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Cardiac amyloidosis, in the three forms of immunoglobulin light chain (AL), transthyretin (ATTR) wild type (ATTRwt) and mutated (ATTRv) amyloidosis, is an increasingly known and recognized disease in the cardiovascular setting. The first stage of the patient's journey is the clinical suspicion of the disease, which is placed, in presence of a hypertrophic phenotype, by the identification of red flags, both extracardiac and cardiac clues whose presence increase the probability of being faced with a patient with this disease. The second stage is represented by diagnosis, which occurs with certainty through the identification of amyloid substance in cardiac tissue. This stage is spotted in wo parts, i.e. disease confirmation and disease etiology definition (AL vs ATTRwt vs ATTRv). However, it is possible in some selected cases to make a diagnosis of ATTR without the need for tissue assessment, in presence of a positive grade 2-3 bisphosphonate scintigraphy and absence of monoclonal component. Once the diagnosis has been made, the third stage is the assessment of prognosis, the fourth is the patient therapy pathway and fifth is the follow-up plan. Prognosis evaluation is based on different staging systems at the onset of the disease, whose applicability in the era of new effective therapies is still to be defined. To date, the transthyretin tetramer stabilizer tafamidis is the only approved treatment for both wild-type and mutant ATTR cardiomyopathy without polyneuropathy, while ATTRv with associated neuropathy can benefit from treatment with patisiran, an inhibitor of hepatic protein synthesis. Therapies for complications and comorbidities, must be addressed individually, due to the lack of specific clinical trials on this category of patients. In fact, it is important to take into consideration the risks linked to the use of some drugs due to the infiltration of the conduction tissue by the amyloid substance, which increases the risk of bradycardia and heart blocks, the tendency towards hypotension and the increased thromboembolic risk. It is also essential to follow the course of the disease and the efficacy of the treatment in affected patients with a standardized follow-up, and to identify early the signs/symptoms of the disease in asymptomatic TTR mutation carriers.This ANMCO position paper on amyloidosis aims to provide the clinical cardiologist with a practical summary of the disease, to accompany the patient with amyloidosis in the various stages of his journey.

According to the progressive increase in the number of medical records checked by the Agenzia di Tutela della Salute (ATS) of the Metropolitan City of Milan, the San Raffaele Hospital established a Unit supporting healthcare personnel in clinical documentation management. Therefore, in 2003 the Servizio Valutazione Appropriatezza della Documentazione clinica (SVAD), consisting of a nursing staff highly qualified in checking the appropriateness of clinical pathways, completeness and correctness of the clinical documentation and appropriate coding in the hospital discharge cards, was set up in the Health Directorate. Since 2018, the Service has seen an increase in resources, a re-organization and integration with the Operating Units. The aim of the article is to describe the introduction of a new organizational model and the results obtained, with reference to the quality self-control carried out for the ATS. In order to conduct a descriptive analysis of the trend, the sample data, required by the ATS in the three-year period 2018-2020, stratified by outcome and consequent percentage of reduction on the reimbursement of hospitalization, were considered. We observe an overall percentage increase in medical records without any reduction from 2018 to 2020, going from 84% to 94% (+ 10%); at the same time, there is a constant trend of medical records with complete curtailment between 2018 and 2019, while there is a reduction between 2019 and 2020, going from 4% to 2% (-2%). The positive results demonstrate the essential role of SVAD and consolidate an alternative career for nursing staff.

"Sex and gender medicine" is the original name of gender medicine. It is important to define medical concepts without ignoring key terminology. The purpose of "sex and gender medicine" is to focus on both sex and gender differences, to analyze how these two sides of the human being overlap and, finally, to improve their medical understanding. On the one hand sex, besides defining male and female, refers to the biological differences among humans, animals, tissues and cells. On the other, the concept of gender is applicable only to humans, and includes identity, roles and relations in the society. However, despite its 20 years of history, gender medicine is still little known. Biological differences among cardiovascular diseases are ignored. Symptoms and their expressions, which may be different in women, are often described as "atypical" because of the masculine vision of the heart attack and pain. Similarly, anxious syndrome is often conceived as the first reason to explain chest discomfort in women. In reality, prejudices and vagueness around women still dominate prevention and medical treatment. Our objective is to distinguish the concepts of sex and gender in order to understand the best way to face differences and medical knowledge in both.

Introduction: The management of workers with mental disability is a current topic of great interest. The aim of the article is to report the experience of managing cases of employees with mental disabilities in an Italian university hospital and to describe the preventive measures adopted and the therapeutic programs carried out., Methods: A group of 100 workers suffering from psychiatric disorders has been included in a medical surveillance program lasting at least 6 months. The workers were followed up within a protocol that included psychiatric visits, psychotherapeutic interventions, visits by the occupational physician and medico-legal evaluations. Evaluation scales of disease severity and treatment efficacy (CGI) and overall functioning (GAF) were administered at the baseline and after 6 months of follow-up., Results: The sample was mainly composed of nurses (44%) and nursing assistants (24%) and the most commonly diagnosed disorders were mood and anxiety disorders. Participation in the medical surveillance program with the implementation of specific therapeutic strategies and organizational interventions resulted in a statistically significant reduction in the severity of the disease and an improvement in overall functioning and made it possible to keep the job and place of work in almost all cases., Discussion: The results of this experience allow us to affirm that the integration of skills is a valid tool both for the multidisciplinary diagnostic assessment and for the monitoring and management of workers with mental disability under periodic health surveillance.

Introduction: The administration of adequate nutritional intake, from the first days of life, is of fundamental importance in the management of the newborn extremely low birth weight (ELBW): parenteral nutrition (PN), as a support for early enteral feeding, plays a central role in the attempt to guarantee a quantitative and qualitative growth similar to that of the fetus in utero, allowing an adequate caloric, macro and micronutrient intake. The standardized PN, carried out through pre-established bags, allows in the case in which is not possible a personalized preparation, balanced nutritional contributions, reducing the risk of microbiological contamination and errors in preparation., Clinical Case: We describe the case of an extremely preterm infant with various co-morbid conditions (severe respiratory syndrome, cerebral hemorrhage, anemia, sepsis and patency of the arterial duct) in which PN was used in a pre-established bag, as a support to enteral feeding in the first weeks of life, characterized by extreme clinical instability., Conclusions: PN is essential for some types of newborns and in particular for the ELBW preterms in which enteral feeding, although undertaken early, does not guarantee the necessary contributions to promote adequate growth. The use of NP in a pre-made bag can be a valid alternative to individualized formulations, where not available.

Il diabete rappresenta una patologia in costante aumento: familiarità, età e stili di vita rappresentano i principali fattori di rischio per questa malattia e per le complicanze ad essa correlate. Considerando l'importanza del regime alimentare per la prevenzione e il trattamento di questa patologia, scopo del presente studio è stato quello di valutare le conoscenze alimentari di pazienti al primo accesso presso un centro di Diabetologia e di indagare sulla loro eventuale influenza su alcuni parametri ematici. È stato somministrato il questionario di Moynihan. La relazione tra i punteggi ottenuti e le variabili emoglobina glicata, BMI, glicemia a digiuno, è stata analizzata attraverso regressione multipla basata sul metodo dei minimi quadrati ordinari (modello OLS). Il response rate è stato del 73,3%. Il punteggio medio totale ottenuto dal questionario è stato di 23,61 ed è stata osservata una correlazione statisticamente significativa (p<0,0473) tra i migliori punteggi del questionario e i valori di Hb1Ac. Questo studio è il primo passo di un'indagine più ampia che verrà condotta nell'ottica di promuovere una formazione del paziente volta a verificare nel tempo le ricadute positive sulle scelte alimentari e sui parametri clinici.

