Cover StoryFrom OSN Europe

High carbon footprint of cataract surgery raises awareness of need for more sustainable practices in operating rooms

Health care procedures are a large contributor to carbon emissions throughout the world. Presently, surgeons and health care organizations are analyzing the effects of carbon emissions from cataract surgeries and how to decrease the carbon footprint of these procedures.

In 2013, researchers from the United Kingdom published a benchmark component analysis study on the carbon emissions per cataract surgery. Daniel S. Morris, FRCSEd(Ophth), a consultant ophthalmologist at the University Hospital of Wales, U.K., and lead author of the study, noted one cataract surgery had a carbon footprint of 181.1 kg carbon dioxide equivalent (CO2 eq).

Cataract surgery carbon footprint

The study included 2,230 patients treated for cataracts in Cardiff. The procedures had a total carbon footprint of 405.4 tons of CO2 eq. Putting this into context, the average carbon footprint for one U.K. resident per year is generally estimated at 10 tons of CO2 eq, which is 5 to 10 times more than the quantity per passenger generated by a flight to New York from London, according to the study.

Daniel S. Morris, FRCSEd(Ophth), estimated that the average carbon footprint for one U.K. resident per year is 10 tons of CO2 eq, 5 to 10 times more than the quantity per passenger generated by a flight to New York from London.

“There is a lot of waste with every cataract surgery. In our study, we were looking at three different areas for each procedure. One was the energy use in the hospital, the second was the travel made by patients and staff, and the third was the procurement and disposal of equipment for the surgery (instruments, IOL, etc.). We saw, potentially, that there was a lot of energy being used during a surgery and by getting to and from a procedure, but the procurement section came out the highest per procedure,” Morris said, totaling 54% of the total emissions for each surgery.

Packaging adds waste

The packaging of supplies, the ordering model employed by hospitals for surgical supplies and the materials that come with each supply bundle all contribute to the total carbon footprint of surgery.

“Right now, we will put a purchase order in for just a couple of intraocular lenses at a time, and they will be sent out in one delivery truck. But what we should be doing is thinking ahead by a month and ordering 1,000 lenses, not just two or three, so we would just have one truck coming out a month and not 50 trucks a month,” Morris said. “There is also a huge amount of packaging for just one tiny lens, which is a requirement from the regulators. There is a 70-page booklet inside of each lens package, and that is really not required by us. We need to lobby the regulators with our industrial partners to change this, and that would make a big difference.”

“Even something as small as multiple patient trips to a hospital for preoperative and postoperative examinations can increase the carbon footprint for a single procedure,” he said.

Patients make four to five visits to a hospital for pre- and post-surgery evaluations, Morris said. With thousands of patients making these trips each year, it may make sense for more institutions to offer cataract surgery on a “one-stop basis.”

“They would be seen in the morning by nurses, who perform a pre-assessment, and would then have surgery in the afternoon and be discharged back to the optometrist after that,” he said.

A call to increase sustainability

The Royal College of Ophthalmologists published an Ophthalmic Services Guidance in 2013 that urged the United Kingdom to put more of an emphasis on sustainability in ophthalmology. The guidance said that cataract surgeries are an ideal area in which to “target carbon reduction strategies.”

About 300,000 cataract surgeries are performed in the United Kingdom annually, the guidance said.

“To date, various studies have demonstrated potential opportunities for the execution of sustainable eye care. Somner and colleagues highlighted that during cataract surgery, small-incision surgery produced less CO2 emission than phacoemulsification techniques. Similarly, it has been postulated that simple technological strategies such as re-designing of taps used for surgical scrubbing can significantly decrease the amount of water wasted during surgical procedures,” according to the guidance.

Morris suggested the cataract surgery model employed by the hospitals in the Aravind Eye Care System in India could be a way to possibly cut back on the carbon footprint for the procedures.

Aravind Eye Care System

“In 2015 I was involved by Cassandra L. Thiel, PhD, a postdoctoral researcher at the University of Pittsburgh, in a sustainability research project in ophthalmology. She was interested in the lower environmental impact of our cataract surgery model,” Rengaraj Venkatesh, MD, chief medical officer at Aravind Eye Hospital, Pondicherry, India, said.

“We were not aware at the time that our high-volume, cost-effective cataract surgery protocol was also environment-friendly. We have learned a lot from this project. Our results were presented at the Association for Research in Vision and Ophthalmology meeting in Seattle and raised great interest,” he said.

