Effetto antinfiammatorio del trattamento emodialitico in pazienti con malattia renale cronica allo stadio terminale e COVID-19: confronto fra due filtri dializzatori (ATA vs PMMA)

Background I filtri dializzatori ad alto flusso potrebbero mitigare la “tempesta citochinica" nell'infezione da Sars-COV-2, ma il loro impatto nei pazienti in dialisi cronica non è accertato. Lo scopo delle studio è valutare l’effetto del filtro in triacetato asimmetrico di cellulosa (ATA) e in polimetilmetacrilato (PMMA) sui marcatori infiammatori in pazienti in dialisi cronica affetti da SARS-CoV-2. Metodi Si tratta di uno studio prospettico osservazionale su pazienti in trattamento emodialitico cronicp con COVID-19 arruolati da marzo 2020 a Maggio 2021.Le variabili cliniche, la conta leucocitaria, la IL-6, la proteina C-reattiva (PCR), la procalcitonina (PCT) e la ferritina sono state determinate al basale. I valori ematici di PCR, PCT, e IL-6 sono stati determinati pre e post-dialisi per ogni seduta effettuata (i valori ottenuti sono stati corretti per ’emoconcentrazione). I pazienti sono stati trattati con emodiafiltrazione online con un filtro ad alto flusso in PMMA o ATA. L’end-point primario è stato valutare l’effetto dei due filtri sulle molecole infiammatorie, in particolare sulla reduction ratio (RR) della IL-6. Risultati Dei 74 pazienti arruolati, 48 sono trati trattati con filtro ATA e 26 con filtro PMMA (420 vs 191 sedute dialitiche). La RR percentuale mediana della IL-6 è risultata maggiore nel gruppo ATA (17,08% IQR -9,0 - 40.0 vs 2,95% IQR -34,63 – 27,32. Anche le RR percentuale di PCR e PCT sono state maggiori nel gruppo ATA. La regressione logistica multipla avente come variabile dipendente una IL-6RR maggiore del 25%, ha mostrato che ATA determinava una maggiore probabilità di raggiungere l’outcome dopo correzione per i parametri infiammatori pre-dialisi (OR 1,721 95% CI 1,176 – 2,538 p=0,0056). Al contrario una PCR elevata riduceva la probabilità di ottenere una IL-6RR significativa (OR 0,9101 95% CI 0,868 – 0,949, p<0.0001). Conclusioni Nella nostra popolazione il filtro ATA ha mostrato un migliore profilo antiinfiammatorio.

Le pressioni sui servizi sanitari (demografiche, epidemiologiche, sociali, pandemia COVID-19) e la risposta del sistema ospedaliero. Il caso studio del Policlinico S. Orsola di Bologna

I sistemi sanitari sono messi sotto stress da fattori diversi che possono essere sintetizzati schematizzando il problema in pressioni sistemiche e pressioni pandemiche leggendole secondo due vettori paralleli: fattori modificabili e fattori non modificabili. I fattori non modificabili sono legati alla condizione socio-demografica di una popolazione (reddito pro-capite, livello di istruzione) e alle caratteristiche individuali dei pazienti che accedono ai servizi (condizioni di moltimorbidità, fragilità, età, sesso) mentre i fattori modificabili sono legati al modello organizzativo del servizio regionale e Aziendale. I fattori modificabili sono quelli che leggendo i fattori non modificabili possono adattarsi al contesto specifico e con gradi di flessibilità variabile rispondere alle domande emergenti. Il tradizionale approccio ospedaliero, ancora in gran parte basato su modelli organizzativi funzionalmente e strutturalmente chiusi, costruiti attorno alle singole discipline, non si è rivelato in grado di rispondere adeguatamente da solo a questi bisogni di salute complessi che necessitano di una presa in carico multidisciplinare e coordinata tra diversi setting assistenziali. La pandemia che ha portato in Italia ad avere più di 8 milioni di contagiati ha esacerbato problemi storici dei sistemi sanitari. Le Regioni e le Aziende hanno fronteggiato un doppio binario di attività vedendo ridursi l’erogazione di servizi per i pazienti non Covid per far fronte all’incremento di ricoveri di pazienti Covid. Il Policlinico S. Orsola ha in questa congiuntura storica sviluppato un progetto di miglioramento del percorso del paziente urgente coinvolgendo i professionisti e dando loro strumenti operativi di analisi del problema e metodi per identificare risposte efficaci. Riprendendo infine la distinzione tra pressioni modificabili e non modificabili il lavoro mostra che dall’analisi delle cause profonde dei nodi critici del percorso del paziente si possono identificare soluzioni che impattino sugli aspetti organizzativi (modificabili) personalizzando l’approccio per il singolo paziente (non modificabile) in un’ottica patient centred.

