Search

Deterioration of physical and functional capacities is often seen in nursing homes. The present study aimed at assessing the effectiveness of an individually tailored physical exercise intervention on mobility and functional decline in nursing home residents in a 1-year follow-up period. Information on gender, age, education, profession and cognitive status was collected at baseline and at 6 and 12 months of the intervention. The decline in functional capacity and mobility was assessed using the Barthel index. Some 221 participants were included. Results from the multivariate logistic regression showed how residents who never participated in physical activities had a five-fold higher risk of mobility decline compared with residents who did engage for the whole follow-up time. A lower effect was seen in residents who participated for only 6 months. Although dementia appeared to be a significant predictor of decline, a substantial stabilisation in mobility capacity was noted in patients with both mild and severe dementia performing exercise. The findings suggest that preventing or slowing physical decline in nursing home residents is an achievable goal, and even those with a higher degree of cognitive decline may benefit from a tailored physical activity plan.

Background The worldwide prevalence of obstructive lung disease (OLD) is increasing, especially among people >65 years old, and nearly three in four adults with OLD have two or more comorbid conditions. This study describes the impact of such comorbidities on the healthcare service usage and related costs in a country with universal health coverage, basing on a large cohort of elderly patients with OLD and employing real-world data. Methods We carried out a retrospective cohort study on a large population of elderly (age >64 years) patients with OLD served by a Local Health Unit in northern Italy. Their comorbidities were assessed using the clinical diagnoses assigned by the Adjusted Clinical Group (ACG) system to individual patients by combining different information flows. Correlations between number of comorbidities and total annual healthcare service usage and costs were examined with Spearman’s test. Regression models were applied to analyze the associations between the above-mentioned variables, adjusting for age and sex. Results All types of healthcare service usage (access to emergency care; number of outpatient visits; number of hospital admissions) and pharmacy costs increased significantly with the number of comorbidities. Average total annual costs increased steadily with the number of comorbidities, ranging from € 1158.84 with no comorbidities up to € 9666.60 with 6 comorbidities or more. Poisson regression analyses showed an independent association between the number of comorbidities and the use of every type of healthcare service. Conclusion These results based on real-world data provide evidence that the burden of care for OLD patients related to their comorbidities is independent of and in addition to the burden related to OLD alone and is strongly dependent on the number of comorbidities, suggesting a holistic approach to multimorbid patients with OLD is the most sound public health strategy.

Background Clinical factors, such as tumor thickness, ulceration and growth phase have a role as prognostic factors for stage I melanoma. However, it is still under debate whether these variables influence the related direct costs. We aimed to investigate which clinical factors represent direct health care “cost drivers” for stage I melanoma. Materials and method Analyses were conducted on a cohort of patients diagnosed with stage I melanoma. Differences in the costs incurred by different groups of patients were examined using Mann-Whitney or Kruskal-Wallis non-parametric tests. Log linear multivariate analysis was used to identify the clinical drivers of the total direct costs one and two years after diagnosis. The study was conducted from the perspective of Italy's National Health care System. Results One year after diagnosis, patients whose melanomas had a Breslow thickness ≥0.8 mmin (compared with those with lower thickness) and a vertical growth phase (compared with those with radial growth) incurred higher costs for hospitalization, as well as higher overall costs. One year after their diagnosis, treatment of patients with stage I melanoma in the vertical growth phase costs 50% more (95% CI: 22–85%) than their counterparts with a radial growth pattern, resulting in an estimated absolute increase of € 256.23. Having a tumor thicker than 0.8 mm prompted an increase of 91% (95% CI: 43–155%) in the costs (€955.24 in absolute terms). Conclusion Our data indicate a heterogeneity in the direct costs of stage I melanoma patients during the first year after diagnosis, which can be partly explained by clinical prognostic factors, like tumor thickness and growth pattern.

Background In 2017, varicella vaccination became mandatory for all children in Italy, based on a two-dose schedule administered at 12-15 months of age and 5 to 6 years of age. Varicella vaccines are available in different formulations (as a single vaccine or as a combination vaccine together with measles, mumps, and rubella) and are made by multiple manufacturers with different effectiveness profiles. This study calculates the cost-effectiveness of a range of varicella vaccination strategies to identify the optimal strategy for Italy. Methods A dynamic transmission cost-effectiveness model was applied in Italy to simulate the long-term (50 years) costs and outcomes associated with different varicella vaccination strategies. Five vaccination strategies were evaluated using the model: two doses of two different combination Measles-Mumps-Rubella-Varicella vaccines (either Vaccine A (MSD) [denoted QQVa] or Vaccine B (GSK) [denoted QQVb]); a first dose of a single Varicella vaccine followed by a second dose of a combination vaccine (either Vaccine C (MSD) followed by Vaccine A [denoted MQVa] or Vaccine D (GSK) followed by Vaccine B [denoted MQVb]); or no vaccine at all (NV). The model was adapted for Italy using publicly available Italian data and expert opinion. Results Over the 50-year time-horizon, in the absence of universal varicella vaccination, there would be 34.8 million varicella cases, 142 varicella-infection-related deaths, and €23 billion in societal costs. The cost per capita from a societal perspective ranged from €164.55 to €392.18 with NV being the most expensive and QQVa the least expensive. The most effective strategy was QQVa, which resulted in a 66% decrease in varicella cases and 30% reduction in varicella-related deaths compared to NV strategy. QQVa led to a net saving in societal cost around €13 billion compared to NV as the cost of vaccination was more than offset by the savings that resulted from the reduced burden of illness. Conclusion Varicella vaccination has a major impact on reducing varicella incidence, prevalence, and societal costs. This analysis supports the policy for universal varicella vaccination in Italy as the NV strategy was the most expensive and resulted in the poorest outcomes. QQVa offers the greatest benefits at the lowest cost and should be considered as a potential priority strategy for Italian population.