Rengaraj Venkatesh

Aravind’s reduced carbon footprint is due primarily to the use of reusable materials. The surgical instruments, phaco tips, sleeves and irrigation-aspiration handpieces are flash sterilized in between surgeries, while the tubing and cassettes of phaco machines are disposed only at the end of the day.

“We also use the same gloves for 10 consecutive cases, disinfecting them with antiseptic solution after each case. Gowns and large drapes are also washed, dried and autoclaved,” Venkatesh said.

Each surgery completed at Aravind results in an average 0.25 kg of waste, of which two-thirds is recycled. In a Western hospital, according to Thiel, 6.5 kg to 8.5 kg of waste is generated by the same procedure, all of which goes to a landfill.

“In the United States and Europe, where flash sterilization is not recommended, the full-cycle sterilization takes 1 to 2 hours. If you do 20 cases, you need to have 20 surgical sets, while we need seven or eight sets and flash sterilize them in between cases, which takes 15 to 20 minutes,” Venkatesh said.

To optimize time and energy consumption, each surgeon operates on two tables, assisted by two scrub nurses and a circulating nurse. By the time one surgery is completed, the second scrub nurse has prepared the next case.

“We save a lot of time and a lot of electricity, and this allows us to deal efficiently with high-volume surgery. With 8 to 10 surgeons working with this two-table system, 10 cases per hour can be comfortably performed by each surgeon,” Venkatesh said.

A low rate of infection

Aravind has rigorous data collection procedures, which have shown that the infection rate is low. The endophthalmitis rate is 0.05%, which compares favorably with the international rate of 0.08%.

“This in spite of reusing, flash sterilizing and not changing the tubing and cassettes for every case, and also taking into account that many of our patients come from outreach eye camps where literacy and hygiene are often below standards. This shows that nothing of what we do puts safety at risk,” Venkatesh said.

Reducing the carbon footprint also comes from cutting down on transport.

“We use city centers and primary eye care centers called the vision centers to do postoperative follow-up for cataract patients,” Venkatesh said. “We are also discussing with Aurolab, our provider of intraocular lenses, to do a special smaller packaging for the IOLs we use internally. In addition, we are bringing solar energy to our hospitals.”

Is Aravind model exportable?

Many hospitals across India, Nepal, Indonesia, the Philippines, Sri Lanka, Malawi, Nigeria, Kenya, Congo and Ghana have adopted the Aravind model.

“The Lions Aravind Institute of Community Ophthalmology provides consultancy on capacity building, so that these hospitals don’t have to reinvent anything, just adopt the Aravind model and rapidly become self-sufficient,” Venkatesh said.

Interest is growing in the developed world as well. Golden Jubilee Hospital in Glasgow, Scotland, deals with high-volume cataract surgery and recently received a significant investment by the Scottish government to expand services. A Scottish delegation recently visited the Aravind hospital.

“Their intention is to work at a similar model to increase efficiency and reduce the carbon footprint of surgery to the extent that their country’s regulations allow them to do so,” Venkatesh said.

Marie-José Tassignon, MD, PhD, OSN Europe Edition Associate Editor, visited Aravind and said she was greatly impressed by the efficient system that keeps the cost for private patients affordable, which allows the hospital to use this money to treat patients who cannot pay.

Marie-José Tassignon

“Also, their attitude toward environmental issues is something we should look at. Most of us have never considered the impact of our profession in terms of pollution. We should definitely be more eco-conscious in our practice, but on the other hand, regulations are forcing us into the opposite direction of producing more and more waste and consuming an increasing amount of energy,” she said.

Regulations should be re-evaluated to cut down on what is harmful for the environment without compromising safety.

“Reducing waste means, for instance, stop accepting the very expensive custom procedure packs that are marketed as mandatory to guarantee safety. And for sure there are alternatives to a lot of things, like the bulky disposable drapes, and less costly,” Tassignon said.

“We are often caught in a loop, where whatever we do to consume less ends up into consuming more in terms of time and resources,” she said. “For instance, multiple-dose vials cost less and reduce waste, but require a lot of surveillance, time-consuming paperwork and verification processes, as well as carrying a higher risk of human mistakes and contamination. At the end of the day, they may cost more because there is more time and more personnel involved and therefore less time for the patients. No wonder single doses are by far preferred nowadays.”

