averaged 1.6 (1.5) times as many non-specific DIW (M = 25.8 days in the first year and M = 19.1 days in the second year), moderate case participants averaged 2.8 (2.3) times as many non-specific DIW (M = 44.7 days in the first year and M = 30.6 days in the second year), and severe case participants averaged 5.1 (3.7) times as many non-specific DIW (M = 81.4 days in the first year and 48.9 days in the second year).Mental distress, as measured with the HADS at t0, showed a significant effect on the number of non-specific DIW in the first year  and the second year , moderate case participants averaged 10.5 (4.7) times as many specific DIW (M = 27.5 days in the first and M = 20.1 days in the second year), and severe case participants averaged 27.3 (10.3) times as many specific DIW (M = 71.5 days in the first and M = 43.9 days in the second year).This increase of non-specific DIW was mainly driven by an increase of specific DIW in the first year .The increases of DIW in the first and second years were obtained on both the anxiety and depression subscales . Again, the number of non-specific medical costs increased continuously according to the degree of mental distress: While participants classified as no cases averaged 2031 EUR non-specific medical costs in the first year (2260 EUR in the second year), mild case participants had 1.2 (1.2) times as many non-specific medical costs (M = 2330 EUR in the first year and M = 2635 EUR in the second year); moderate case participants had 1.5 (1.5) times as many non-specific medical costs (M = 3048 EUR in the first and M = 3292 EUR in the second year); and severe case participants had 2.7 (1.9) times as many non-specific medical costs (M = 5544 EUR in the first and M = 5181 EUR in the second year).The increase of DIW depending on mental distress was also reflected in higher non-specific medical costs in the first year . While participants classified as no cases averaged 199 EUR specific medical costs in the first year (213 EUR in the second year), mild case participants had 2.2 (1.3) times as many specific medical costs (M = 434 EUR in the first and M = 272 EUR in the second year); moderate case participants had 4.7 (3.1) times as many specific medical costs (M = 941 EUR in the first and M = 661 EUR in the second year); and severe case participants had 11.4 (6.2) times as many specific medical costs (M = 2272 EUR in the first and 1319 EUR in the second year).The increase of non-specific medical costs was again mainly driven by an increase of specific medical costs in the first year .The increases in medical costs in the first and second years were obtained on both the anxiety and depression subscales  was significantly related to the number of non-specific DIW in the first and second years. Accordingly, the number of non-specific DIW increased continuously based on the level of mental distress. Compared to the reference group classified as no cases, severe cases had 5.1-times as many non-specific DIW in the first year and 3.7-times as many non-specific DIW in the second year. Not surprisingly, the increase of non-specific DIW was mainly driven by a significant increase of specific DIW. Compared to the no cases, severe cases showed 27.3-times as many specific DIW in the first year and 10.3-times as many specific DIW in the second year.These results demonstrate that mental distress impacts a person’s life for several years by predicting their sickness absence rates even 2 years later. This increased sickness absence rate might be, in turn, related to a generally reduced social and occupational functioning levels and reduced well-being of individuals . FurtherBoth the anxiety and depression subscales of the HADS were predictive for specific and non-specific DIW. This is not surprising since 78% of all specific DIW due to mental illness and burnout in our sample were caused by the diagnostic groups affective disorders  and neurotic, stress and somatoform disorders . This roughly corresponds to results from other studies in Germany, in which 88.6% of all specific DIW resulted from affective (41.4%) or neurotic, stress, and somatoform disorders (47.2%) . AccordiBeyond non-specific and specific DIW, our results demonstrated that mental distress is also significantly related to individuals’ specific and non-specific medical costs in the first and second year. Specific costs in the first year were 11.4-times higher for severe cases, compared to no cases. Even in the second year, severe cases showed 6.2-times as many specific costs as no cases. This amounts to an additional average specific cost of 2073 EUR per person and year for severe cases in the first year and 1106 EUR per person and year in the second year for the public health care system. The predictive effect of non-specific costs was considerably smaller, but also significant. Compared to no cases, severe cases averaged 2.7-times the costs in the first and 1.9-times the costs in the second year. This amounts to additional average non-specific costs of 3513 EUR per person and year for severe cases in the first year and 2922 EUR per person and year in the second year for the public health care system. The significant relationship between mental distress and non-specific medical costs was mainly driven by specific medical costs. However, these results also imply that subclinical psychiatric symptoms are associated with non-psychiatric medical