La gestione delle cure oncologiche in Emilia-Romagna al tempo del COVID-19 tra lavoro invisibile e nuove pratiche di cura

L’insorgere della pandemia da COVID-19 ha comportato una pesante riorganizzazione delle strutture ospedaliere e lo stesso sistema delle cure oncologiche è stato ripensato cercando di garantire, da un lato, la sicurezza dei pazienti e del personale sanitario e, dall’altro, la continuità delle cure. Il progetto analizza l’impatto di questa riorganizzazione sulle traiettorie di malattia dei pazienti oncologici e sul lavoro di cura dei diversi attori coinvolti nella definizione di queste traiettorie. La ricerca, focalizzata sul contesto ospedaliero emiliano-romagnolo, si è svolta tramite la realizzazione di interviste qualitative a personale sanitario ospedaliero, associazioni di volontariato, pazienti e caregiver. La gestione del rischio Covid ha comportato un consistente impegno in termini di safety work da parte del personale sanitario. Inoltre, le limitazioni degli accessi agli ambienti ospedalieri, imposte come misure di sicurezza, hanno comportato l’esclusione di familiari e associazioni di volontariato dagli ospedali e, di conseguenza, una maggiore solitudine del paziente in tutte le fasi del percorso di cura. L’assistenza fornita da queste figure ricomprende una componente di “lavoro invisibile” che la situazione pandemica ha permesso di far emergere. Infatti, i familiari supportano indirettamente e informalmente il lavoro del personale sanitario all’interno dello stesso ambiente ospedaliero. I professionisti intervistati hanno riconosciuto il venir meno di questo supporto. La risposta del personale ospedaliero, e infermieristico in particolare, si è articolata in due direzioni al fine di sopperire a queste mancanze: da un lato, incrementando la componente di sentimental work, e quindi di supporto emotivo ai pazienti; dall’altro, attraverso buone pratiche orientate a rispondere ai bisogni dei pazienti, intesi non solo in senso biomedico, ma anche psicologico e relazionale. Possiamo quindi concludere che, sotto certi aspetti, la pandemia è stata contrastata con una maggiore umanizzazione delle cure oncologiche e una maggiore attenzione ai bisogni dei pazienti intesi nella loro interezza e complessità.

Differenze di genere tra le caratteristiche cliniche e outcome dei pazienti con cancro ospedalizzati per COVID-19.