The aim of the present study is to use the ACG (Adjusted Clinical Groups) System to create an impactibility model by identifying homogeneous clinical subgroups of patients with high risk of an adverse health outcome in a population of heart failure patients with complex health care needs (PCHCN). This method will allow policy makers to target and prioritize services for the highest risk PCHCN in the context of limited health care resources, by identifying relatively homogeneous groups of patients with similar comorbidities. Subjects classified in 2012 as PCHCN in a local health unit by the ACG System were linked with hospital discharge records in 2013. The authors applied the Apriori algorithm to identify the most common sets of the most predictive diseases for the following outcomes of interest: at least 1 admission and at least 1 preventable admission in the year. Predictive performance for the former outcome was compared between the impactability model with the available ACG's individual risk score. The Apriori algorithm also was applied to predict the latter outcome as an example of an event that a policy maker would be able to prevent. Evidence showed no statistically significant difference between the 2 methods. The present model also displayed evidence of good calibration. The Apriori algorithm was applied as an impactibility model, built based on the ACG System, that allowed the authors to obtain an "ACG-based group risk score" and use it to identify clinically homogeneous subgroups of PCHCN. This will help policy makers develop "tool kits" for homogeneous groups of patients that improve health outcomes.

Soil transmitted helminthiasis (STHs) are endemic in Nepal but since the country territory is extremely heterogeneous, a multidisciplinary assessment is required to evaluate the risk of infection in different areas. Prevalence data were retrieved with systematic literature search and geographical coordinates were assigned to each survey site. Spatial stratification was then implemented considering land use and ecological parameters. STH transmission boundaries were tested after reference criteria and elevation was evaluated as additional predictor: the elevation threshold of 3057 m above sea level is demarking the STH transmission limit. Areas above this threshold are safe, but since lodging in at-risk sites is a compulsory stopover for international travelers, STH risk exposure should be considered for every travel to the country.

Objective Assess the risk of hospitalizations for bacterial pneumonia or pneumococcal infections, in a cohort of young individuals with celiac disease (CD) compared to matched references. Study design The cohort consists of 213,635 individuals, born in 1989–2012 and resident in Friuli-Venezia Giulia (Italy). Through pathology reports, hospital discharge records or co-payment exemptions, we identified 1294 CD patients and 6470 reference individuals matched by gender and birth year. We considered hospital admissions for first episodes of bacterial pneumonia and pneumococcal infections. Hazard ratios (HRs) for episodes after CD diagnosis were calculated with Cox regression and odds ratios (OR) for the ones before CD diagnosis with conditional logistic regression. Further analyses were performed on unvaccinated follow-up periods. Results 14 CD patients (in 9450 person-years) and 42 references (in 48,335 person-years) experienced a first episode of bacterial pneumonia, with an increased risk among CD patients (HR 1.82; 95%CI 0.98–3.35). Risks of bacterial pneumonia were significantly increased before CD diagnosis and especially the year before CD diagnosis (OR 6.00, 95%CI 1.83–19.66). Risks of pneumococcal infections showed a non-significant increase in CD patients. Conclusions CD children and youth showed an increased risk of bacterial pneumonia, especially in proximity to CD diagnosis. Anti-pneumococcal vaccination should be recommended to all young CD patients.

In 2002, the WHO European Region was declared polio-free. Nonetheless global eradication has not yet been completed and the reintroduction from at risk areas is still possible. This seroprevalence study evaluated samples collected from each Italian region in the 12−50 years old age range to assess protection against Poliovirus (PV) 1, 2 and 3 among subjects immunised with different vaccination schedules. 1073 samples (50.5% females) were examined. WHO standardized microneutralization assay was used. Seroprotection rates were 92.9%, 96.2% and 83.4%, for PV1, PV2 and PV3, respectively. Geometric Mean Titres (GMTs) were higher for PV2 (52.8) and PV1 (41.1) than for PV3 (21.0). Increasing the age, a decreasing trend in seropositivity was observed, in particular for PV3. The 2017–2019 Italian National Immunisation Plan emphasises, as primary objective, the maintenance of the polio-free status and strongly validates the 2 + 1 schedule in the first year of life with IPV vaccine associated with the administration of booster doses at 6 years and during the adolescence. Surveillance system and high population immunity are crucial to ensure the maintenance of polio-free status.