Background: Percutaneous ventricular assist devices (pVADs) are frequently used for the treatment of patients with cardiogenic shock (CS) due to acute myocardial infarction (AMI) and as a support in percutaneous coronary intervention (PCI) for high-risk patients. CS is a clinical condition characterized by inadequate tissue perfusion due to cardiac dysfunction and for 80% of cases it is caused by AMI with left ventricular insufficiency. CS is responsible for about 50% of deaths in patients with myocardial infarction. Usually, PCIs do not require hemodynamic support, which could be however necessary in patients undergoing high-risk PCI. Presently, available pVADs in Europe are Impella 2.5, Impella CP, HeartMate PHP, TandemHeart, PulseCath iVAC2L. The aim of this review is to evaluate the efficacy and safety of pVADs in patients with refractory CS complicating AMI or undergoing high-risk PCI., Methods: We systematically searched for randomized controlled trials (RCTs) and controlled observational studies in PubMed, Embase and PubMed CENTRAL databases until September 2018. We included studies comparing pVADs with intra-aortic balloon pumps (IABP) or medical therapy in patients with CS complicating AMI or undergoing high-risk PCI. Researchers independently assessed records' eligibility, inclusion and methodological quality of included studies. If possible, data of included studies was combined in a meta-analysis. Risk ratio (RR) and 95% confidence interval (CI) were calculated using a random effects model., Results: Overall, 8 studies were included. Five studies (3 RCTs and 2 observational studies) evaluated pVADs in patients with SC complicating AMI. Meta-analyses showed that 30-day mortality did not differ between patients treated with pVADs and the control group (RR 1.05, 95% CI 0.84-1.31). However, risk of major bleeding was 2 times higher in patients treated with pVADs compared to controls. Three studies evaluated pVADs in patients undergoing high-risk PCI. Due to the lack of data, it was not possible to combine study results in a meta-analysis. One RCT reported no difference in 30- and 90-day mortality between patients randomized to Impella or IABP. Two non-randomized controlled studies reported no difference in terms of in-hospital all-cause mortality between the two groups., Conclusions: Our meta-analysis suggests similar results in terms of efficacy and safety between pVADs and control (IABP and medical therapy) for the treatment of patients with CS complicating AMI or undergoing high-risk PCI.

Introduction: Cement-based material containing asbestos was found in the water of a pond in the city of Milan, Italy, where recreational fishing activities take place. Some fishes are in 'no-kill' fishing areas, others are caught and consumed., Objective: To verify the presence of asbestos in water, sediments and some fish species living in the pond. To verify the presence of asbestos in fish feed and to test fish exposure by ingestion., Methods: Samples of water, sediments, fish feed and fish species have been collected and the presence of asbestos fibers has been ascertained in the different matrices., Results: No traces of asbestos were found in water. Instead, the asbestos content in sediments was beyond regulatory limits. Asbestos was detected also in benthic fish species, and in rainbow trout (Oncorhynchus mykiss) that does not reproduce in the pond but must be restocked periodically through aquaculture. In the meat of the grass carp (Ctenopharyngodon idella) 36,000,000 fibers/100 g of wet cloth have been found. Values up to 15,000,000 ff/100 g of wet cloth have been detected in the rainbow trout. Asbestos has also been found in animal feeds, in particular crocidolite fibers and asbestos tremolite bundles., Conclusions: Benthic fish species have likely been contaminated by their close contact with the polluted bottom of the pond. Instead, the presence of asbestos in the trout is probably linked to a previous contamination during farming, since this fish spend a brief period of time in the water of the pond. Asbestos distribution and concentration exclude a risk for public health; however, some values of asbestos found in fish meat deserve attention. Accordingly, precautionary indications have been given to the Municipality of Milan and to the fishermen association. A larger scale monitoring of water, food and animal feed is worth performing to better assess exposure by ingestion.