outcomes. This finding is consistent with other research indicating, for example, an association between psychotic symptoms and diabetes , lonelinThese results underline the socio-economic burden of mental distress for public health care systems. However, they also show that this burden can be predicted by self-reported mental distress at an early stage. This result is consistent with previous studies, which have identified subclinical symptoms in the general population as predictive for later mental disorders –29. TherAlthough our data represent costs from a German population, these results can be seen as an indicator for other industrialized countries, since both the prevalence of mental disorders  and the percentage of direct and indirect medical costs due to mental illness in Germany  are comparable to other EU countries .Most demographic characteristics of our sample showed no consistent effects across the different dependent variables. However, these have been included mainly as control variables to control possible confounding variables. Future studies should specifically focus on these variables to draw reliable conclusions about socio-demographic variables’ influence on absence days and medical costs. Only the participants’ age showed a consistent pattern with increased non-specific DIW and non-specific medical costs for both years, but no differences in specific DIW and specific medical costs. Lower education in our sample was significantly related to non-specific DIW. However, on specific DIW, the increase by lower education yielded significance only in the second year. These results are in line with prior studies showing that mental distress (anxiety symptoms), higher age, and lower education emerged as significant predictors of non-specific DIW . Given tContrary to prior studies, in which female gender was found to be a significant predictor of specific DIW , 54, ourOur study’s major strengths relate to its longitudinal research design and the analysis of real DIW and medical cost data from a health insurance company in conjunction with psychometrically assessed mental distress from individuals. By including DIW and medical costs in the first and second year, we were able to show that self-reported mental distress was predictive for DIW and medical costs regardless of the DIW and medical costs occurring immediately after the HADS assessment, and this enabled us to show the long-term consequences of severe mental distress. By including specific and non-specific DIW and specific and non-specific costs as dependent variables, we were able to show the importance of mental health for general, occupational functioning and point to the consequences of mental distress for companies and the public health care systems. Furthermore, the available cut-off scores of the HADS to distinguish between no, mild, moderate, and severe cases allowed us to demonstrate clear, practical implications for the consequences of severe mental distress in applied settings. However, this study has some limitations, which should be considered when interpreting the results.n = 11 participants in the unemployment group). Third, in addition to the sample characteristics analyzed in this study, other variables might impact the relationship between mental distress and DIW, such as the quality of health management in organizations [Firstly, we only investigated the main effects of the sample characteristics and mental distress. However, more complex interaction effects between the independent variables are conceivable and should be investigated in future studies using larger sample sizes. Secondly, although our total sample was reasonably large, it is not a representative sample of the German population. Accordingly, we have included sociodemographic variables including sex, age groups, employment status, education and marital status in the models. However, some socio-demographic subgroups might be too small, resulting in limited power to retrieve reliable conclusions about the effect of different sample characteristics on DIW and medical costs, respectively , orizations . In addiThis study shows the extent to which self-reported mental distress is related to the subsequent inability to work and to medical costs. On an individual level, our results indicate that mental distress affects a person’s life after a span of 2 years by reducing occupational and social functioning. On a societal level, our results demonstrate the high socio-economic costs of mental distress through productivity losses due to reduced functional levels. The results, therefore, suggest that joint efforts should be made to effectively reduce mental distress . IndividIndividuals with severe mental distress or those with manifested mental disorders should be given rapid access to specialized help in the form of evidence-based psychotherapeutic or psychiatric treatments . Prior sIn summary, our study demonstrates the extent to which mental distress is associated with reduced occupational and social functioning. Accordingly, mental distress significantly impacts the number of DIW and medical costs for a span of 2 years following the initial HADS assessment. These results indicate that improving preventive structures for at-risk populations and increasing access to specialized treatments for individuals with mental disorders might reduce individual suffering as well as public costs.