PURPOSE: The present work aimed at conducting a real-world data analysis on the management costs and survival analysis comparing data from non–small-cell lung cancer (NSCLC) cases diagnosed in the Veneto region before (2015) and after (2017) the implementation of a regional diagnostic and therapeutic pathway including all new diagnostic and therapeutic strategies. METHOD: This study considered 254 incidental cases of NSCLC in 2015 and 228 in 2017 within the territory of the Padua province (Italy), as recorded by the Veneto Cancer Registry. Tobit regression analysis was performed to verify if total and each item costs (2 years after NSCLC diagnosis) are associated with index year, adjusting by year of diagnosis, sex, age, and stage at diagnosis. Logistic regression models were run to study overall mortality at 2 years, adjusting by the same covariates. RESULTS: The 2017 cohort had a lower mortality odd (odds ratio, 0.93; P = .02) and a significant increase in the average overall costs ( P = .009) than the 2015 cohort. The Tobit regression analysis by cost item showed a very significant increase in the average cost of drugs (coefficient = 5,953, P = .008) for the 2017 cohort, as well as a decrease in the average cost of hospice care (coefficient = –1,822.6, P = .022). CONCLUSION: Our study showed a survival improvement for patients with NSCLC as well as an economic burden growth. Physicians should therefore be encouraged to follow new clinical care pathways, while the steadily rising related costs underscore the need for policymakers and health professionals to pursue.

Previous research had shown the number of comorbidities is a major factor influencing the burden of care for elderly patients with obstructive lung disease (OLD). This retrospective cohort study on a large population of elderly patients (age > 65 years) with OLD in northern Italy measures the use of healthcare resources associated with the most frequent combinations of comorbidities and investigates the most common reasons for hospitalization. Total health costs, pharmacy costs, emergency department (ED) visits, outpatient visits, and hospital admissions are assessed for every subject. The most common causes of hospitalization by a number of comorbidities and the most common sets of three comorbidities are identified. For each comorbidity group, we rank a list of the most frequent causes of hospitalization, both overall and avoidable with effective ambulatory care. A small group of patients suffering from major comorbidities accounts for the use of most healthcare resources. The most frequent causes of hospitalization are respiratory failure, heart failure, chronic bronchitis, and bronchopneumonia. The most common conditions manageable with ambulatory care among causes of hospitalizations are heart failure, bacterial pneumonia, and COPD. The set of three comorbidities responsible for the highest average total costs, and the highest average number of hospitalizations and outpatient visits comprised hypertension, cardiac arrhythmias, and heart failure. The main reasons for hospitalization proved to remain linked to heart failure and acute respiratory disease, regardless of specific combinations of comorbidities. Based on these findings, specific public health interventions among patients with OLD cannot be advised on the basis of specific sets of comorbidities only.

Background Non‐small cell lung cancer (NSCLC) is the first cause of cancer‐related death among men and the second among women worldwide. It also poses an economic threat to the sustainability of healthcare services. This study estimated the direct costs of care for patients with NSCLC by stage at diagnosis, and management phase of pathway recommended in local and international guidelines. Methods Based on the most up‐to‐date guidelines, we developed a very detailed “whole‐disease” model listing the probabilities of all potentially necessary diagnostic and therapeutic actions involved in the management of each stage of NSCLC. We assigned a cost to each procedure, and obtained an estimate of the total and average per‐patient costs of each stage of the disease and phase of its management. Results The mean expected cost of a patient with NSCLC is 21,328 € (95% C.I. −20 897−22 322). This cost is 16 291 € in stage I, 19530 € in stage II, 21938 € in stage III, 22175 € in stage IV, and 28 711 € for a Pancoast tumor. In the early stages of the disease, the main cost is incurred by surgery, whereas in the more advanced stages radiotherapy, medical therapy, treatment for progressions, and supportive care become variously more important. Conclusions An estimation of the direct costs of care for NSCLC is fundamental in order to predict the burden of new oncological therapies and treatments on healthcare services, and thus orient the decisions of policy‐makers regarding the allocation of resources. Key points Significant findings of the study The high costs of surgery make the early stages of the disease no less expensive than the advanced stages. What this study adds An estimation of the direct costs of care is fundamental in order to orient the decisions of policy‐makers regarding the allocation of resources., The high costs of surgery make the early stages of the disease no less expensive than the advanced stages. An estimation of the direct costs of care is fundamental in order to orient the decisions of policy‐makers regarding the allocation of resources.