Obiettivo: Lo scopo principale di questo studio è analizzare lo sviluppo di complicanze cardiovascolari (CV) nei pazienti con neoplasia e malattia moderata-severa da COVID-19 e valutare differenze di genere per il rischio di mortalità intraospedaliera o di complicanze CV. Materiali e Metodi. Popolazione oggetto di studio. Pazienti inclusi nel registro ISACS-COVID 19 (ClinicalTrials.gov: NCT05188612), dati raccolti a partire da Febbraio 2020 a Luglio 2022. I pazienti arruolati sono stati reclutati da centri ospedalieri di cinque paesi: Italia, Croazia, Macedonia, Serbia e Romania. Le caratteristiche d’inclusione comprendono: età >18 anni, essere ospedalizzati e avere diagnosi certa d’infezione da SARS-CoV2. Gli endpoint analizzati sono stati: mortalità intraospedaliera e lo sviluppo di scompenso cardiaco acuto (SCA) nei pazienti con neoplasia. Risultati. La popolazione finale oggetto dello studio era di 4,014 pazienti ospedalizzati per malattia da COVID-19. Di questi circa l’8% risultava affetto da neoplasia. I pazienti con neoplasia risultavano essere più frequentemente donne (49% vs 40%, p=0.004), con un’età media più alta (68.3±12.95 vs 65.2±15.6, p<0.001) ma con profilo di rischio CV simile ai pazienti liberi da neoplasia. A seguito di analisi logistica di regressione multivariata, le donne non risultavano avere un incremento del rischio di mortalità intraospedaliera (OR 0.83;95%CI 0.66-2.45), mentre la presenza di tumore era significativamente associata ad incremento di mortalità (OR 1.68;95%CI 1.16-2.45). Restringendo le analisi di regressione logistica ai pazienti oncologici, le donne presentavano un incremento del rischio di sviluppo di SC acuto (OR3.07;95%CI 1.14 – 8.30) così come lo era la presenza di tumore al seno (OR 2.26; 95%CI 1.38 – 12.1). Conclusioni. La presenza di neoplasia rappresenta una condizione che incrementa il rischio di mortalità intraospedaliera nei pazienti ricoverati con COVID-19, mentre il genere femminile no. Le donne sembrano avere un rischio aumentato di sviluppo di SC acuto soprattutto se presentano un tumore al seno

Advancing digital healthcare research and machine learning-aided knowledge extraction amidst the COVID-19 pandemic

The rapid progression of biomedical research coupled with the explosion of scientific literature has generated an exigent need for efficient and reliable systems of knowledge extraction. This dissertation contends with this challenge through a concentrated investigation of digital health, Artificial Intelligence, and specifically Machine Learning and Natural Language Processing's (NLP) potential to expedite systematic literature reviews and refine the knowledge extraction process. The surge of COVID-19 complicated the efforts of scientists, policymakers, and medical professionals in identifying pertinent articles and assessing their scientific validity. This thesis presents a substantial solution in the form of the COKE Project, an initiative that interlaces machine reading with the rigorous protocols of Evidence-Based Medicine to streamline knowledge extraction. In the framework of the COKE (“COVID-19 Knowledge Extraction framework for next-generation discovery science”) Project, this thesis aims to underscore the capacity of machine reading to create knowledge graphs from scientific texts. The project is remarkable for its innovative use of NLP techniques such as a BERT + bi-LSTM language model. This combination is employed to detect and categorize elements within medical abstracts, thereby enhancing the systematic literature review process. The COKE project's outcomes show that NLP, when used in a judiciously structured manner, can significantly reduce the time and effort required to produce medical guidelines. These findings are particularly salient during times of medical emergency, like the COVID-19 pandemic, when quick and accurate research results are critical.

The predictive role of the human gut microbiota in covid-19: implications for disease severity and post-covid syndrome