Regulators, health economics experts, hygiene professionals and doctors should work together with industry to develop new strategies, she said.

“It is difficult, but not impossible. We are more aware of the environmental problems our world is facing and cannot deny the need to be responsible, also in the closed world of the operating room,” Tassignon said. – by Michela Cimberle and Robert Linnehan

Disclosures: Morris, Tassignon and Venkatesh report no relevant financial disclosures.

POINTCOUNTER

At a time of increasing concern about global warming, how does the environmental impact of reusable and disposable instruments compare?

POINT

Think about reusing more, managing waste better

Pavel Stodulka

We, as ophthalmic surgeons, are polluting quite a lot. Taking into consideration how small the eye is, it is unbelievable the amount of waste we produce for a single surgical procedure. Our peers 30 years ago would not believe where we are today. I am not too old but old enough to remember the times when we had literally, with the exception of syringes, no disposable tools at all for cataract surgery, including the drapes and scrubs. All that was revolutionized in favor of disposable. It is on one side very good because it enhances safety, but on the other side we are polluting a lot and should think about that.

If I were granted a wish, I would want an environment-friendly machine to convert disposables into heat and electricity for the clinic. First, I would not have to pay for the waste to be disposed somewhere else; second, I would save on energy bills; and third, I would avoid some of the pollution produced by trucks coming in and out for the waste. I do not know what the regulations are in other countries, but in the Czech Republic all the disposable waste generated by cataract surgery — which is bloodless surgery with a low risk of infection — is considered to be an infectious hazard, and we have to put it into red boxes, label it and send it to be destroyed as a highly infectious material. This prevents us from separating materials, and yet the small plastic IOL containers are not infectious and could be piled one into the other to save space and be disposed of with the recyclable plastics. The same applies to syringes that contain only saline solution. But current rules prevent us from doing so.

One small thing I do and teach co-workers is to put the surgical gloves into the sleeve of the gown and then fold the gown tightly into its sleeve to save space in the garbage. In my clinic, we reuse the phaco handpiece and instruments such as the chopper and spatula. We use disposable syringes and cartridges, while phaco tips and cannulas are sometimes disposable and sometimes reusable. We tend to reuse some instruments because it is cost-effective, easier and more environment-friendly. At the clinic, including the OR, we run paper-free electronic medical records and have online access to diagnostic devices so there are no printouts needed for our surgical patients. We only print a final report for them as a handout.

Pavel Stodulka, MD, PhD, is an OSN Europe Edition Board Member and CEO of Gemini Eye Clinic, Zlin and Prague, Czech Republic. Disclosure: Stodulka reports he is a consultant for Bausch + Lomb.

COUNTER

Single-use products have increased patients’ safety

Paolo Lanzetta

As ophthalmologists, we have no proper answer to this question. We need experts’ advice on how to reduce greenhouse gas emissions and adopt environment-friendly surgical models. We may reduce single-use in favor of reusable instruments and scrubs, but what is the environmental impact of increased autoclave sterilization, and how much we gain in doing so, we do not know.

I am open to the adoption of new strategies for sustainable eye care as long as I do not have to compromise on patients’ safety. The introduction of single-use instruments, draping and surgical clothing has undoubtedly improved safety, and this has coincided with the advent of phacoemulsification and other breakthrough techniques. Patients have the right to be guaranteed observance of safety and quality standards, and I would not feel comfortable adopting procedures that may put patient safety at risk and not provide the best of eye care. I very much admire my colleagues of Aravind Hospital who have greatly implemented environment-friendly measures. This is a good start that should be combined with advancements in safety of surgical procedures. Obviously, we cannot recant the ABCs of OR safety.

People are nowadays becoming more conscious of how their consumption behavior is impacting the world around them. In our homes, we are adopting environment-friendly behaviors such as minimizing and separating waste, but this is thanks to years of planning, organizing and implementing laws and regulations. We need similar evidence-based planning and regulations for the operating room to implement sustainable environment-friendly practices in the OR without sacrificing safety.

Paolo Lanzetta, MD, is OSN Europe Edition Board Chairperson and head of the Ophthalmology Department, University of Udine, and scientific director of IEMO, Udine, Italy. Disclosure: Lanzetta reports no relevant financial disclosures.