Background Human papillomavirus (HPV) is a common sexually transmitted pathogen and the cause of several cancers and of anogenital warts. With this study, we estimated the trend of hospitalizations for anogenital warts (AGWs) in the Veneto region (Italy) from 2007 to 2018. Methods The analysis included all the hospital discharge records of public and accredited private hospitals occurred in Veneto residents in the timespan 2007–2018. The ICD9-CM code 078.11 considered were those associated with condyloma acuminatum and those associated with surgical interventions for vulval/vaginal warts, penile warts anal warts. Annual total and sex- and age-specific hospitalization rates and trends were calculated and correlated with the different HPV vaccine coverage over the study period. Results We observed an overall reduction of hospitalization rates for AGWs: from 15.0 hospitalizations every 100,000 Veneto residents in years 2007–08 to 10.9 hospitalizations every 100,000 Veneto residents in year 2017–18 (− 37.4%; p Conclusion The marked decline in hospitalization rates for AGWs in Veneto Region is probably attributable to the high coverage rates of HPV vaccination programs implemented since 2008.

Background: A few years after the introduction in Italy of a four-component anti-meningococcal B vaccine (4CMenB), we evaluated the effectiveness and impact of vaccination in two regions using different schedules (2, 4, 6, 12 months in Tuscany vs. 7, 9, 15 months in Veneto) through an observational retrospective study. Methods: Vaccination started in 2014 in Tuscany and in 2015 in Veneto, the data collected referred to the period 2006&ndash, 2018 for Tuscany and 2007&ndash, 2018 for Veneto. Cases of invasive meningococcal disease due to N. Meningitidis B were identified by culture and/or real-time PCR. Results: In Tuscany, pre-vaccine incidence was 1.96 (95% CL 1.52, 2.40) and dropped to 0.62 (95% CL 0.60, 0.64) in the post-4CMenB era. Evaluating only vaccinated children, post-4CMenB incidence was 0.12 (95% CL 0.08, 0.15). In Veneto pre-vaccine incidence was 1.94 (95% CL 1.92, 1.96) and dropped to 1.34 (95% CL 1.31, 1.38) in the post-4CMenB era. In the vaccinated population, MenB incidence was 0.53 (95% CL 0.50, 0.56). Vaccine effectiveness was 93.6% (95% CL 55.4, 99.1) in Tuscany and 91.0% (95% CL 59.9, 97.9) in Veneto, with mean vaccine coverages of 83.9% and 81.7%, respectively. The overall impact (evaluating both vaccinated and unvaccinated children) was 0.68 (95% CL 0.10, 0.89) in Tuscany and 0.31 (95% CL &minus, 0.56, 0.69) in Veneto, the total impact (evaluating only vaccinated children) was 0.94 (95% CL 0.56, 0.99) and 0.90 (95% CL 0.57, 0.97), respectively. The relative case reduction (RCR) was 65% in Tuscany and 31% in Veneto. Considering the vaccinated population, the RCR was equal to 91% and 80%, respectively. Conclusion: In conclusion, 4CMenB appears to have a very high effectiveness in Italy, the impact of vaccination appears greater where the immunization program is started early.

Background: Invasive meningococcal disease (IMD) in high-income countries usually occurs sporadically with low incidence and occasionally as small clusters or outbreaks. The WHO guidelines (GLs) for IMD outbreak applies only to African countries with high endemic incidence. Several high-income countries developed their own GLs on IMD outbreak, and we compare their terminology, classification, definitions, and public health interventions. Methods: National IMD outbreak GLs of the European Union and the Organisation for Economic Co-operation and Development member states were compared. Due to linguistic barriers, 17 out of forty-one countries were selected, and the GLs on the websites of the national health authorities were independently screened by two researchers. Results: National GLs on IMD outbreak were available for 12 countries. All GLs classify IMD outbreak into organization and community based using different terminology (cluster, epidemic, etc.). Two GLs introduce also a third condition of hyperendemic. Definitions, thresholds, and countermeasures vary among countries. Conclusions: Different definitions of organization and community-based outbreaks and countermeasures are expected because of uncertainties about their effectiveness, and differences between countries in health-care systems and public health policy approaches. Nevertheless, variations in terminology, definitions and countermeasures are confusing and reflect the need for an international standardization.

Aims To describe the impact of diabetes comorbidities on the health care services use and costs of a cohort of elderly patients with diabetes and high health care needs (HHCN), based on real-world data. Methods We focused on a cohort of diabetic patients with HHCN belonging to Resource Utilization Bands 4 and 5 according to the Adjusted Clinical Group (ACG) system. Their comorbidities were assessed using the clinical diagnoses that the ACG system assigns to single patients by combining different information flows. Regression models were applied to analyze the associations between comorbidities and health care service use or costs, adjusting for age and sex. Results Our analyses showed that all health care service usage measures (e.g. access to emergency care; number of outpatient visits) and the total annual costs and pharmacy costs are associated significantly with comorbidity class. Instead, no differences in hospitalization rates by comorbidity class were revealed. Conclusion The association between a larger number of comorbidities and higher total health care service usage and costs was seen mainly for primary care services. This underscores the need to strengthen primary care for today’s aging and multimorbid population.