The COVID-19 pandemic, sparked by the SARS-CoV-2 virus, stirred global comparisons to historical pandemics. Initially presenting a high mortality rate, it later stabilized globally at around 0.5-3%. Patients manifest a spectrum of symptoms, necessitating efficient triaging for appropriate treatment strategies, ranging from symptomatic relief to antivirals or monoclonal antibodies. Beyond traditional approaches, emerging research suggests a potential link between COVID-19 severity and alterations in gut microbiota composition, impacting inflammatory responses. However, most studies focus on severe hospitalized cases without standardized criteria for severity. Addressing this gap, the first study in this thesis spans diverse COVID-19 severity levels, utilizing 16S rRNA amplicon sequencing on fecal samples from 315 subjects. The findings highlight significant microbiota differences correlated with severity. Machine learning classifiers, including a multi-layer convoluted neural network, demonstrated the potential of microbiota compositional data to predict patient severity, achieving an 84.2% mean balanced accuracy starting one week post-symptom onset. These preliminary results underscore the gut microbiota's potential as a biomarker in clinical decision-making for COVID-19. The second study delves into mild COVID-19 cases, exploring their implications for ‘long COVID’ or Post-Acute COVID-19 Syndrome (PACS). Employing longitudinal analysis, the study unveils dynamic shifts in microbial composition during the acute phase, akin to severe cases. Innovative techniques, including network approaches and spline-based longitudinal analysis, were deployed to assess microbiota dynamics and potential associations with PACS. The research suggests that even in mild cases, similar mechanisms to hospitalized patients are established regarding changes in intestinal microbiota during the acute phase of the infection. These findings lay the foundation for potential microbiota-targeted therapies to mitigate inflammation, potentially preventing long COVID symptoms in the broader population. In essence, these studies offer valuable insights into the intricate relationships between COVID-19 severity, gut microbiota, and the potential for innovative clinical applications.

Development and optimization of techniques and design parameters for the engineering of atmospheric pressure plasma devices for biomedical applications and plasma medicine

In the last decades, the possibility to generate plasma at atmospheric pressure gave rise to a new emerging field called plasma medicine; it deals with the application of cold atmospheric pressure plasmas (CAPs) or plasma-activated solutions on or in the human body for therapeutic effects. Thanks to a blend of synergic biologically active agents and biocompatible temperatures, different CAP sources were successfully employed in many different biomedical applications such as dentistry, dermatology, wound healing, cancer treatment, blood coagulation, etc.… Despite their effectiveness has been verified in the above-mentioned biomedical applications, over the years, researchers throughout the world described numerous CAP sources which are still laboratory devices not optimized for the specific application. In this perspective, the aim of this dissertation was the development and the optimization of techniques and design parameters for the engineering of CAP sources for different biomedical applications and plasma medicine among which cancer treatment, dentistry and bioaerosol decontamination. In the first section, the discharge electrical parameters, the behavior of the plasma streamers and the liquid and the gas phase chemistry of a multiwire device for the treatment of liquids were performed. Moreover, two different plasma-activated liquids were used for the treatment of Epithelial Ovarian Cancer cells and fibroblasts to assess their selectivity. In the second section, in accordance with the most important standard regulations for medical devices, were reported the realization steps of a Plasma Gun device easy to handle and expected to be mounted on a tabletop device that could be used for dental clinical applications. In the third section, in relation to the current COVID-19 pandemic, were reported the first steps for the design, realization, and optimization of a dielectric barrier discharge source suitable for the treatment of different types of bioaerosol.

mHealth-based Methods for Neuromotor Assessment and Rehabilitation

Recent years observed massive growth in wearable technology, everything can be smart: phones, watches, glasses, shirts, etc. These technologies are prevalent in various fields: from wellness/sports/fitness to the healthcare domain. The spread of this phenomenon led the World-Health-Organization to define the term 'mHealth' as "medical and public health practice supported by mobile devices, such as mobile phones, patient monitoring devices, personal digital assistants, and other wireless devices". Furthermore, mHealth solutions are suitable to perform real-time wearable Biofeedback (BF) systems: sensors in the body area network connected to a processing unit (smartphone) and a feedback device (loudspeaker) to measure human functions and return them to the user as (bio)feedback signal. During the COVID-19 pandemic, this transformation of the healthcare system has been dramatically accelerated by new clinical demands, including the need to prevent hospital surges and to assure continuity of clinical care services, allowing pervasive healthcare. Never as of today, we can say that the integration of mHealth technologies will be the basis of this new era of clinical practice. In this scenario, this PhD thesis's primary goal is to investigate new and innovative mHealth solutions for the Assessment and Rehabilitation of different neuromotor functions and diseases. For the clinical assessment, there is the need to overcome the limitations of subjective clinical scales. Creating new pervasive and self-administrable mHealth solutions, this thesis investigates the possibility of employing innovative systems for objective clinical evaluation. For rehabilitation, we explored the clinical feasibility and effectiveness of mHealth systems. In particular, we developed innovative mHealth solutions with BF capability to allow tailored rehabilitation. The main goal that a mHealth-system should have is improving the person's quality of life, increasing or maintaining his autonomy and independence. To this end, inclusive design principles might be crucial, next to the technical and technological ones, to improve mHealth-systems usability.