Health care procedures are a large contributor to carbon emissions throughout the world. Presently, surgeons and health care organizations are analyzing the effects of carbon emissions from cataract surgeries and how to decrease the carbon footprint of these procedures.

In 2013, researchers from the United Kingdom published a benchmark component analysis study on the carbon emissions per cataract surgery. Daniel S. Morris, FRCSEd(Ophth), a consultant ophthalmologist at the University Hospital of Wales, U.K., and lead author of the study, noted one cataract surgery had a carbon footprint of 181.1 kg carbon dioxide equivalent (CO2 eq).

Cataract surgery carbon footprint

The study included 2,230 patients treated for cataracts in Cardiff. The procedures had a total carbon footprint of 405.4 tons of CO2 eq. Putting this into context, the average carbon footprint for one U.K. resident per year is generally estimated at 10 tons of CO2 eq, which is 5 to 10 times more than the quantity per passenger generated by a flight to New York from London, according to the study.

Daniel S. Morris, FRCSEd(Ophth), estimated that the average carbon footprint for one U.K. resident per year is 10 tons of CO2 eq, 5 to 10 times more than the quantity per passenger generated by a flight to New York from London.

“There is a lot of waste with every cataract surgery. In our study, we were looking at three different areas for each procedure. One was the energy use in the hospital, the second was the travel made by patients and staff, and the third was the procurement and disposal of equipment for the surgery (instruments, IOL, etc.). We saw, potentially, that there was a lot of energy being used during a surgery and by getting to and from a procedure, but the procurement section came out the highest per procedure,” Morris said, totaling 54% of the total emissions for each surgery.

Packaging adds waste

The packaging of supplies, the ordering model employed by hospitals for surgical supplies and the materials that come with each supply bundle all contribute to the total carbon footprint of surgery.

“Right now, we will put a purchase order in for just a couple of intraocular lenses at a time, and they will be sent out in one delivery truck. But what we should be doing is thinking ahead by a month and ordering 1,000 lenses, not just two or three, so we would just have one truck coming out a month and not 50 trucks a month,” Morris said. “There is also a huge amount of packaging for just one tiny lens, which is a requirement from the regulators. There is a 70-page booklet inside of each lens package, and that is really not required by us. We need to lobby the regulators with our industrial partners to change this, and that would make a big difference.”

“Even something as small as multiple patient trips to a hospital for preoperative and postoperative examinations can increase the carbon footprint for a single procedure,” he said.

Patients make four to five visits to a hospital for pre- and post-surgery evaluations, Morris said. With thousands of patients making these trips each year, it may make sense for more institutions to offer cataract surgery on a “one-stop basis.”

“They would be seen in the morning by nurses, who perform a pre-assessment, and would then have surgery in the afternoon and be discharged back to the optometrist after that,” he said.

A call to increase sustainability

The Royal College of Ophthalmologists published an Ophthalmic Services Guidance in 2013 that urged the United Kingdom to put more of an emphasis on sustainability in ophthalmology. The guidance said that cataract surgeries are an ideal area in which to “target carbon reduction strategies.”

PAGE BREAK

About 300,000 cataract surgeries are performed in the United Kingdom annually, the guidance said.

“To date, various studies have demonstrated potential opportunities for the execution of sustainable eye care. Somner and colleagues highlighted that during cataract surgery, small-incision surgery produced less CO2 emission than phacoemulsification techniques. Similarly, it has been postulated that simple technological strategies such as re-designing of taps used for surgical scrubbing can significantly decrease the amount of water wasted during surgical procedures,” according to the guidance.

Morris suggested the cataract surgery model employed by the hospitals in the Aravind Eye Care System in India could be a way to possibly cut back on the carbon footprint for the procedures.

Aravind Eye Care System

“In 2015 I was involved by Cassandra L. Thiel, PhD, a postdoctoral researcher at the University of Pittsburgh, in a sustainability research project in ophthalmology. She was interested in the lower environmental impact of our cataract surgery model,” Rengaraj Venkatesh, MD, chief medical officer at Aravind Eye Hospital, Pondicherry, India, said.

“We were not aware at the time that our high-volume, cost-effective cataract surgery protocol was also environment-friendly. We have learned a lot from this project. Our results were presented at the Association for Research in Vision and Ophthalmology meeting in Seattle and raised great interest,” he said.