Background Pulmonary diseases are a common and costly cause of 30-day readmissions. Few studies have focused on the difference in risk for rehospitalization between men and women in older patients. In this study we analyzed the association between sex and the risk of readmission in a cohort of patients admitted to the hospital for chronic obstructive pulmonary disease (COPD) exacerbation and other major pulmonary diseases. Methods This was a retrospective cohort study based on administrative data collected in the Veneto Region in 2016. We included 14,869 hospital admissions among residents aged ≥65 years for diagnosis related groups (DRGs) of the most common disorders of the respiratory system: bronchitis and asthma, pneumonia, pulmonary edema, respiratory failure, and COPD. Multilevel logistic regressions were performed to test the association between 30-day hospital readmission and sex, adjusting for confounding factors. Results For bronchitis and asthma, male patients had significantly higher odds of 30-day readmission than female patients (adjusted odds ratio (aOR), 2.07; 95% confidence interval (CI), 1.11–3.87). The odds of readmission for men were also significantly higher for pneumonia (aOR, 1.40; 95% CI, 1.13–1.72), for pulmonary edema and respiratory failure (aOR, 1.28; 95% CI, 1.05–1.55), and for COPD (aOR, 1.34; 95% CI, 1.00–1.81). Conclusions This study found that male sex is a major risk factors for readmission in patients aged more than 65 years with a primary pulmonary diagnosis. More studies are needed to understand the underlying determinants of this phenomena and to provide targets for future interventions.

AIM To ascertain whether cholestasis affects the expression of two CYP3A isoforms (CYP3A1 and CYP3A2) and of pregnane X receptor (PXR) and constitutive androstane receptor (CAR). METHODS Cholestasis was induced by bile duct ligation in 16 male Wistar rats; whereas 8 sham-operated rats were used as controls. Severity of cholestasis was assessed on histological examination of liver sections, and serum concentrations of albumin, AST, ALT, GGT, ALPK and bilirubin. Gene and protein expressions of PXR, CAR, CYP3A1 and CYP3A2 were assessed by means of qRT-PCR and Western blot, respectively. Alterations in CYP3A activity were measured by calculating the kinetic parameters of 4-OH and 1’-OH-midazolam hydroxylation, marker reactions for CYP3A enzymes. RESULTS The mRNA and protein expression of CYP3A1 increased significantly in mild cholestasis (P < 0.01). At variance, mRNA and protein expression of CYP3A2 didn’t change in mild cholestasis, whereas the expression and activity of both CYP3A1 and CYP3A2 decreased dramatically when cholestasis became severe. Consistently with these observations, the nuclear expression of both PXR and CAR, which was measured because they both translocate into the cell nucleus after their activation, virtually disappeared in the late stage of cholestatic injury, after an initial increase. These results indicate that early- and late-stage cholestasis affects CYP3A-mediated drug metabolism differently, probably as consequence of the different activation of PXR and CAR. CONCLUSION Early- and late-stage cholestasis affects CYP3A-mediated drug metabolism differently. PXR and CAR might be targeted therapeutically to promote CYP3A-mediated liver detoxification.

Background Human papillomavirus (HPV) is one of the most common sexually transmitted pathogens. This observational study was conducted to estimate the trend of hospitalization for genital warts (GWs) in the Veneto region (Italy) from 2004 to 2015. Methods All patients with GWs were identified in the hospital discharge records of all public and accredited private hospitals that related to Veneto residents and contained the ICD9-CM code 078.11 associated with a genital surgical procedure (vulval/vaginal warts, penile warts and anal warts). Annual total and sex- and age-specific hospitalization rates and trends were calculated and correlated with the different HPV vaccine coverage over the study period. Results An annual rate of 11.8 per 100,000 population (8.6 per 100,000 males, and 14.8 per 100,000 females) was found, corresponding to 6076 hospitalizations for condyloma (53.3% vulval/vaginal, 35.8% anal, 8.3% penile, and 2.6% both penile or vulval/vaginal and anal). Among females, the rate of overall GWs remained stable to 2007 (19.1 per 100,000), then dropped significantly, reaching a rate of 11.3 per 100,000 in 2015 (average annual percent changes [AAPC]: -6.1%; 95% CI: -8.4; −3.7). For males, the overall rate increased over the study period (from 6.4 per 100,000 in 2004 to 10.8 per 100,000 in 2015; AAPC: 3.8%; 95% CI: 1.2; 6.4). Among the potentially vaccinated females (12- to 20-year-olds) there was a 62.1% decrease in the number of vulval/vaginal warts from the years 2010-2012 to the years 2013-2015 due to an increase in the HPV coverage rate. A similar reduction among males was observed in the same period and the same age group for penile warts (−68.2%). Conclusion GWs have an important impact on the health services and data suggest that GW-related hospitalization rates rapidly decline in a population with a high HPV vaccination coverage (about 75%). Further efforts should be made to better clarify the epidemiological picture regarding HPV-related diseases, with particular regard to sexual behavior.