The human gut microbiome in disease: Role in chemotherapy treatments and relationship with clinical outcomes

The gut microbiome (GM) is a plastic entity, capable of adapting in response to intrinsic and extrinsic factors. However, several circumstances can disrupt this homeostatic balance, forcing the GM to shift from a health-associated mutualistic configuration to a disease-associated profile. Nowadays, a new frontier of microbiome research is understanding the GM role in chemo-immunotherapies and clinical outcomes. Here, the role of the genotoxin‐producing pathogen Salmonella in colorectal carcinogenesis was characterized by in-vitro models. A synergistic effect of Salmonella and the CRC-associated mutation (APC gene) promoted a tumorigenic microenvironment by increasing cellular genomic instability. Subsequently, the GM involvement in anti-cancer therapies was investigated via next-generation sequencing in different patient cohorts. The GM trajectory during treatments was characterized for women with epithelial ovarian cancer and pediatric patients undergoing hematopoietic stem cell transplantation (HSCT). The results highlighted the loss of GM homeostasis, with diversity reduction, decrease in health-associated microorganisms and pathobiont bloom. Interestingly, a distinctive GM profile was identified in ovarian cancer patients with a poor response to chemotherapy compared to patients in remission. Moreover, maintenance of GM homeostasis through enteral feeding in pediatric HSCT patients highlighted a better prognosis, with reduced risk of clinical complications. In this context, the gut resistome – the pattern of GM antibiotic-resistance genes (ARGs) – was evaluated longitudinally in HSCT patients. The results showed new acquisitions and consolidation of ARGs already present in patients developing clinical complications. Antibiotic exposure was also evaluated in infants under low-dose antibiotic prophylaxis for vesico-ureteral reflux showing an impairment of the GM configuration with possible long-term health implications. Dramatic GM dysbiosis was finally observed in critically ill patients with COVID-19 (undergoing multiple drug therapies) and correlated with increased risk of bloodstream infection. All these findings pointed out the importance of maintaining GM homeostasis during chemotherapy treatments for improving patients’ clinical outcomes.

The dark and bright side of remote work: social isolation, concentration, and performance of remote workers

This dissertation, comprised of three separate studies, focuses on the relationship between remote work adoption and employee job performance, analyzing employee social isolation and job concentration as the main mediators of this relationship. It also examines the impact of concern about COVID-19 and emotional stability as moderators of these relationships. Using a survey-based method in an emergency homeworking context, the first study found that social isolation had a negative effect on remote work productivity and satisfaction, and that COVID-19 concerns affected this relationship differently for individuals with high and low levels of concern. The second study, a diary study analyzing hybrid workers, found a positive correlation between work from home (WFH) adoption and job performance through social isolation and job concentration, with emotional stability serving respectively as a buffer and booster in the relationships between WFH and the mediators. The third study, even in this case a diary study of hybrid workers, confirmed the benefits of work from home on job performance and the importance of job concentration as a mediator, while suggesting that social isolation may not be significant when studying employee job performance, but it is relevant for employee well-being. Although each study provides autonomously a discussion and research and practical implications, this dissertation also presents a general discussion on remote work and its psychological implications, highlighting areas for future research

Instrumental and sensory analyses for the characterization of food, phytotherapeutic or pharmaceutical hemp products