Rengaraj Venkatesh

Aravind’s reduced carbon footprint is due primarily to the use of reusable materials. The surgical instruments, phaco tips, sleeves and irrigation-aspiration handpieces are flash sterilized in between surgeries, while the tubing and cassettes of phaco machines are disposed only at the end of the day.

“We also use the same gloves for 10 consecutive cases, disinfecting them with antiseptic solution after each case. Gowns and large drapes are also washed, dried and autoclaved,” Venkatesh said.

Each surgery completed at Aravind results in an average 0.25 kg of waste, of which two-thirds is recycled. In a Western hospital, according to Thiel, 6.5 kg to 8.5 kg of waste is generated by the same procedure, all of which goes to a landfill.

“In the United States and Europe, where flash sterilization is not recommended, the full-cycle sterilization takes 1 to 2 hours. If you do 20 cases, you need to have 20 surgical sets, while we need seven or eight sets and flash sterilize them in between cases, which takes 15 to 20 minutes,” Venkatesh said.

To optimize time and energy consumption, each surgeon operates on two tables, assisted by two scrub nurses and a circulating nurse. By the time one surgery is completed, the second scrub nurse has prepared the next case.

“We save a lot of time and a lot of electricity, and this allows us to deal efficiently with high-volume surgery. With 8 to 10 surgeons working with this two-table system, 10 cases per hour can be comfortably performed by each surgeon,” Venkatesh said.

A low rate of infection

Aravind has rigorous data collection procedures, which have shown that the infection rate is low. The endophthalmitis rate is 0.05%, which compares favorably with the international rate of 0.08%.

“This in spite of reusing, flash sterilizing and not changing the tubing and cassettes for every case, and also taking into account that many of our patients come from outreach eye camps where literacy and hygiene are often below standards. This shows that nothing of what we do puts safety at risk,” Venkatesh said.

Reducing the carbon footprint also comes from cutting down on transport.

“We use city centers and primary eye care centers called the vision centers to do postoperative follow-up for cataract patients,” Venkatesh said. “We are also discussing with Aurolab, our provider of intraocular lenses, to do a special smaller packaging for the IOLs we use internally. In addition, we are bringing solar energy to our hospitals.”

PAGE BREAK

Is Aravind model exportable?

Many hospitals across India, Nepal, Indonesia, the Philippines, Sri Lanka, Malawi, Nigeria, Kenya, Congo and Ghana have adopted the Aravind model.

“The Lions Aravind Institute of Community Ophthalmology provides consultancy on capacity building, so that these hospitals don’t have to reinvent anything, just adopt the Aravind model and rapidly become self-sufficient,” Venkatesh said.

Interest is growing in the developed world as well. Golden Jubilee Hospital in Glasgow, Scotland, deals with high-volume cataract surgery and recently received a significant investment by the Scottish government to expand services. A Scottish delegation recently visited the Aravind hospital.

“Their intention is to work at a similar model to increase efficiency and reduce the carbon footprint of surgery to the extent that their country’s regulations allow them to do so,” Venkatesh said.

Marie-José Tassignon, MD, PhD, OSN Europe Edition Associate Editor, visited Aravind and said she was greatly impressed by the efficient system that keeps the cost for private patients affordable, which allows the hospital to use this money to treat patients who cannot pay.

Marie-José Tassignon

“Also, their attitude toward environmental issues is something we should look at. Most of us have never considered the impact of our profession in terms of pollution. We should definitely be more eco-conscious in our practice, but on the other hand, regulations are forcing us into the opposite direction of producing more and more waste and consuming an increasing amount of energy,” she said.

Regulations should be re-evaluated to cut down on what is harmful for the environment without compromising safety.

“Reducing waste means, for instance, stop accepting the very expensive custom procedure packs that are marketed as mandatory to guarantee safety. And for sure there are alternatives to a lot of things, like the bulky disposable drapes, and less costly,” Tassignon said.

“We are often caught in a loop, where whatever we do to consume less ends up into consuming more in terms of time and resources,” she said. “For instance, multiple-dose vials cost less and reduce waste, but require a lot of surveillance, time-consuming paperwork and verification processes, as well as carrying a higher risk of human mistakes and contamination. At the end of the day, they may cost more because there is more time and more personnel involved and therefore less time for the patients. No wonder single doses are by far preferred nowadays.”