Though there is no ‘Diabetes Virus’, multiple agents such as mumps virus, rubella virus, influenza virus, type A hepatitis virus, enterovirus, rotavirus, cytomegalovirus, varicella-zoster virus, human herpesvirus 6, Epstein-Barr virus, and also SARS-CoV-2 have been reported to be associated to diabetes ,2. DiabeIn susceptible strains of mice, an antecedent infection with the B variant of encephalomyocarditis virus (EMC) does prevent diabetes caused by the highly diabetogenic D variant of EMC ,12. In hOne crucial question for the treatment of type 1 diabetes in the early phases is whether the disease would ameliorate if persistent infection could be terminated. To this end, multiple anti-enterovirus drugs are expected in the near future ,15,16. IBiology. I look forward to receiving your research and review articles.The susceptibility to multiple viruses, the regulation of viral infection in type 1 diabetes, the host factors that make some individuals susceptible to virus-induced diabetes undoubtedly merit intensive research. Investigations of this type may also foster progress in other immune-mediated conditions. Thus, critically presenting the results of ongoing research on virus-related diabetes and endocrine diseases does represent the scope of a dedicated issue of


The paper presents a very efficient, quick, low-cost and minimally micro-destructive approach to discriminating between Roman artefacts sculpted with Göktepe  or Carrara  white marbles by using a standard X-Ray Powder Diffractometer (XRPD) and a refinement of the unit cell parameters and volume of calcite. At present, the routine way of differentiating between these two almost indistinguishable by-eye marbles is based on the typically higher strontium content of calcite in the Microasiatic lithotype, a unique geochemical-crystallographic feature with respect to all other non-Göktepe fine-grained white marbles used in classical times. The XRPD approach has been verified by testing eighteen samples of known composition, nine from Carrara and nine from Göktepe quarries, which had already been analysed with other laboratory techniques. The applicability of the method to archaeological artefacts was confirmed by an archaeometric study performed on some famous Roman sculptures of the National Archaeological Museum of Venice and from Hadrian’s Villa at Tivoli. The results show that Göktepe/Carrara discrimination is always possible and that this XRPD approach can potentially become a useful and low-cost routine procedure to solve provenance issues. The worldwide success of marble is inscribed in the intrinsic beauty of the material, which can be enhanced through different working processes, capable of generating numerous aesthetic results from the same type of marble. As is well known, the history of the use of crystalline white marble goes back thousands of years, starting already in prehistoric times. In particular, the creation of the first marble objects dates back to the late Neolithic, in the Cyclades , where characteristic small idols/figurines, peculiar to the artistic production of the Cycladic civilization, were produced from the end of the IV to the end of the III millennium BC. White marbles outcrop copiously in various regions of the Mediterranean basin , and their use was consequently widespread from the origins of archaic Greek sculpture and then, from the V century BC, in the architecture of the classical and later periods, when a huge amount of marble was employed and the quality of the craftsmanship reached extraordinary artistic levels. For the Roman elite, monumental marble sculpture and architecture offered potent emblematic and symbolic propaganda ways of exhibiting, upholding and amplifying their social status.2; buildings, statues, artefacts and monuments in general, if accurately dated, can in turn reveal when a specific quarry started its activity and how the demand for its marble developed; damaged architectural or sculptural marble elements can be restored, replaced or integrated with sound material sourced directly from the ancient quarries2.Archaeologists and art historians have always been extremely interested in the identification of the quarry of provenance of ancient marble artefacts, which is one the most hotly debated issues of petroarchaeometry. The devising of a reliable method for determining the provenance of marble has meant that sculptures of uncertain ascription can be attributed to a specific production area, workshop or artist ; marbles recovered from shipwrecked cargoes enable ancient trade routes to be reconstructed2. In particular, the detailed mineralogical-petrographic examination of a thin section and the determination of the C and O stable isotopic ratios on the same sample is currently the most widely used and reliable combination. Such a combination exploits the most recently updated databases for the main Mediterranean marbles most commonly used in classical antiquity and it associates the global reference isotopic diagrams to the maximum grain size (MGS) of the different varieties2. When petrographic and isotopic features are compared