Introduction and Objectives: This volume provides an update of the health status of the populations living in the National Priority Contaminated Sites (NPCSs) included in the SENTIERI Project. This update is part of an epidemiological surveillance programme carried out in NPCSs, promoted by the Italian Ministry of Health as a further step of a project started in 2006, when the health status of residents in contaminated sites was first addressed within the National Strategic Program "Environment and Health". The Report focuses on five health outcomes: mortality, cancer incidence, hospital discharges, congenital anomalies, and children, adolescents and young adults' health. A key element of SENTIERI project is the a priori evaluation of the epidemiological evidence of a causal association between the considered cause of disease and the exposure. When an a priori evidence is identified, it is given a greater importance in the comment of the study findings., Methods: The present update of the SENTIERI Project concerns 45 NPCSs including in all 319 Italian Municipalities (out of over 8,000 Municipalities), with an overall population of 5,900,000 inhabitants at the 2011 Italian Census. Standardized Mortality Ratios (SMRs) and Standardized Hospitalization Ratios (SHRs), referring to a time window of 2006-2013, were computed for all the 45 NPCSs, using as a reference the corresponding mortality and hospitalization rates of the Regions where each NCPS is located. Standardized Incidence Ratios (SIRs) were computed by the Italian Association of Cancer Registries (AIRTUM) for the 22 NPCSs served by a Cancer Registry. AIRTUM covers about 56% of Italy, with partly different time-windows. SIRs have been estimated using as reference population the 4 macroareas in which Italy is divided (North-West, North-East, Centre, South). Prevalence of congenital anomalies was computed for 15 NPCSs., Results: An all-cause excess of 5,267 and 6,725 deaths was observed, respectively, in men and women; the cancer death excess was of 3,375 in men and 1,910 in women. It was estimated an excess of cancer incidence of 1,220 case in men and 1,425 in women over a five-year time window. With regard to the diseases with an a priori environmental aetiological validity, an excess for malignant mesothelioma, lung, colon, and gastric cancer, and for non-malignant respiratory diseases was observed. Cancer excess mainly affected NPCSs with presence of chemical and petrochemical plants, oil refineries, and dumping hazardous wastes. An excess of non-malignant respiratory disease was also detected in NPCSs in which steel industries and thermoelectric plants were present. An excess of mesothelioma was observed in NPCSs characterized by presence of asbestos and fluoro-edenite; it was also observed where the presence of asbestos was not reported in the legislative national decrees which define the NPCS areas. It is worth noting that, even if the presence of asbestos is not reported in many NPCSs legislative decrees, petrochemical plants and steel industries, for instance, are often characterized by the presence of a large amount of this mineral that, in the past, was extensively used as an insulating material. For the first time, the present Report includes a focus on the health status of children and adolescents (1,160,000 subjects, aged 0-19 years), and young adults (660,000 subjects, aged 20-29 years). Among infants (0-1 year), an excess of 7,000 hospitalizations was observed, 2,000 of which due to conditions of perinatal origin. In the age class 0-14, an excess of 22,000 hospitalizations for all causes was observed; 4,000 of them were due to acute respiratory diseases, and 2,000 to asthma. Data on cancer incidence for subjects aged 0-24 years were derived from general population cancer registries for twenty NPCSs, and from children cancer registries (age group: 0-19 years) for six NPCSs; 666 cases where diagnosed in the age group 0-24 years, corresponding to an excess of 9%. The main contributions to this excess are from soft tissue sarcomas in children (aged 0-14 years), acute myeloid leukaemia in children (aged 0-14 years) and in the age group 0-29 years, non-Hodgkin lymphoma and testicular cancer in young adults (aged 20-29 years). In seven out of 15 NPCSs, an excess prevalence rate of overall congenital anomalies at birth was observed. Congenital anomalies excesses included the following sites: genital organs, heart, limbs, nervous system, digestive system, and urinary system., Conclusions: The main findings of SENTIERI Project have been the detection of excesses for the diseases which showed an a priori epidemiological evidence of a causal association with the environmental exposures specific for each considered NPCS. These observations are valuable within public health, because they contribute to priority health promotion activities. Looking ahead, the health benefits of an improved environmental quality might be appreciated in terms of reduction of the occurrence of adverse health effects attributable to each Site major pollutant agents. Due to the methodological approach of the present study, it was not possible to adjust for several confounding factors reported to be risk factors for the studied diseases (e.g., smoking, alcohol consumption, obesity). Even if excesses of mortality, hospitalization, cancer incidence, and prevalence of congenital anomalies were found in several NPCSs, the study design and the multifactorial aetiology of the considered diseases do not permit, for all of them, to draw conclusions in terms of causal links with environmental contamination. Moreover, it must be taken into consideration that economic factors and the availability of health services may also play a relevant role in a diseases outcome. A few observations regarding some methodological limitations of SENTIERI Project should be made. There is not a uniform environmental characterisation of the studied NPCSs in term of quality and detection of the pollutants, because this information is present in different databases which at present are not adequately connected. Moreover, the recognition of a contaminated site as a National Priority Site is based on soil and groundwater pollution, and the available information on air quality is currently sparse and not homogenous. Another limitation, in term of statistical power, is the small population size of many NPCSs and the low frequency of several health outcomes. A special caution must be paid in data interpretation when considering the correspondence between the contaminated areas and the municipality boundaries, as they do not always coincide perfectly: in some cases, a small municipality with a large industrial site, while in other settings only a part of the municipality is exposed to the sources of pollution. Furthermore, all available health information systems are currently accessible at municipality level. The real breakthrough is essentially comprised of the development and fostering of a networking system involving all local health authorities and regional environmental protection agencies operating in the areas under study. The possibility to integrate the geographic approach of SENTIERI Project with a set of ad hoc analytic epidemiological investigations, such as residential cohort studies, case control studies, children health surveys, biomonitoring surveys, and with socioepidemiological studies, might greatly contribute to the identification of health priorities for environmental remediation activities. Finally, as discussed in the last section of the report, there is a need to adopt, in each NPCS, a two-way oriented communication plan involving public health authorities, scientific community, and resident population, taking into account that the history, the cultural frame and the network of relationships specific of each local context play a major role in the risk perception perspective.

Background: The epidemiological data on the incidence of congenital heart defects derive from retrospective registries based on birth discharge codes with methodological limits and different selection criteria. Our aim was to determine the actual incidence of congenital heart defects in the first year of life in a population of residents in a province of Tuscany, Italy., Methods: This prospective study was conducted in 31 185 newborn residents in the province, enrolling a consecutive population throughout the first year of life and followed up at least for one year. The population cohort was controlled and merged with a retrospective research of the diagnostic codes derived from hospital discharge records of the region of Tuscany., Results: A congenital heart disease was suspected in 10 167 newborns, 32.6% of all live births. Overall, 524 defects were diagnosed (5.2% of the exams), with an incidence at birth of 16.8/1000/year (M/F ratio 0.84). Isolated ventricular septal defects were 343 and 198 spontaneously closed within one year, therefore, the total number dropped to 326 with a one-year incidence of 10.35/1000/year. Besides ventricular septal defects, the most common defects were atrial septal defects (7.3%), followed by ductus arteriosus (4.2%), aortic coarctation (4%), pulmonary stenosis (3.3%) and tetralogy of Fallot (3.1%)., Conclusions: The one-year inclusion period and follow-up allowed us to exclude those defects whose hemodynamic significance is not clear at birth, or are spontaneously reversible within the first year of life. Nevertheless, with the inclusion of defects not evident at birth, congenital heart defects are still common.

Objectives: to estimate the health impact of asbestos fibres naturally occurring in Mount Pollino area (Basilicata Region, Southern Italy)., Design: geographic mortality, hospitalization, and incidence study. Setting and participant s: population resident in 12 Municipalities of Mount Pollino area with naturally occurring asbestos fibres., Main Outcome Measures: standardized mortality ratio (SMR) and standardized hospitalization rate (SHR) for asbestos-related diseases; standardized incidence ratio (SIR) for mesotheliomas. Result s: in the area of Mount Pollino, where asbestos fibres naturally occur, especially in the sub-area in which fibres are close to dwellings and settlements, it was observed: • a significant excess of mesothelioma incidence (SIR: 208; CI95% 111-355; 13 observed); • a non-significant excess of hospitalization for malignant pleural neoplasms (SHR: 176; CI95% 93-335; 9 observed); • a significant excess for mortality and hospitalization for pneumoconiosis (SMR: 534; CI95% 345-824; 20 observed - SHR: 245; CI95% 149-405; 15 observed); • a significant excess for hospitalization (SHR: 852; CI95% 290-2,506; 3 observed) for asbestosis., Conclusion: it is necessary to continue environmental monitoring and environmental remediation in the area with higher asbestos exposure. It is suggested to implement a permanent process of epidemiological surveillance in this same area. A communication plan with local administrators, general practitioners, school teachers, media, and the resident population at large should be realized.

Introduction: In recent years, Italy has seen a reduction in workplace accidents due to several factors, including the controls carried out by the Health and Safety at Work Services (PSAL) of the Local Health Units (ATS)., Objective: To verify the contribution of PSAL Services to injury reduction. In particular, to identify the existence of a difference between incidence rates of accidents in companies before and after inspections and possible variations in rates between inspected and non-inspected companies., Methods: We analyzed data of the activities carried out by the PSAL Services of the Lombardy Region in the system I.M.Pre.S@ (Computerization and Health Prevention Monitoring) in the period 2010-2015, together with data from the Regional Accident Database of the National Institute for Insurance against Accidents at Work (INAIL). The "difference in difference" (DID) method was used to evaluate the different effect on inspected and non-inspected industries., Results: Between the pre- and post-vigilance periods, inspected companies showed a greater reduction either of total injury rates (DID=-2.7 per 1000 worker-years; 90% confidence interval (CI): -4.1; -1.3) or of severe injury rates (DID=-1.1; 90% CI: -1.7; -0.5). These effects were visible in the majority of ATS and occupational sectors., Conclusions: This study, made possible by a valid and efficient regional data tracking system, has shown the positive effect of the PSAL prevention actions on the frequency of both total and severe injuries.