To address the request to develop rapid and easy methods for determining the cannabinoids, an HPLC-UV method (8 min) to separate and quantify the 10 main cannabinoids in hemp inflorescences was developed, and in-house validated. Moreover, the antioxidant activity of cannabidiol (CBD) in two oily matrices was investigated and compared to that of α-tocopherol, in relation to the growing market of oily solutions containing cannabidiol. Then, since no univocal legislation on the evaluation of quality and authenticity of hemp seed oil (HSO) exists, the composition and quality of cold-pressed HSOs were also explored, highlighting a great variability in terms of oxidative state minor compounds content. From the sensory point of view, a panel was trained, a specific sensory wheel and a profile sheet were developed. Due to the Covid-19 pandemic, the sensory evaluation was also performed at home. The panel showed a good performance both in the laboratory and remotely. Moreover, a focus group was used to investigate consumers’ attitudes, pointing out that a high-quality HSO has to be cold-pressed and green for them. Then, the evaluation of stability during the storage of HSOs was investigated. The results showed that photo-oxidation did not seem to significantly affect the quality of the oil during the first 3 months of storage. Finally, a study about the evolution of the volatile profile of 9 HSOs, under accelerated oxidation conditions, allowed identifying volatile markers of HSOs oxidation and freshness. This Ph.D. was developed in the context of the scholarship “Harmonized procedures of analysis of medical, herbal, food and industrial cannabis: development and validation of cannabinoids’ quality control methods, of extraction and preparation of derivatives from the plant raw material, according to the product destination” funded by Enecta S.r.l.

Applications of network-based approaches in drug research

Recent research trends in computer-aided drug design have shown an increasing interest towards the implementation of advanced approaches able to deal with large amount of data. This demand arose from the awareness of the complexity of biological systems and from the availability of data provided by high-throughput technologies. As a consequence, drug research has embraced this paradigm shift exploiting approaches such as that based on networks. Indeed, the process of drug discovery can benefit from the implementation of network-based methods at different steps from target identification to drug repurposing. From this broad range of opportunities, this thesis is focused on three main topics: (i) chemical space networks (CSNs), which are designed to represent and characterize bioactive compound data sets; (ii) drug-target interactions (DTIs) prediction through a network-based algorithm that predicts missing links; (iii) COVID-19 drug research which was explored implementing COVIDrugNet, a network-based tool for COVID-19 related drugs. The main highlight emerged from this thesis is that network-based approaches can be considered useful methodologies to tackle different issues in drug research. In detail, CSNs are valuable coordinate-free, graphically accessible representations of structure-activity relationships of bioactive compounds data sets especially for medium-large libraries of molecules. DTIs prediction through the random walk with restart algorithm on heterogeneous networks can be a helpful method for target identification. COVIDrugNet is an example of the usefulness of network-based approaches for studying drugs related to a specific condition, i.e., COVID-19, and the same ‘systems-based’ approaches can be used for other diseases. To conclude, network-based tools are proving to be suitable in many applications in drug research and provide the opportunity to model and analyze diverse drug-related data sets, even large ones, also integrating different multi-domain information.

Small Area Estimation of Economic Security

The objective of this thesis is the small area estimation of an economic security indicator. Economic security is a complex concept that carries a variety of meanings. In the literature there is no a formal unambiguous definition for economic security and in this work we refer to the definition recently provided for its opposite, economic insecurity, as the “anxiety produced by the possible exposure to adverse economic events and by the anticipation of the difficulty to recover from them” (Bossert and D’Ambrosio, 2013). In the last decade interest for economic insecurity/security has grown constantly, especially since the financial crisis of 2008, but even more in the last year after the economic consequences due to the Covid-19 pandemic. In this research, economic security is measures through a longitudinal indicator that takes into account the income levels of Italian households, from 2014 to 2016. The target areas are groups of Italian provinces, for which the indicator is estimated using longitudinal data taken from EU-SILC survey. We notice that the sample size is too low to obtain reliable estimates for our target areas. Therefore we resort to some Small Area Estimation strategies to improve the reliability of the results. In particular we consider small area models specified at area level. Besides the basic Fay-Herriot area-level model, we propose to consider some longitudinal extensions, including time-specific random effects following an autoregressive processes of order 1 (AR1) and a moving average of order 1 (MA1). We found that all the small area models used show a significant efficiency gain, especially MA1 model.