Primary biliary cholangitis (PBC) is often associated with other autoimmune diseases, but little is known about the influence of thyroid disease (TD) on the natural history of PBC. Our aim is to analyze the association between PBC and TD, and the latter's impact on the natural history of PBC at two European centers.The study involved 921 PBC patients enrolled between 1975 and 2015 in Padova (376 patients) and Barcelona (545 patients), with a mean follow-up of 126.9±91.7 months. Data were recorded on patients' histological stage at diagnosis, biochemical data, associated extrahepatic autoimmune conditions, and clinical events, including hepatic decompensation.A total of 150 patients (16.3%) had TD, including 94 patients (10.2%) with Hashimoto's thyroiditis; 15 (1.6%) with Graves' disease; 22 (2.4%) with multinodular goiter; 7 (0.8%) with thyroid cancer; and 12 (1.3%) with other thyroid conditions. The prevalence of different types of TD was similar in Padova and Barcelona, except for Graves' disease and thyroid cancer, which were more frequent in the Padova cohort (15.7 vs. 5.0%, and 8.6 vs. 1.3%, respectively, P0.05). Overall, there were no differences between PBC patients with and without TD in terms of their histological stage at diagnosis, hepatic decompensation events, occurrence of HCC, or liver transplantation rate. The presence of associated TD was not associated with lower survival for PBC patients in either cohort.TDs, and autoimmune TD like Hashimoto's thyroiditis in particular, are often associated with PBC, but the presence of TD does not influence the rate of hepatic complications or the natural history of PBC.

is missing (Short communication)

HPV vaccination is a milestone in primary prevention. However in Italy, vaccine coverage is still nowhere near the target of 95%. We investigated factors associated with inclination to get vaccinated in university students, as they are likely to have just assumed a central role in their healthcare decision-making. University students aged 18-25 were asked to fill in a questionnaire. The effect of socio-demographic and behavioural characteristics on HPV awareness was assessed with a logistic regression adjusting for age, gender, nationality, degree course, relationship, age at first intercourse, number of sexual partners, smoking, sexual orientation, past diagnosis of STDs and knowledge of people who had received HPV vaccine. A second regression adjusting also for information sources, awareness and knowledge investigated factors associated with inclination to receive vaccine. Nine thousand nine hundred and eighty-eight questionnaires were included (response rate 91.3%); awareness of HPV and vaccine was 83.3% and 69.9% respectively. Awareness (AOR: 3.3; 95% CI: 2.3-4.6) and a good knowledge positively affected acceptability, as well as a previous diagnosis of STDs and knowledge of vaccinated people. Healthcare workers (AOR: 1.6; 95% CI: 1.4-1.9) and family members (AOR: 1.7; 95% CI: 1.4-2.1) were the most influencing information sources, even if knowledge of vaccinated people was by far more persuasive (AOR: 2.7; 95% CI: 2.2-3.3). Only 12% of participants were acquainted with skin to skin HPV transmission, while 75% believed in a full effectiveness of condom; less than 22% associated HPV with cancer (other than cervical cancer). Efforts to increase awareness are likely to be worth considering that: awareness is the main determinant of vaccine acceptance; only 50% of individuals not interested in receiving vaccine were aware of it; males are much less aware (AOR: 0.09; 95% CI: 0.07-0.11). Moreover, this study spotlights some misconceptions around HPV and acknowledges a pivotal role of healthcare workers, family and peer influence.

Italy is a low-incidence country for tuberculosis (TB). We describe a TB outbreak in a primary school in north-eastern Italy, involving 10 cases of active pulmonary disease and 42 cases of latent infection. The index case was detected in March 2019, while the primary case, an Italian-born schoolteacher, was likely infectious since January 2018. Administration of a pre-employment health questionnaire to school staff with sustained contact with children should be considered in low-incidence countries.

Background: The higher effectiveness of MF59®-adjuvanted trivalent influenza vaccine (MF59-TIV) vs. nonadjuvanted TIV in preventing influenza-related hospitalizations was found considering few influenza seasons, local and heterogeneous settings. This study evaluated the relative vaccine effectiveness (rVE) of MF59-TIV vs. nonadjuvanted TIV on the risk of hospitalization for pneumonia and cerebro/cardiovascular events across 15 consecutive influenza seasons. Research design and methods: Using Health Search Database, a case-control study was nested in a cohort of elderly vaccinated with MF59-TIV or TIV. Conditional logistic regression was used to estimate the odds ratio with 95% confidence intervals (CI) of hospitalizations potentially related to influenza in patients vaccinated with MF59-TIV or TIV. Results: Of 43,000 patients vaccinated with MF59-TIV (66.2%) and TIV (33.8%) for the first time, 103 cases of hospitalization for pneumonia or cerebro/cardiovascular events (0.11 per 1,000 person-weeks) during 15 influenza seasons were identified. The MF59-TIV was associated with a reduced risk of hospitalizations for pneumonia and cerebro/cardiovascular events vs. TIV [rVE: 39% (95% CI: 4-61%)]. Conclusions: In a 15-season cohort of elderly, MF59-TIV seems to reduce the risk of hospitalizations for pneumonia and cerebro/cardiovascular events when compared with nonadjuvanted TIV. Our findings support the recommendation for MF59-TIV in the elderly population.