step by step in this way it often proves possible to identify where the marble constituent of a given archaeological/historical object was originally quarried. We use the term “often” advisedly; it does not mean “always”.For all these reasons, in the absence of an effective non-destructive technique, geologists  and scholars of other disciplines, especially chemists and physicists, have been trying for more than a century to achieve a consistent identification of the source areas by means of a unique or multiple laboratory analysis. To date, when marbles are found as original structural or decorative elements of ancient buildings or in sculptures, or when ancient spolia are reused in Medieval or Renaissance monuments , a multi-method approach offers the best means of successful identification, combining at least two different analytical methodologies and jointly processing all the data obtained3, has raised attention and much discussion. The importance of this fine-grained white marble has been claimed as extraordinarily high by the authors who first published on the quarries7. Their analyses and deductions, however, have prompted arguments among some scholars, e.g.,12. These disagreements have concerned mainly the real extent to which Göktepe white marble was preferred for high quality sculptural purposes and also the methodology adopted in determining the provenance of these artefacts. In fact, further petrographic investigations13 have shown that although the Göktepe marbles can exhibit a unique set of features, their fabrics and grain size are more variable than initially suggested and several types of other important classical fine-grained white marbles 15 showed very high Sr and very low Mn concentrations, which were suggested as the key criteria for distinguishing Göktepe marble from other white fine-grained marbles used in antiquity, especially from marmor lunense, i.e. Carrara marble from the Apuan Alps in Italy. This is a critical point because the macroscopic characteristics, microscopic/petrographic features  and O–C stable isotope composition  measurements, and statistical elaboration of data. Geochemical studies performed on white marble from Göktepe, e.g.,ion Fig.  of Carra12 proposed an improved methodology for the identification of Göktepe white marble and a consistent comparison with the Carrara type. The multi-method approach they proposed includes a detailed petrographic study in thin section, a cathodoluminoscopic characterization and a combination of isotope measurements with elemental ratios. The most important features of white Göktepe marble that arise from this study are: (a) a general homeoblastic fabric, sometimes with triple joints, often formed by small calcite crystals (MGS from 0.6 to 2.05 mm) mainly with curved/straight boundaries . Equally frequently, the fabric is heteroblastic and slightly foliated (frequently with traces of strain), at times showing very fine intergranular calcite grains and areas of decussate fabric related to rudist’ clast-relics. This set of petrographic characteristics together with the possible presence of small pink-to-light purple fluorite crystals, can be very peculiar; (b) oval domains and tiny spots with low intensity orange calcite in otherwise non-luminescent and dolomite-free marble; (c) tailed area on the stable C versus O isotope plot towards depleted values. Nevertheless, the isotopic domain partially overlaps with that of Carrara marble; (d) very narrow range of 87Sr/86Sr isotopic ratio around 0.7073; (e) low Mg, Mn, Fe and REE, but very high Sr contents.Nevertheless, despite the apparently wide range of analytical methods used for identification of Göktepe white marble, ambiguity still existed. For this reason, Wielgosz-Rondolino et al.6, Poretti et al.15 and Prochaska et al.16, the research conducted by Wielgosz-Rondolino et al.12 confirms that important geochemical parameters for discrimination between Carrara and Göktepe marbles are C and O isotope compositions, Sr and Mn contents, and Mg and trace element distribution, but it also indicates 87Sr/86Sr values as a further valuable proxy. Their data clearly show that the best discrimination between Göktepe, Carrara and other fine-grained white marbles is obtained when the Sr isotope signature is combined with Mn/Sr and Sr/Mg elemental ratios and δ18O values. Such combinations  can provide decisive results even when the individual proxies overlap, because when combined they should normally generate separate clouds of projection points.As already suggested by Attanasio et al.12 suggest that in the case of precious artefacts, when the petrographic investigations in thin section are not possible and least destructive methods are necessary, a combination of only Sr, C and O isotope analyses may be preferred, as they require less material than the elemental analysis performed by ICP spectrometry or atomic absorption; (3) the whole set of discriminant analyses entails a major cost per sample (many hundreds of euros).So far, all the laboratory approaches proposed by different scholars to identify the Göktepe marble and, especially, to