Introduction: The review aimed to identify and analyse the future development on the topic by analysing the main themes discussed in number of scientific journal focused on Mental Health both by nurses and physicians.., Method: 4 international journals focused on Mental health and psychiatry International Journal of Mental Health Nursing, Archives of Psychiatric Nursing, American Journal of Psychiatry, Australian and New Zeland Journal of Psychiatry as well as two journal focused generically on health, Journal of Advanced Nursing and Lancet were scrutinized. We have analysed the papers of 2012-2015 for the specialised journals and last and first 6 months of 2012 and 2013 and 2014-2015 for the generic. Editorials, comments and contributions regarding theoretical models were exluded. From the analysis we identified 9 themes and for each theme the pertinent category. For the diagnostic grouping we used the International Statistical Classification of Diseases and Related Health Problems 10th Revision., Results: A trend in research about mood disorders, schizophrenia and addictions and comorbidity emerged according to the 2099 abstracts analysed. Within medical research antidepressants were the most studied psychotropic medication and cognitive behaviour therapy was the most studied psychotherapy. Within nursing research: the nurse-patient relationship, adherence and monitoring of pharmacological therapy, the treatment planning and the working environment, the nursing training and its efficacy. The clinical research trials were twice as frequent in the medical versus nursing research where qualitative research prevails., Conclusion: The research challenge will be to find a new paradigm fit for the future psychiatry having at its disposition the patient's genoma, and needing to routinely use biomarkers for a personalised therapy. A further challenge might be the promotion of interprofessional research between doctors and nurses and the acquisition of new competences of health professionals needed to tackle the reduced life expectancy of psychiatric patients and to address not only their mental illnesses but also their physical ailments.

The cohort study aims to test the hypothesis of an association between specific exposure/s and adverse health outcomes. The cohorts include the subjects who experience the exposure/s and are followed up over time to ascertain the health outcomes. This contribution presents the database for the analysis of mortality studies which is made available for public institutions carrying out cohort studies in Italy. The rates were computed from official mortality data from ISTAT. The database contains 141 causes or groups of causes for the years 1970-2012 ensuring correspondence with subsequent editions of ICD (International Classification of Diseases) VIII, IX and X.

The integration of current data sources is now a practice widely used in epidemiology, especially in the environmental field. To better describe the health profile of populations residing in proximity to areas characterized by a "strong environmental pressure", the combined use of multiple indicators (i.e., mortality, hospitalization, cancer incidence) is recommended. To choose an indicator is complex, as indicators should be contextualized and they need to be related to the several issues involved in the studied pathology. This chapter explores the general considerations that are to be addressed both at the time of the study design, during the selection of outcomes and of the proper data sources, and at the time of the discussion of the results, when different and complementary data are compared. A special focus is devoted to the case of mesothelioma.

SENTIERI-ReNaM Project analysed the incidence of malignant mesothelioma (MM) for the period 2000-2011 in 39 National Priority Contaminated Sites (NPCSs), and assessed the overall impact of mesothelioma in different types of NPCSs. In the study period, 2,683 incident cases of malignant mesothelioma were recorded: 1,998 males (74.5%), 685 females (25.5%). Excluding cases with non attributable exposure and those non interviewed, exposure was identified in 1,926 cases (70% of all cases): 1,541 males (occupational exposure: 1,414; environmental exposure: 82), 385 females (occupational exposure: 103; environmental exposure: 141). Women experienced mainly environmental and domestic exposures to asbestos. Standard Incidence Ratio (SIR) excesses were observed in men in 27 out of 39 NPCSs and defects in the remaining 12; in women, 20 NPCSs showed SIR excesses, defects in 15; in 4 NPCSs no MM cases occurred among female population. The highest rates were found in NPCSs with asbestos-cement plants (Broni and Casale Monferrato), respectively, 98 per 100,000 per year and 68.6 in men, 72.1 and 45.8 in women. Excluding these two sites, the highest incidence rates were found in the group with harbours and shipyards, where the rates were, respectively, 13.2 among men and 2.5 among women. The results of this report will be communicated to national and local institutions, as well as to NPCSs resident populations.

Objectives: we analysed evidence on effective interventions to improve the quality of care and management in patients with diabetes type 2. This review focuses particularly on audit and feedback intervention, targeted to healthcare providers, and continuous quality improvement (CQI) involving health professionals and health care systems, respectively., Methods: we searched The Cochrane Library, PubMed, and EMBASE (search period: January 2005-December 2015) to identify systematic reviews (SR) and randomized controlled trials (RCTs) considering patients' outcomes and process measures as quality indicators in diabetes care. Selection of studies and data extraction were carried out independently by two reviewers. Methodological quality of individual studies was assessed using the checklist «Assessment of methodological quality of systematic review» (AMSTAR) and the Cochrane's tool, respectively. We produced summaries of results for each study design., Results: the search process resulted in 810 citations. One SR and 7 RCTs that compared any intervention in which audit and feedback and CQI was a component vs. other interventions were selected. The SR found that audit and feedback activity was associated with improvements of glycaemic (mean difference: 0.26; 95%CI 0.08;0.44) and cholesterol control (mean difference: 0.03; 95%CI -0.04;0.10). CQI interventions were not associated with an improvement of quality of diabetes care. The RCTs considered in this review compared a broad range of interventions including feedback as unique activity or as part of more complex strategies. The methodological quality was generally poor in all the included trials., Conclusions: the available evidence suggests that audit and feedback and CQI improve quality of care in diabetic patients, although the effect is small and heterogeneous among process and outcomes indicators.

Unlabelled: . Contact with death or illness and career choice in non-medical health professions and business students: a cross-sectional analysis., Purpose: It is anecdotally reported that a personal severe illness or the death of a significant person might be key reasons for the choice of a career in the non-medical health professions., Aim: The aim of the questionnaire was to explore past relevant life events before starting professional studies (severe personal illness; severe illness or death of a significant person; drug addiction of a relative or friend) by comparing students of nursing or other non medical health professions with business students., Methods: An anonymous questionnaire with standardized closed questions was distributed in 2010 to a group of bachelor students of non-medical health professions (nursing, physiotherapy, occupational therapy and rescue care) and to a control group of business students at the University of Applied Sciences and Arts of Southern Switzerland., Results: Students of non-medical health professions had been, compared to business students, significantly more exposed to severe illnesses or the death of a relative (OR 3.070, CI95% 1.716-5.494), to personal severe illness (OR 3.950, CI95% 1.384-11.279) and to addiction of a relative or friend (OR 2.672, CI95% 1.316-5.422) before starting their professional studies., Conclusions: This cross-sectional analysis suggests that exposure to a severe illness or death may play an important role in the choice of career, probably by supporting intrinsic motivations. Further research should explore the role of those past life experience in professional behavior.

This article explores the origins and the development of women-protective anti-abortion arguments in a globalized world. Unlike fetus-base pro- life arguments, women protective ones focus on gender stereotypes and on the theory of gender complementarity. The article traces the influence of US conservative groups in spreading such arguments beyond the US borders, so that in today's globalized world, womnen-protective arguments have become central in abortion and contraception related legislation and litigation in the US, Europe and Russia. The article points to the dangers of the women-protective anti-abortion strategy, which aims at disempowering women, by denying them agency and control over reproduction, resulting in a direct challenge to gender equality.