Background Depression has been associated with a higher risk of cardiovascular events and a higher mortality in patients with one or more comorbidities. This study investigated whether continuative use of antidepressants (ADs), considered as a proxy of a state of depression, prior to acute myocardial infarction (AMI) is associated with a higher mortality afterwards. The outcome to assess was mortality by AD use. Methods A retrospective cohort study was conducted in the Veneto Region on hospital discharge records with a primary diagnosis of AMI in 2002–2015. Subsequent deaths were ascertained from mortality records. Drug purchases were used to identify AD users. A descriptive analysis was conducted on patients’ demographics and clinical data. Survival after discharge was assessed with a Kaplan-Meier survival analysis and Cox’s multiple regression model. Results Among 3985 hospital discharge records considered, 349 (8.8%) patients were classified as ‘AD users’. The mean AMI-related hospitalization rate was 164.8/100,000 population/year, and declined significantly from 204.9 in 2002 to 130.0 in 2015, but only for AD users (− 40.4%). The mean overall follow-up was 4.6 ± 4.1 years. Overall, 523 patients (13.1%) died within 30 days of their AMI. The remainder survived a mean 5.3 ± 4.0 years. After adjusting for potential confounders, use of antidepressants was independently associated with mortality (adj OR = 1.75, 95% CI: 1.40–2.19). Conclusions Our findings show that AD users hospitalized for AMI have a worse prognosis in terms of mortality. The use of routinely-available records can prove an efficient way to monitor trends in the state of health of specific subpopulations, enabling the early identification of AMI survivors with a history of antidepressant use.

HPV is involved in cervical, anal, penile, vulvar and oropharyngeal cancers, as well as genital warts. It is important to investigate knowledge and attitudes among university students, considering in this age a shift in healthcare decision-making from parents to students themselves. The aim of this study was to estimate knowledge and perception of HPV in terms of potential shame for HPV-related conditions, trust in vaccine efficacy and worry for potential side effects. The study involved students (18-25 years old) from the Universities of Padua and Verona, Italy. Socio-demographic and behavioural characteristics were collected with a questionnaire (n = 9988). Female gender and older age were positively associated with higher knowledge. The adjusted logistic regression showed an association between the set of perceptions investigated and the vaccination status, while a direct connection with knowledge was not found. However, another adjusted linear regression showed that a good set of perceptions could be partially explained by a high level of knowledge. Perceptions seem to fill an intermediate position between the knowledge and the decision to get vaccinated. The potential shame deriving from asking for HPV-vaccination was not identified as a relevant barrier. Having received information from healthcare workers, family and school showed to be positively associated with the adhesion to the vaccination policy. This study identifies university students as a possible target for HPV vaccination and pinpoints specific areas that might be targeted as first to encourage vaccine uptake. Primary prevention together with screening programmes remains essential in further reducing the burden of HPV-related diseases.

Summary Background More than 10 years have elapsed since human papillomavirus (HPV) vaccination was implemented. We did a systematic review and meta-analysis of the population-level impact of vaccinating girls and women against human papillomavirus on HPV infections, anogenital wart diagnoses, and cervical intraepithelial neoplasia grade 2+ (CIN2+) to summarise the most recent evidence about the effectiveness of HPV vaccines in real-world settings and to quantify the impact of multiple age-cohort vaccination. Methods In this updated systematic review and meta-analysis, we used the same search strategy as in our previous paper. We searched MEDLINE and Embase for studies published between Feb 1, 2014, and Oct 11, 2018. Studies were eligible if they compared the frequency (prevalence or incidence) of at least one HPV-related endpoint (genital HPV infections, anogenital wart diagnoses, or histologically confirmed CIN2+) between pre-vaccination and post-vaccination periods among the general population and if they used the same population sources and recruitment methods before and after vaccination. Our primary assessment was the relative risk (RR) comparing the frequency (prevalence or incidence) of HPV-related endpoints between the pre-vaccination and post-vaccination periods. We stratified all analyses by sex, age, and years since introduction of HPV vaccination. We used random-effects models to estimate pooled relative risks. Findings We identified 1702 potentially eligible articles for this systematic review and meta-analysis, and included 65 articles in 14 high-income countries: 23 for HPV infection, 29 for anogenital warts, and 13 for CIN2+. After 5–8 years of vaccination, the prevalence of HPV 16 and 18 decreased significantly by 83% (RR 0·17, 95% CI 0·11–0·25) among girls aged 13–19 years, and decreased significantly by 66% (RR 0·34, 95% CI 0·23–0·49) among women aged 20–24 years. The prevalence of HPV 31, 33, and 45 decreased significantly by 54% (RR 0·46, 95% CI 0·33–0·66) among girls aged 13–19 years. Anogenital wart diagnoses decreased significantly by 67% (RR 0·33, 95% CI 0·24–0·46) among girls aged 15–19 years, decreased significantly by 54% (RR 0·46, 95% CI 0.36–0.60) among women aged 20–24 years, and decreased significantly by 31% (RR 0·69, 95% CI 0·53–0·89) among women aged 25–29 years. Among boys aged 15–19 years anogenital wart diagnoses decreased significantly by 48% (RR 0·52, 95% CI 0·37–0·75) and among men aged 20–24 years they decreased significantly by 32% (RR 0·68, 95% CI 0·47–0·98). After 5–9 years of vaccination, CIN2+ decreased significantly by 51% (RR 0·49, 95% CI 0·42–0·58) among screened girls aged 15–19 years and decreased significantly by 31% (RR 0·69, 95% CI 0·57–0·84) among women aged 20–24 years. Interpretation This updated systematic review and meta-analysis includes data from 60 million individuals and up to 8 years of post-vaccination follow-up. Our results show compelling evidence of the substantial impact of HPV vaccination programmes on HPV infections and CIN2+ among girls and women, and on anogenital warts diagnoses among girls, women, boys, and men. Additionally, programmes with multi-cohort vaccination and high vaccination coverage had a greater direct impact and herd effects. Funding WHO, Canadian Institutes of Health Research, Fonds de recherche du Quebec – Sante.

