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The integration of Building Information Modeling (BIM) with intelligent optimization techniques can significantly enhance the design efficiency of water distribution networks (WDNs). Despite this, the dynamic interoperability between BIM platforms and hydraulic simulation tools remains limited. This study introduces DyEHS (Dynamo–EPANET–Harmony Search), a novel workflow integrating Autodesk Civil 3D, EPANET, and Harmony Search via Dynamo, to address this gap. DyEHS enables the automated optimization of pipe diameters and network layouts, aiming to minimize capital costs while satisfying hydraulic constraints. In a real-world case study, DyEHS achieved a 15% reduction in the total pipe network costs compared to traditional uniform-diameter designs, while ensuring that all nodes maintained a minimum pressure of 25 m. This quantifiable improvement highlights the tool’s potential for practical engineering applications, offering a robust, adaptable, and fully integrated BIM-based solution for WDN design.

Background Treatment-resistant depression (TRD) is defined by the European Medicines Agency as a lack of clinically meaningful improvement after treatment, with at least two different antidepressants. Individual, familiar, and socio-economic burden of TRD is huge. Given the lack of clear guidelines, the large variability of TRD approaches across different countries and the availability of new medications to meet the need of effective and rapid acting therapeutic strategies, it is important to understand the consensus regarding the clinical characteristics and treatment pathways of patients with TRD in Italian routine clinical practice, particularly in view of the recent availability of esketamine nasal spray. Methods A Delphi questionnaire with 17 statements (with a 7 points Likert scale for agreement) was administered via a customized web-based platform to Italian psychiatrists with at least 5 years of experience and specific expertise in the field of depression. In the second-round physicians were asked to answer the same statements considering the interquartile range of each question as an index of their colleagues’ responses. Stata 16.1 software was used for the analyses. Results Sixty panellists, representative of the Italian territory, answered the questionnaire at the first round. For 8/17 statements more than 75% of panellists reached agreement and a high consensus as they assigned similar scores; for 4 statements the panellists assigned similar scores but in the middle of the Likert scale showing a moderate agreement with the statement, while for 5 statements there was indecision in the agreement and low consensus with the statement. Conclusions This Delphi Panel showed that there is a wide heterogeneity in Italy in the management of TRD patients, and a compelling need of standardised strategies and treatments specifically approved for TRD. A high level of consensus and agreement was obtained about the importance of adding lithium and/or antipsychotics as augmentation therapies and in the meantime about the need for long-term maintenance therapy. A high level of consensus and agreement was equally reached for the identification of esketamine nasal spray as the best option for TRD patients and for the possibility to administrate without difficulties esketamine in a community outpatient setting, highlighting the benefit of an appropriate educational support for patients.

Major Depressive Disorder (MDD) with suicidal ideation, intent, or behavior is a psychiatric emergency with controversial care management. Our study describes the comprehensive treatment pathways of this population in Italian routine clinical practice. ARIANNA [NCT 04463108] is an observational prospective and retrospective cohort study involving both primary data collection and secondary data extract. A total of 137 adult MDD patients with suicidality were enrolled from 24 Italian care sites and followed for 90 days. Other than the description of treatment patterns, the impact of treatment on depressive symptoms and suicidality, the burden on the patient's and caregiver's quality of life, healthcare resource utilization and costs were described. Of the 133 eligible patients, 68.4% were female, and the median age was 47. Approximately half of the study population had a current severe major depressive episode. Treatment strategies at the time of active suicidal ideation with intent definition/confirmation (t0) were heterogeneous, increasing in complexity during observation. According to the MADRS, patients with remission at t0+1 day were 2.6%, with the mean total score decreasing from 37.2 at t0 to 32.3. The study sites were not randomly selected. To the best of our knowledge, this is the first cohort study that prospectively describes the characteristics of patients with MDD and suicide risk in Italy, and how they are treated in clinical practice. The study confirms this is a difficult-to-treat population. In addition, a lack of rapid, effective treatment for reducing depressive symptoms and suicidality is observed. •First hybrid-design study describing patients with MDD and suicide risk in Italy.•At the confirmation of suicidality, a change in MDD treatment strategy occurred.•Comprehensive treatments administered in this critical population are heterogenous.•During the 90-day follow-up, about 48% of patients had depressive symptoms' remission.•Healthcare resource consumption is high and driven by hospitalizations.

The increasing frequency of extreme rainstorms due to climate changes calls for cost-effective methodologies to optimize drainage networks and flood risk mitigation practices. This paper presents an effective methodology that combines two well-known methods to optimize the drainage network design. The methodology uses the Harmony Search algorithm to identify the best solution for the drainage network and the simulations obtained through the Storm Water Management Model to verify the respect of the hydraulic constraints. The methodology is applied to the literature case study of Anytown, showing a significant reduction of 34.5% of the drainage network design cost compared with the common Rational Method. Moreover, the methodology is able to identify the optimum allocation and volumes of detention ponds for runoff control in case of variations in rainfall regime. The methodology allowed to prevent floods, by decreasing the channel filling degree.

Background Laparoscopic cholecystectomy (LC) is a frequent operation in adults but is seldom performed in children. A retrospective review of 109 consecutive patients who underwent LC over an 11-year period was performed to see what lessons were learned from this experience. Methods From January 1996 to January 2007, a total of 109 patients were referred to our unit to undergo LC. Nine adult patients were excluded from the analysis. The remaining 100 pediatric patients form the basis of this report. Isolated cholecystectomies were performed using a four-trocar technique, with a fifth trocar added for cases in which splenectomy was required. One patient with main bile duct dilatation at preoperative echography underwent peroperative cholangiography. Results We recorded three anatomic anomalies (3%), two involving the bile duct and one the cystic artery. We recorded four minor problems during surgery: In one case there was failure of the tip of reusable scissors, and in three cases there was a small perforation of the gallbladder during the dissection step. We recorded four (4%) postoperative complications, which required redo surgery: one patient with bleeding from the cystic artery; one case of dislocation of clips positioned on the cystic duct; and two patients with lesions of the main bile duct that had not been detected during surgery. The treatment consisted in choledojejunostomy on postoperative day 7 in one case and suture of the choledocus on a stent positioned using endoscopic retrograde cholangiopancreatography on postoperative day 5 in the second case. Both biliary complications occurred in patients more than 14 years of age. We also recorded one umbilical granuloma. Conclusions LC is an effective procedure in children . On the basis of our experience, it seems that major complications can occur even with experienced surgeons, and they are more frequent in teenagers. Biliary or vascular anomalies of the gallbladder are encountered in about 3% of patients.