Interrupted aortic arch (IAA) is a rare congenital malformation of the aorta and aortic arch. We report the case of a 68-year-old female with hypertension and poor control of blood pressure levels. She was diagnosed with aortic coarctation by aortography during young age. A double access angiography was performed that showed a type A IAA, a rare condition in adults that may cause hypertension.

Objective: To estimate the prevalence of Parkinson's disease using electronic health archives and to obtain a knowledge base for its governance., Materials: Drug prescriptions, tax-exemptions and hospital discharge records relating to assisted of Health Services Agency "Triestina" in the year 2011., Results: We identified 909 cases (crude prevalence rate: 380/100.000). The percentage contribution of drug prescriptions, tax-exemptions and hospital discharge records is: 81.5%, 36.1% and 35.2%., Conclusions: The use of drug prescriptions to detect patients with Parkinson's disease can be effectively supplemented by data of hospital discharges and tax-exemptions, but they still show an underestimation of 17%.

Varicella is an infectious disease still frequent in Italy, where 8 out 20 Regions have adopted universal vaccination programs starting from 2003. Accordingly to National Vaccination Plan, all Regions should introduce universal varicella vaccination in 2015. An independent multidisciplinary group of experts met to discuss some debated questions. The available evidence of varicella vaccine efficacy in the 8 Regions was evaluated and the evidence of safety of monovalent and combined varicella vaccines are presented. The strategy for introducing universal varicella vaccine in the pediatric immunization schedule is discussed. The expert group concludes that available evidence supports the active offer of varicella vaccine in all Italian Regions and that catch up programs for susceptible cohorts should be encouraged.

Rehabilitative and preventive cardiology (CRP) is configured as intervention prevention to "gain health" through a process of multifactorial care that reduces disability and the risk of subsequent cardiovascular events. It makes use of an interdisciplinary team in which every professional needs to have multiple intervention paths because of the different levels of clinical and functional complexity of cardiac patients who currently have access to the rehabilitation. The document refers to the use of interventions by nurses, physiotherapists, dietitians and psychologists that are part of the rehabilitation team of CRP. Interventions of which have been documented, on scientific bases and clinical practice, empirical effectiveness and organizational efficiency. The methodological approach of this paper is a first attempt to define, through the model of consensus, the minimum standards for a CRP evidence based characterized by clearly defined criteria that can be used by operators of CRP. The document describes the activities to be carried out in each of the phases included in the pathways of care by nurses, physiotherapists, dietitians and psychologists. The routes identified were divided, according to the type of patients who have access to the CRP and to the phases of care, including the initial assessment, intervention, evaluation and final reporting, in high medium and low complexity. Examples of models of reporting, used by the operators of the team according to the principles of good clinical practice, are provided. This is made to allow traceability of operations, encourage communication inside the working group and within the patient and the caregiver. Also to give any possible indication for the post-rehabilitation.

Introduction: The interlinked REACH-CLP regulations promote the sharing of knowledge regarding the risks and hazards of chemicals throughout the supply chain. The safety data sheet (SDS) is the main instrument to achieve this goal., Objective: to study 100 SDS of paints and coatings sector in order to highlight major criticisms related to health and safety of workers., Materials and Methods: Using the criteria prescribed by Regulation 453/2010/EC and preparing a suitable check list, some items of the sections 1 "Identification of the substance/mixture and of the company", 2 "Hazards identification", 3 "Composition/information on ingredients", the first part of section 7 "Precautions for safe handling", sections 8 "Exposure controls/personal protection" and 16 "Other information", were therefore evaluated for their appropriateness., Results: Seven SDS were written in a foreign language and were excluded from further analysis. Of the remaining 93 SDS, only 23% had a proportion of adequate items greater than 80%, 49 % had adequate items between 60 and 80%, and 28% had less than 60% adequate items. The most critical sections were those relating to workers' safe handling and exposure controls and protection., Conclusion: In conclusion, from the analysis of SDS we found high percentages of inadequacy, especially in sections 7 and 8, the most relevant for the protection of the health and safety of workers.

The Istituto Superiore di Sanità (National Institute of Health-ISS), in partnership with a network of Italian national and regional scientific institutions, initiated the SENTIERI Project (Epidemiological Study of Residents in Italian Contaminated Sites-NPCSs), the objectives, methods and initial results of which were published by Epidemiologia & Prevenzione in 2010 and 2011. In the course of 2013, some of the SENTIERI Project findings were published in international scientific journals, and the "SENTIERI approach" was among those sanctioned by the World Health Organization to conduct an initial description of the health status of residents of contaminated sites. The present Report, set up jointly by ISS and the Italian Network of Cancer Registries (AIRTUM), as anticipated in the 2011 Report, aims to provide, for each of the 18 National Priority Contaminated Sites included in the SENTIERI Project where the Italian Association of Cancer Registries is active, a mortality update to 2010, analyses of cancer incidence (1996-2005 in 17 NPCSs) and of hospital discharges (2005-2010), as is explained in detail in Chapter 2, pertaining to the project's materials and methods. The results of the analyses for each NPCS are presented in Chapter 3, while Chapter 4 includes a critical appraisal, a discussion of the methodological approach and a series of concluding remarks. The second section of the Report takes an in-depth look at important issues of public health and scientific research in contaminated sites. This Report represents an important step towards implementing a permanent epidemiological surveillance system in Italy's contaminated sites, the ultimate goal of the SENTIERI Project.

Protecting children's health from the effects of environmental contamination is a public health priority. In recent years, particular care has been devoted in Italy to the study of the relationship between environmental pollutants and health during infancy. The SENTIERI Project has called attention to increases in infant mortality in National Priority Contaminated Sites (NPCSs). SENTIERI KIDS provides a blueprint for the establishment of a task force charged with establishing multi and inter-disciplinary cooperation between central and regional institutions on the subject of children's health in contaminated sites. SENTIERI KIDS introduces a multiple outcome analytical model based on updated health outcomes (mortality, cancer incidence, hospital discharges) in order to establish a permanent observation system to monitor the state of health of infants residing in contaminated areas. This will pave the way for more in-depth epidemiological enquiries on an individual basis, and support the establishment and continued monitoring of primary prevention projects. Particular attention is devoted to issues of information and communication.

The Report considers three health outcomes - mortality, cancer incidence and hospital discharges - studied using homogenous methods and using data from official sources, namely the National Institute of Statistics (Istat), Italian Network of Cancer Registries (AIRTUM) and the Health Ministry. The timeframes of observation are: 2003-2010 for mortality, 1996-2005 for cancer incidence and 2005-2010 for hospital discharges. The causes of death are those examined by the SENTIERI Project. Hospital discharges are analysed with reference to the main diagnosis. The study of cancer incidence applies to the sites selected by AIRTUM. Statistical parameters (SMR, Standardized Mortality Ratio; SIR, Standardized Incidence Ratio; SHR, Standardized Hospitalization Ratio) were computed with a 90% confidence interval; the estimators were adjusted for age and socioeconomic status.