Regulators, health economics experts, hygiene professionals and doctors should work together with industry to develop new strategies, she said.

“It is difficult, but not impossible. We are more aware of the environmental problems our world is facing and cannot deny the need to be responsible, also in the closed world of the operating room,” Tassignon said. – by Michela Cimberle and Robert Linnehan

PAGE BREAK

Disclosures: Morris, Tassignon and Venkatesh report no relevant financial disclosures.

POINTCOUNTER

At a time of increasing concern about global warming, how does the environmental impact of reusable and disposable instruments compare?

POINT

Think about reusing more, managing waste better

Pavel Stodulka

We, as ophthalmic surgeons, are polluting quite a lot. Taking into consideration how small the eye is, it is unbelievable the amount of waste we produce for a single surgical procedure. Our peers 30 years ago would not believe where we are today. I am not too old but old enough to remember the times when we had literally, with the exception of syringes, no disposable tools at all for cataract surgery, including the drapes and scrubs. All that was revolutionized in favor of disposable. It is on one side very good because it enhances safety, but on the other side we are polluting a lot and should think about that.

If I were granted a wish, I would want an environment-friendly machine to convert disposables into heat and electricity for the clinic. First, I would not have to pay for the waste to be disposed somewhere else; second, I would save on energy bills; and third, I would avoid some of the pollution produced by trucks coming in and out for the waste. I do not know what the regulations are in other countries, but in the Czech Republic all the disposable waste generated by cataract surgery — which is bloodless surgery with a low risk of infection — is considered to be an infectious hazard, and we have to put it into red boxes, label it and send it to be destroyed as a highly infectious material. This prevents us from separating materials, and yet the small plastic IOL containers are not infectious and could be piled one into the other to save space and be disposed of with the recyclable plastics. The same applies to syringes that contain only saline solution. But current rules prevent us from doing so.

One small thing I do and teach co-workers is to put the surgical gloves into the sleeve of the gown and then fold the gown tightly into its sleeve to save space in the garbage. In my clinic, we reuse the phaco handpiece and instruments such as the chopper and spatula. We use disposable syringes and cartridges, while phaco tips and cannulas are sometimes disposable and sometimes reusable. We tend to reuse some instruments because it is cost-effective, easier and more environment-friendly. At the clinic, including the OR, we run paper-free electronic medical records and have online access to diagnostic devices so there are no printouts needed for our surgical patients. We only print a final report for them as a handout.

Pavel Stodulka, MD, PhD, is an OSN Europe Edition Board Member and CEO of Gemini Eye Clinic, Zlin and Prague, Czech Republic. Disclosure: Stodulka reports he is a consultant for Bausch + Lomb.

COUNTER

Single-use products have increased patients’ safety

Paolo Lanzetta

As ophthalmologists, we have no proper answer to this question. We need experts’ advice on how to reduce greenhouse gas emissions and adopt environment-friendly surgical models. We may reduce single-use in favor of reusable instruments and scrubs, but what is the environmental impact of increased autoclave sterilization, and how much we gain in doing so, we do not know.

I am open to the adoption of new strategies for sustainable eye care as long as I do not have to compromise on patients’ safety. The introduction of single-use instruments, draping and surgical clothing has undoubtedly improved safety, and this has coincided with the advent of phacoemulsification and other breakthrough techniques. Patients have the right to be guaranteed observance of safety and quality standards, and I would not feel comfortable adopting procedures that may put patient safety at risk and not provide the best of eye care. I very much admire my colleagues of Aravind Hospital who have greatly implemented environment-friendly measures. This is a good start that should be combined with advancements in safety of surgical procedures. Obviously, we cannot recant the ABCs of OR safety.

People are nowadays becoming more conscious of how their consumption behavior is impacting the world around them. In our homes, we are adopting environment-friendly behaviors such as minimizing and separating waste, but this is thanks to years of planning, organizing and implementing laws and regulations. We need similar evidence-based planning and regulations for the operating room to implement sustainable environment-friendly practices in the OR without sacrificing safety.

Paolo Lanzetta, MD, is OSN Europe Edition Board Chairperson and head of the Ophthalmology Department, University of Udine, and scientific director of IEMO, Udine, Italy. Disclosure: Lanzetta reports no relevant financial disclosures.