distinguish it from the Carrara variety, involve the joint use of several analytical techniques. These methods have some potentially major negative consequences: (1) the whole instrumental apparatus needed is quite composite and only a very small number of laboratories are adequately equipped; furthermore, the complete analytical procedure is not so effortless and quick as to be considered as a real “routine method”; (2) the multi-analytical method requires a not inconsiderable amount of sample material; in fact, Wielgosz-Rondolino et al.12 are reconsidered for this purpose. In particular, in order to provide robust statistical data, we have analysed 18 different samples, 9 marbles from the district of the Carrara quarries  and 9 marbles from the Göktepe area .This paper aims to describe a quick, low-cost and only minimally micro-destructive approach  able to distinguish between Göktepe and Carrara marbles on the basis of their dissimilar basic mineralogy  as revealed by the X-ray powder diffraction (XRPD) technique. A representative number of the powdered samples already used by Wielgosz-Rondolino et al.α2, to suppress Kβ lines and thus avoiding the use of an Fe filter. Divergence slits of 0.25°, antiscatter slits of 1° and Soller slits of 0.04 rad complete the incident beam setup.XRPD measurements were performed using a Philips X’Pert Pro MPD diffractometer. This instrument implements a long fine focus Co anode working at 40 kV–40 mA and a goniometer with radius of 240 mm that operates in the θ/θ geometry. Incident beam optics include the Bragg-BrentanoHD (BBHD) module that is a wafer crystal of W/Si, manufactured to improve signal-to-noise and peak-to-background ratios. It is also designed to maintain a divergent beam, reducing KSix samples were split and XRPD analyses replicated also by means of a PANalytical Empyeran multi-function diffractometer, which implements a Copper anode. The "PANalytical Empyeran" diffractometer worked under the same operating condition used for the "Philips X’Pert Pro MPD"; the results obtained were perfectly in agreement and confirm that there was no instrumental bias.Diffracted beam optics are composed of an antiscatter slit of 9.1 mm aperture, Soller slits of 0.04 rad and X’Celerator Position Sensitive Detector with a 2.122° 2θ active length. Total scan time per sample is approximatively 2.5 h and 1 h when using "Philips X’Pert Pro MPD" and PANalytical Empyeran multi-function diffractometers, respectively. A beam knife, positioned above the sample centreline, was used to reduce the air scattering contribution at low 2θ angle.Measures were carried out at angles of between 3° and 95° 2θ, using a 0.008° step size, counting 100 s per virtual step on a spinning sample (1 revolution per second). Samples were prepared using the back-loading procedure in order to reduce crystallite preferred orientations.17 as implemented in Profex-BGMN v.4.1.018 was used in the Rietveld refinements. A preliminary verification step consisted in checking the instrumental contribution to line broadening by fitting the diffraction profile of the Si standard (NIST SRM-640c). This procedure involved the verification of FPA configuration bundled with software, after considering the presence of the BBHD module. Crystal structures were taken from the BGMN structure database. The refinement strategy included the variations of the following parameters: coefficients of the Lagrangian polynomial function used to describe the background (6 coefficients for each sample), scale factors, unit cell parameters, crystallite size, texture and microstrain. Neither atomic coordinates nor atomic displacement parameters were refined.The fundamental parameters approachX-ray powder diffractograms relative to all 18 samples are shown in Fig. 19) and this should cause a slight but detectable increase in the unit-cell parameters and volume of calcite. In order to verify such possible influence on the volume (and on the a and c cell parameters), we have refined the unit-cell parameters of all 18 samples and the relative data are reported in Table In general, some varieties of Carrara marble that are extremely pure can certainly exist; consequently, this first very simple XRPD approach would probably not be sufficient to avoid potential identification problems. However, a detailed analysis of the calcite structure in terms of unit cell parameters could provide more information. As we remarked in the introduction, marbles from Göktepe generally show much higher Sr contents; Sr is a larger cation than Ca  on the Acropolis of Athens in Hellenistic times were initially present in Rome; they are now scattered in many cities and three of them probably correspond to those in Venice today20: the “Dead Galatian” (inv. No. 56), the “Kneeling Galatian” (inv. no. 57), and the “Falling Galatian” (inv. no. 55); the first two were previously analysed by Attanasio et al.22 and supposed to have been carved in Göktepe marble on the basis of isotopic and EPR data combined with Sr content , while the third one had never been studied before. Information on the discovery of these three “little barbarians” is not completely clear. We know that the “Falling Galatian” and the “Kneeling Galatian” were found by Cardinal Domenico Grimani in the early sixteenth century, perhaps on the northern side of the Quirinal Hill23 or around the Baths of Agrippa24, located in the Campus Martius, where Grimani had already discovered other antiquities. Toward the end of his life Domenico Grimani donated his collection to the Venetian state. By contrast, we have no exact information about the discovery of the “Dead Galatian”, even if generally it is assumed that this sculpture was found along with the other two.Three famous under-lifesize sculptures of Galatian soldiers (Gauls) defeated in combat, exhibited at the National Archaeological Museum of Venice Fig. . Accorditondo with zodiac; and Ti-VA-34: large mask) kindly provided by Maria Pilar Lapuente Mercadal , who previously analysed them by means of petrographic, geochemical and physical (cathodoluminescence) techniques and hypothesised an origin from Göktepe for Ti-VA-19 and Ti-VA-62, and from Carrara in the case of sample Ti-VA-34,25. The same geographic provenance of the marbles was confirmed successively by Wielgosz-Rondolino et al.12 also by using Sr isotopes.Three samples of artefacts from Hadrian’s Villa in Tivoli  and kneeling (inv. no. 57) Galatians is very fine-grained (grain-size mainly below 0.2 mm), with MGS values of 0.30 mm and 0.76 mm, respectively, and shows an homeoblastic mosaic made of calcite crystals with curved (± straight ± embayed) boundaries. Very fine intergranular calcite grains are also present , which are consistent with those established for Carrara marble  as opposed to the marble from Carrara, which is much less pure. Though this first general mineralogical difference was very easy to observe by X-ray powder diffraction, account must be taken of the fact that, albeit very rarely, some varieties of Carrara marble can contain equally pure calcite; this can restrict the chance of safe discrimination between the two marbles by using only the qualitative XRD technique. However, the most significant result comes from the unit-cell refinements of calcite from the marbles of both localities. These are certainly new data that have never been reported before as a direct comparison between the two lithotypes.We should remark that the unit-cell volume of a mineral is generally affected by the chemical composition of the mineral itself and, therefore, in the studied case, we can easily observe that the higher amount of Sr within the calcite structure of Göktepe marble with respect to that from Carrara systematically causes a larger cell volume (this can be expected as Sr is a much larger cation than Ca). Evidently, such approach is considerably more significant than a simple X-ray powder diffraction data collection because it is carried out only on calcite and is independent of the presence of further minerals in the rock. This means that, when a Göktepe versus Carrara (or non-Göktepe) origin is hypothesised, due to different chemical composition among different calcites, it will be possible to retrieve a reliable and distinguishable discriminant feature with a very limited amount of powder sample (starting from 5 mg), at much lower costs with respect to other laboratory techniques, lower measurement times, and very easy sample preparation . Thus, only if this kind of simple XRD analysis indicates a non-Göktepe origin will it be necessary also to consider the classic thin section microscopic study supplemented by the Carbon and Oxygen isotopic signature .marmor lunense to be hypothesized. These data show that the Venetian group of sculptures of “Galatian soldiers” is not homogeneous and, more in general, that Roman marble copies of the bronze statues of barbarians originally erected on the Acropolis of Athens were not produced only with Microasiatic marbles.The validity of the approach was confirmed by the results obtained on six archaeological samples already analysed throughout different and more elaborate chemical-physical laboratory techniques. Two of the “little Barbarians” statues of the National Archaeological Museum of Venice and two sculptures from Hadrian’s Villa in Tivoli were found to be made of Göktepe marble, whereas the remaining artefacts revealed unit-cell parameters which match those recorded for the Carrara marble. Furthermore, in the case of the so-called “Falling Galatian” sculpture of the Venetian National Archaeological Museum, our analyses support an origin of the marble which is certainly different from the Göktepe quarries and allows the use of Docimium marble, i.e. the other important Microasiatic variety, but also the Greek Paros-1  and Pentelic  marbles—to verify possible differentiations and complete the database; (2) to apply and test this method on a more significant number of archaeological and museum artefacts for which an uncertain Göktepe origin has been proposed.Further steps in this research will be (1) to extend the XRPD study of the calcite cell parameters/volume to the other fine-grained white marbles used in classical times—especially, the