Rehabilitation and secondary prevention programs are recognized as an essential part of the overall care of patients with cardiovascular disease. They consist of multidisciplinary strategies aiming at the reduction of modifiable risk factors for cardiovascular disease. There are some evidence of the efficacy of nutritional care in modifying eating habits and behavior in patients undergoing cardiac rehabilitation. In 2007, the Italian Association of Dietitians (ANDID) appointed a working group of dietitians, skilled in nutrition applied in cardiovascular disease, with the aim to make an overview of the available scientific literature and to develop a Professional Position Paper on the role of Dietitian in cardiac rehabilitation and secondary prevention. The first Position Paper, developed in 2008, covered the available evidence about the dietitian professional role and contribution in the management of the topic. The working group has recently updated the contents by introducing, in agreement with the work done by ANDID, the methodology of the Nutrition Care Process and Model (NCP), a systematic problem-solving method intended to stimulate critical thinking, decision-making and address issues related to food and nutritional assistance, in order to provide a safe, effective and high quality care.

The SENTIERI Project represents the first comprehensive analysis of the health impact of residence in National Priority Contaminated Sites (NPCSs). For the first time, it considers three distinct health outcomes: mortality (2003-2010), cancer incidence (1996- 2005) and hospital discharges (2005-2010). The Report includes a commentary explaining methodology and approach, as well as remarks on the causal association between environmental exposures and investigated health outcomes based on the a priori assessments of the epidemiological evidence; the main implications for public health and scientific research priorities are also presented. The approach put forward by SENTIERI was among those sanctioned by the World Health Organization to conduct an initial description of the health status of residents of contaminated sites. Results relating to individual diseases that can be traced back to a single agent, such as asbestiform fibres, can be easily analysed. The Biancavilla NPCS (where the fluoro-edenite asbestiform fibre was found) displays excesses of pleural mesothelioma and its proxy, malignant pleural tumours, as does Priolo, where asbestos coexists with other pollutants. Increased risk was also recorded in NPCSs adjacent to the coast hosting harbour areas (such as Trieste, Taranto and Venice) or comprising industrial areas specialising in the production of chemicals (Laguna di Grado e Marano, Priolo and Venezia) and steel (Taranto, Terni, Trieste). Increases of pathologies, such as cancer and respiratory diseases, connected to more than one agent, in industrial sites with multiple and diverse sources of exposures, prove harder to interpret. There are also more complex cases in which results do not appear consistent in the three databases or by gender (such as lung cancer in Venice, where mortality and hospital discharges have only increased among women). In order to adequately examine these we must consider factors such as the appropriateness of the health outcome showing the increase, considering latency and the length of the observation period. Of further interest are results relating to diseases of the urinary tract such as kidney failure in the NPCSs of Basso bacino del fiume Chienti, Taranto, Milazzo and Priolo. Overall, the results discussed above are consistent with the previous findings pertaining to mortality for 1995-2002. The present analysis also introduces a new element - the study of cancer incidence and hospital discharges - which can tell us a great deal about diseases with high survival rates or non lethal ones. The first is the case of thyroid cancer, which presents increases in both databases and for both genders in a number of NPCSs (Brescia-Caffaro, Laghi di Mantova, Milazzo, Sassuolo- Scandiano and Taranto). The study of cancer incidence and hospital discharges also revealed cancer excesses for melanoma, breast cancer and non Hodgkin lymphoma in Brescia-Caffaro NPCS where PCBs (Polychlorinated biphenyl) are the site's main pollutant. PCBs, according to the 2013 evaluation of the International Agency for Research on Cancer, are ascertained human carcinogens for melanoma and probable carcinogens for breast cancer and non-Hodgkin lymphoma. The results pertaining to cancer incidence in the 17 NPCSs can also be presented using rankings by area or disease analyzed by a multivariate hierarchical Bayesian model. These rankings reveal an overlapping of credibility intervals, such that it is not possible to speak of a limited number of cancer sites or of certain NPCSs as being particularly affected. Every NPCS, therefore, must be considered individually and ordering them by ranking of cancer incidence wouldn't be appropriate. Data collected concerning some of the NPCSs in the context of the SENTIERI Project is so conclusive that remediation measures can immediately be put in place. This is the case in the Biancavilla and Brescia-Caffaro NPCSs. A similar conclusion can be drawn for complex locations such as Taranto, where, based on the results of SENTIERI Projects and the whole available information, we can safely conclude that exposure to environmental agents played an important role, allowing us to set in place 'Integrated evaluation of environmental and health impact procedures'. SENTIERI approach does not allow definitive causal assessments. However, as stated above, these results do provide a topic for further study without getting in the way of initiatives promoting urgent environmental remediation.

Of the 18 National Priority Contaminated Sites (NPCSs) analysed in this Report, some have a single source of environmental contamination (such as fluoro-edenite in Biancavilla). In most cases, however, we are looking at multiple heterogeneous sources of contamination. In this respect, the a priori causal evaluation of the association between diseases and environmental exposures in NPCSs, based on epidemiological evidence, can help trace the health impact back to specific types of environmental exposure. There are several cases in which the project's findings have been consistent with a priori evidence: stomach cancer (both genders, excess cancer incidence) in the Fidenza NPCS; stomach cancer (women, excess mortality, cancer incidence and hospital discharges) in the Laguna di Grado e Marano NPCS; excess hospitalisation from respiratory diseases in Brescia-Caffaro, Milazzo and Terni Papigno NPCSs; excesses for non-Hodgkin lymphomas and melanoma (incidence and hospitalisation in men and women) and breast cancer (incidence and hospital discharges, women) in Brescia-Caffaro NPCS. In preorder to properly evaluate the population's health profile, we must also observe whether results remain consistent for all three health outcomes or in both genders. The first is the case of excess mortality, cancer incidence and hospital discharges for bladder cancer (men) in Porto Torres and diseases of the urinary tract in the Basso bacino del fiume Chienti NPCS). Gender consistency is observed, for instance, for all cancer in Bolzano, Porto Torres, Venice, Litorale Domizio Flegreo, Priolo, and Taranto, for all causes in Taranto, Litorale Domizio Flegreo and Trieste. The health impact in the various NPCSs needs to be considered carefully and used as a springboard for further analytical research that could confirm and explain causal links to specific environmental exposures. The observations can, however, already be considered as a basis for mandatory primary prevention measures.

The physician's need for medical information updates has been studied extensively in recent years but the point of view of the pharmaceutical industry on this need has rarely been considered. This paper reports the results of a retrospective analysis of the medical information service provided to Italian physicians by an important pharmaceutical company, Novartis Pharma, from 2004 to 2012. The results confirm clinicians' appreciation of a service that gives them access to tailored scientific documentation and the number of requests made to the network of medical representatives has been rising steadily, peaking whenever new drugs become available to physicians. The analysis confirms what -other international studies have ascertained, that most queries are about how to use the drugs and what their properties are. The results highlight some differences between different medical specialties: for example, proportionally, neurologists seem to be the most curious. This, as well as other interesting snippets, is worth further exploration. Despite its limits in terms of representativeness, what comes out of the study is the existence of an real unmet need for information by healthcare institutions and that the support offered by the pharmaceutical industry could be invaluable; its role could go well beyond that of a mere supplier to National Healthcare Systems, to that of being recognised as an active partner the process of ensuring balanced and evidence-based information. At the same time, closer appraisal of clinicians' needs could help the pharma industries to improve their communication and educational strategies in presenting their latest clinical research and their own products.