Collective actions for environmental monitoring and conservation: citizen science, informal environmental education, and participatory approach

This PhD was driven by an interest for inclusive and participatory approaches. The methodology that bridges science and society is known as 'citizen science' and is experiencing a huge upsurge worldwide, in the scientific and humanities fields. In this thesis, I have focused on three topics: i) assessing the reliability of data collected by volunteers; ii) evaluating the impact of environmental education activities in tourist facilities; and iii) monitoring marine biodiversity through citizen science. In addition to these topics, during my research stay abroad, I developed a questionnaire to investigate people's perceptions of natural areas to promote the implementation of co-management. The results showed that volunteers are not only able to collect sufficiently reliable data, but that during their participation in this type of project, they can also increase their knowledge of marine biology and ecology and their awareness of the impact of human behaviour on the environment. The short-term analysis has shown that volunteers are able to retain what they have learned. In the long term, knowledge is usually forgotten, but awareness is retained. Increased awareness could lead to a change in behaviour and in this case a more environmentally friendly attitude. This aspect could be of interest for the development of environmental education projects in tourism facilities to reduce the impact of tourism on the environment while adding a valuable service to the tourism offer. We also found that nature experiences in childhood are important to connect to nature in adulthood. The results also suggest that membership or volunteering in an environmental education association could be a predictor of people's interest in more participatory approaches to nature management. In most cases, the COVID -19 pandemic had not changed participants' perceptions of the natural environment.

Le ricadute dei vincoli di bilancio europei sugli Enti territoriali. Nuove norme per la stabilità.

La disciplina del pareggio di bilancio è in continua evoluzione, soprattutto a fronte delle nuove esigenze finanziarie per contrastare la pandemia. Questo elaborato, studiando la governance economica strutturata dopo la crisi dei debiti, le derivanti scelte italiane in materia di costituzionalizzazione del pareggio di bilancio e le conseguenze sulle autonomie locali, dimostra come il sistema di gestione delle finanze pubbliche a livello comunitario si stia completando, generando un rapporto normativo ciclico tra il livello europeo e quello locale. Ne è emersa una conflittualità tra le Regioni e lo Stato, che è analizzata al fine di comprendere la giustiziabilità costituzionale del pareggio di bilancio, osservando le esigenze di bilanciamento tra l’equilibrio finanziario e la tutela dei diritti sociali. La Corte Costituzionale ha recentemente conferito, in via giurisprudenziale, alla Corte dei Conti la potestà di svolgere un controllo diretto di costituzionalità del rispetto dell’equilibrio di bilancio degli enti nazionali e territoriali. Particolare attenzione viene data, poi, a seguito degli effetti della pandemia da Covid-19 sui bilanci degli Stati. A fronte della crisi pandemica, per la prima volta dall’approvazione del TSCG, la Commissione ha attivato la clausola di salvaguardia generale per sospendere il Patto di Stabilità (c.d. escape clause). Questa clausola ha permesso ai Paesi di ricorrere agli scostamenti di bilancio. Viene infine analizzato il piano “Next Generation EU”, che centralizza i prestiti verso gli Stati membri nel bilancio dell’Unione ed attinge dal mercato dei capitali le risorse necessarie per finanziare un totale di 750 miliardi, attraverso l’emissione di obbligazioni “Eu Bills”. Per la prima volta nella storia, l’Unione, nelle parole della Commissione, agisce sui mercati come se fosse uno Stato. La portata straordinaria del NGEU, con l’emissione di titoli europei, porta ad una sostanziale mutualizzazione dei debiti ed appare come un passo fondamentale verso il completamento dell’UEM e di un sistema federale.