Background: The diagnosis and surgical treatment of patients with Marfan syndrome remain controversial. It is of utmost importance to identify patients at risk for acute aortic events to establish the correct surgical timing and the appropriate surgical treatment., Methods: From May 2008 to December 2012, 500 patients were screened at the Marfan Presidium of the Tor Vergata University Hospital of Rome (Italy). Patients were evaluated by a cardiac surgeon, including echocardiographic, orthopedic, ophthalmologic and dental examinations. All patients received genetic counseling, and genetic sampling was performed if appropriate., Results: The diagnosis of Marfan syndrome was confirmed in 146 patients (29.2%). Fifty-four patients (37%) underwent cardiac surgery on the aortic root, 4 patients had surgery on the mitral valve, 13 patients had combined surgery; 11 cases were emergent surgery for acute aortic dissection. Twenty-eight patients (52%) were operated on at our Division: 13 underwent valve-sparing aortic root replacement (David procedure), 1 underwent Yacoub remodeling procedure and 14 underwent Bentall procedure. Following the establishment of the Marfan Center, the David aortic valve-sparing operation was the most frequently performed procedure compared to the previous period of surgical activity (63 vs 22%, p<0.0001)., Conclusions: Regular follow-up twice a year may allow to identify patients at risk for acute aortic syndromes. Early surgical treatment is recommended in these patients to achieve optimal results of valve-sparing procedures and life-saving management, especially for patients who live far away from a cardiac surgery center.

Although computed tomography (CT) scans remain the basis of morphologic evaluation in the characterization of solitary pulmonary nodules (SPNs), perfusion CT can represent an additional feasible technique offering reproducible measurements, at least in SPNs with a diameter >10 mm. In particular, CT perfusion could reduce the number of SPNs, diagnosed as undetermined at morphologic CT, avoiding long term follow-up CT, FDG-PET studies, biopsy or unnecessary surgery with a significant reduction in healthcare costs. In order to reduce the radiation dose, an optimization of the CT perfusion protocol could be obtained using axial mode acquisition, using shorter acquisition time and adaptative statistical iterative reconstruction algorithm.

The aim of this study was to assess diagnostic accuracy of multislice CT in restaging patients with N2 non-small cell lung carcinoma after neoadjuvant chemotherapy, using a multiparametric approach as compared with traditional size-based radiological criteria. All patients staged as N2 at histologic examination after neoadjuvant chemotherapy were correctly staged with multislice CT (sensitivity, specificity, positive and negative predictive value, and accuracy were 100%, 80%, 85%, 100% and 93,7% respectively, vs 34%, 60%, 34%, 60% and 50% using size-based criteria), suggesting that a multiparametric approach results in improved diagnostic accuracy.

Acute mesenteric ischemia/infarction is a complex and often misdiagnosed syndrome. The availability of new imaging methods, namely multislice computed tomography, has enabled early recognition of signs and symptoms of acute mesenteric ischemia, resulting in timely therapeutic intervention.

Introduction: in Taranto IPS (Italian polluted site, made up of 2 municipalities) the Decree defining site boundaries lists the presence of a refinery, a steel plant, a harbour area and waste landfills together with illegal dumping sites. Previous environmental and epidemiological investigations in the area documented the presence of environmental contamination and increased mortality from respiratory and cardiovascular diseases as well as a number of cancer sites; for these same health outcomes the cohort study of residents showed increased risk both in terms of mortality and morbidity., Objective: to describe the health status of residents in Taranto IPS analyzing different health indicators available at municipal level, i.e. mortality (2003-2009), mortality time trend (1980-2008) and cancer incidence (2006-2007)., Methods: the analyses were carried out for residents in Taranto IPS. Mortality update (SENTIERI Project, 2003-2009) regards 63 single or grouped causes (all ages, both genders); for a selection of causes 0-1 and 0-14 age classes were analyzed (both genders combined). Standardized mortality ratio crude (SMR) and deprivation adjusted together with 90% confidence intervals (90%CI) were computed using regional rates for comparison. Mortality time trend (1980-2008, triennial intervals) were analyzed calculating standardized rates (0-99 years, both genders, per 100,000, Italian population at 2001 Census as reference) and 90%CI. Time trends were computed for all causes, all neoplasms (and lung cancer), cardiovascular diseases (and ischemic heart diseases), respiratory diseases (also acute and chronic) and all causes infant mortality (both genders combined). For cancer incidence (2006-2007) Standardized incidence ratio (SIR) and 90%CI were calculated for both genders; incidence rates of cancer registries of the macroarea South and Islands (2005-2007) and rates of Taranto Province excluding SIN municipalities (2006-2007) were used for comparison., Results: in Taranto IPS mortality among men is in excess in both periods (SENTIERI Project 1995-2002 and 2003-2009) for all causes, all neoplasms (including lung and pleural cancer), dementia, cardiovascular diseases (including hypertension and ischemic heart diseases), respiratory diseases (including the acute ones) and digestive diseases (including liver cirrhosis). All causes infant mortality is in excess in both periods. Time trends show that Taranto IPS rates are higher than regional average in the majority of time intervals for most causes in both genders. Rates are often higher than national average form any triennial intervals. Among males, over the whole period, mortality in Taranto IPS is higher than regional and national average for causes as lung cancer, diseases of the respiratory system, including the chronic ones. Among females, since the early Nineties, lung cancer and ischemic heart diseases are in excess in Taranto IPS. Also infant mortality is higher for the whole period in Taranto IPS than regional and national averages. Cancer incidence results show excesses for cancer sites already indicated by mortality data., Conclusions: mortality analyzed in the context of SENTIERI Project (1995-2002 and 2003-2009), time trend mortality (1980-2008) and cancer incidence (2006- 2007) show, in both genders, excesses for causes for which an etiologic role of environmental exposure present in Taranto IPS are either ascertained or suspected on the basis of a priori evaluation of the epidemiological evidence. The finding of excess infant mortality is of the utmost importance in public health terms. Most diseases showing an increased risk have multifactorial etiology, therefore interventions of proven efficacy, such as smoking cessation, food education, measures for cardiovascular risk reduction and breast cancer and colon screening programmes should be planned. To build a climate of confidence and trust between citizens and public institutions study results and public health actions are to be communicated objectively and transparently.

Acute lung injury/acute respiratory distress syndrome (ALI/ARDS) is a complex pulmonary pathology with high mortality rates, manifesting over a wide range of severity. Clinical diagnosis relies on the following 4 criteria stated by the American-European Consensus Conference: acute onset of impaired gas exchange, severe hypoxemia defined as a PaO2 to FiO2 ratio <300 (PaO2 in mmHg), bilateral diffuse infiltration on chest X-ray; pulmonary artery wedge pressure of ≤18 mmHg to rule out cardiogenic causes of pulmonary edema. The aim of this study was to determine the usefulness of CT in the diagnosis and management of this condition.

Introduction: the potential health impacts due to the decommissioned Nuclear power plants (NPP) located in Borgo Sabotino and Garigliano in Central Italy (active from the early 1960s to the late 1980s) have raised several concerns. Brain, thyroid, breast and lung cancer and leukaemia have been associated with exposure to ionizing radiations, but the health effects of nuclear plants on the resident populations are controversial., Objective: to evaluate whether living close to NPPs is associated with an increased risk of cancer incidence and mortality., Methods: we defined a cohort of residents within 7 km from the NPPs during the period 1996-2002. Individual follow-up for vital status at 01.01.2007 was conducted using municipality data. Gender specific Standardized Incidence and Mortality Ratios, adjusted for age, were calculated (SIR and SMR) using the regional population as reference. Each participant's address was assigned to a distance from the NPP on the basis of a GIS. A relative risk (RR, CI95%), adjusted for age and socioeconomic status, was calculated in 3 bands of increasing radius from the plants: 0-2, 2-4, and 4-7 km (reference group), using a Poisson regression model., Results: the cohort was of 39,775 people, 32%of whom lived near (0-4 km) the NPP. No differences in mortality was found when comparing the cohort with the regional population; among women living within 7 km from the NPP, we found thyroid cancer incidence higher than expected (SIR 1.53 CI95% 1.18-1.95). However, when the analysis was conducted on the basis of the distance from the NPP, we found a statistically significant increase in male mortality only for causes unrelated to radiation exposure (all causes, stomach cancer, and cardiovascular diseases). No mortality excess was observed among women living close to the NPPs. No statistically significant distance-related gradient was observed for cancer incidence both in men and women., Conclusions: living close to the NPP was not associated with mortality for causes related to radiation exposure. However, the results suggest to continue the epidemiological surveillance of the population.

The proposal of a Mediterranean way of life is much more than advise how to eat. The Mediterranean Diet, a model of Sustainable Diet, is an example of how to combine personal choices, economic, social and cultural rights, protective of human health and the ecosystem. There is in fact fundamental interdependence between dietary requirements, nutritional recommendations, production and consumption of food. In literature studies and nutritional and epidemiological monitoring activities at national and international level have found a lack of adherence to this lifestyle, due to the spread of the economy, lifestyles of the Western type and globalization of the production and consumption. To encourage the spread of a culture and a constant practice of the Mediterranean Diet, there are some tools that are presented in this article. The Mediterranean Diet Pyramid in addition to the recommendations on the frequency and portions of food, focuses on the choice of how to cook and eat food. The "Double Food Pyramid" encourages conscious food choices based on "healthy eating and sustainability. All the nutrition professionals and dietitians in particular should be constantly striving to encourage the adoption of a sustainable and balanced nutrition.

The structure of the US legal system, which relies on the presence of different courts to provide for the impartial administration of justice, both civil and criminal is discussed. Therefore, all the steps to conviction or acquittal of the American criminal trial, are taken into consideration. However, there is the presumption of innocence of the accused and the prosecution must prove his guilt beyond any reasonable doubt. Another important procedure in the US trial is the jury selection (voir dire), 12 jurors: 6 for the defense and 6 for the prosecution. In Italy it was observed that the autonomy of the police would squeeze the steering function of the prosecutor, and the practice of "under cover" investigation has granted an extension of police activity.

Introduction: The aim of the study was to conduct a cross sectional study on pain among inpatients and outpatients in a large teaching hospital., Methods: The study was carried out at the Policlinico "Umberto I", Rome, in October 2009, using a questionnaire developed by Gigi Ghirotti Foundation. The pain intensity was graded mild (VAS scale 1-3), moderate (VAS 4-6) and severe (7-10)., Results: The participants were 825 patients (response rate 75.8%), aged over or equal 18 years, 435 females (median age 54, range 18-95) and 390 males (median age 60, range 19-89). 420 patients (50.9%) declared to feel pain during the hospitalization, and among them 84.3% received adequate therapy. 23.3% of responders presented a pain score over 8, with patients admitted to internal medicine wards with highest score (p = 0.037). The pain control (score ³ 6) was obtained in 71.4% patients. Pain and severe pain perception was higher among females (55.6% and 36.1% vs 45.6% and 29.2%, respectively) (p = 0.004 and p = 0.036). The multivariate analysis showed that the following variables are positively associated to the dependent variable "how much pain do you feel in this moment?": female gender (p < 0.001), length of stay (p = 0.081), admission in medical wards (p = 0.028), being admitted in ordinary way (p = 0.004), while if the patients filled in the questionnaire was inversely associated (p < 0.001)., Conclusions: The application of the guidelines on free pain hospital is increasing, however we must consider that almost one fifth of the patients who suffered pain within the hospital did not receive any treatment for that.

Aim: to evaluate endothelial function (EF) in diabetic and non-diabetic patients without CAD by peripheral artery tonometry (PAT) technique., Methods: a cohort of 94 patients (55 men and 39 postmenopausal women; mean age 63 +/- 9 years) undergoing coronary angiography was divided into 2 groups: 58 patients with DM and (group 1) and 36 patients without DM. Endothelial dysfunction (ED) was assessed by digital pulse amplitude, using a fingertip peripheral arterial tonometry (PAT). As a measure of ED, reactive hyperemia index (RHI) was calculated as the ratio of the digital pulse volume during reactive hyperemia following 5 min ischemia and its basal value., Results: prevalence of cardiovascular risk factors was similar between the two groups. RHI values were significantly lower in diabetic patients compared to non-diabetics (1.72 +/- 0.34 vs 2.00 +/- 0.44; p < 0.005) and they correlated with levels of glycosylated hemoglobin (p = 0.05; r = -0.266)., Conclusion: despite similar level of other risk factors, EF was much more impaired in diabetic patients than in non-diabetics. These evidences further support the impact of DM on cardiovascular risk.

Heart failure is characterized by several abnormalities of sympathetic cardiac activity that can be assessed by 123I metaiodobenzylguanidine single photon emission computed tomography (MIBG SPECT). This technique may be useful in the clinical management of heart failure patients. Abnormal MIBG uptake has been demonstrated to be a predictor of death and arrhythmic events in heart failure patients with a prognostic power incremental to that of conventional risk markers; it may also be useful to identify patients at low risk of arrhythmias despite current guideline indications for an implantable cardioverter-defibrillator (ICD) or patients at high risk for arrhythmias not fulfilling ICD indications. This review will focus on the clinical applications of MIBG SPECT in chronic heart failure, on the basis of the most recent evidence.

Carotid Intima Media Thickness (IMT) has been widely used to predict cardiovascular events in primary and secondary prevention studies. Yet, the power of IMT to reclassify risk level on top of conventional risk assessment based on classical risk factors remains unsettled. In fact, recent data indicate that the prognostic power of IMT is lower than that provided by the identification of carotid plaques. The role of IMT as surrogate endpoint to assess the efficacy of cardiovascular protective therapies is also still debated. In fact, no studies have ever been designed and powered to show a relationship between changes in carotid IMT during follow-up and cardiovascular events. Recently, two meta-analysis of trials using IMT as surrogate endpoint failed to demonstrate an association between IMT regression and cardiovascular events. The reasons for the lack of predictive role for changes in IMT are uncertain. It has been shown that IMT is not a pure atherosclerotic index, being substantially affected by age and hemodynamic factors including blood pressure and vessel wall shear stress. In addition, the status of carotid vessels does not strictly reflect that of coronary arteries. Finally, intra and inter-observer variability of measurements may further limit the association between IMT changes in individual patients and cardiovascular risk. Thus, IMT represents a valuable risk marker in population studies but its role for tailoring cardiovascular therapy in clinical practice remains currently uncertain.