HPV vaccination is a milestone in primary prevention. However in Italy, vaccine coverage is still nowhere near the target of 95%. We investigated drivers of vaccine uptake among university students, as they are likely to have just assumed a central role in their healthcare decision-making and potential barriers may differ from parents. University students aged 18-25 were asked to fill in a questionnaire. The effect of socio-demographic and behavioural characteristics on HPV awareness was assessed with a logistic regression adjusting for age, gender, nationality, degree course, relationship, age at first intercourse, number of sexual partners, smoking, sexual orientation, past diagnosis of STDs and knowledge of people who had received HPV vaccine. A second regression adjusting also for information sources, awareness and knowledge investigated drivers of vaccine uptake. 9,988 questionnaires were included; awareness of HPV and vaccine was 83.3% and 69.9%, respectively. Awareness (adjOR: 3.3 95%CI 2.3-4.6) and a good knowledge positively affected acceptability, as well as a previous diagnosis of STDs and knowledge of vaccinated people. Healthcare workers (adjOR 1.6 95%CI 1.4-1.9) and family members (adjOR 1.7 95%CI 1.4-2.1) were the most influencing information sources, even if knowledge of vaccinated people was by far more persuasive (adjOR 2.7 95%CI 2.2-3.3). Only 12% of participants were acquainted with skin to skin HPV transmission, while 75% believed in a full effectiveness of condom; less than 22% associated HPV with cancer (other than cervical cancer). Efforts to increase awareness are likely to be worth considering that: awareness is the main determinant of vaccine uptake; only 50% of individuals not interested in receiving vaccine were aware of it; males are much less aware (adjOR 0.09 95%CI 0.07-0.11). Moreover, this study spotlights some misconceptions and may provide suitable evidence in tailoring more efficacious communication strategies. Key messages There is room for improving the awareness of HPV. Efforts are likely to be worth since it remains the main determinant of vaccine uptake. Awareness has been growing but a gender gap still persists. Communication should focus more on HPV involvement in neoplasia other than cervical cancer; transmission via skin to skin contact; multiple sex partnership; partial protection of condom.

Vaccine hesitancy is a growing concern in many European countries, including Italy, as instanced by alarming results from Eurobarometer 488 dated April 2019. In the view of the current magnitude of the phenomenon, our aim was to investigate its determinants among parents, with a specific view on those working as health professional. In 2017, parents of children aged 3-84 months were recruited online. Based on self-reported vaccine status and timeliness of vaccinations, parents were classified as pro-, hesitant, or anti-vaccine. The association between baseline characteristics and hesitancy was investigated with logistic regression adjusting for child’s and parents’ age, prematurity, presence of older children, previous vaccine adverse reaction in the child at issue, parents’ nationality, education and employment status, health profession of at least one parent, single parenting, vegetarian lifestyle and perceived economic security. A total of 3,865 questionnaires were collected (64% pro-, 32% hesitant, 4% anti-vaccine). Families with at least one health professional as parent were 20% of the sample. Vegetarian lifestyle (aOR 3.0; 95%CI 2.20-4.08), unsatisfactory (aOR 1.67 95%CI 1.08-2.58) and partially satisfactory perceived economic security (aOR 1.40; 95%CI 1.09-1.78) and previous vaccine adverse reactions (aOR 1.25; 95%CI 1.05-1.48) were associated with vaccine hesitancy, while having older children resulted as a protective factor (aOR 0.82; 95%CI 0.69-0.98). No significant association was found with other abovementioned variables, including parent employed as health professional (aOR 0.99; 95%CI 0.81-1.22). Vaccine hesitancy seems to be part of a lifestyle choice and, to a smaller extent, associated with previous vaccine adverse reactions and lower socioeconomic status. Interestingly, parents’ level of education and employment in healthcare do not affect vaccine acceptance. The latter poses a challenge, given their crucial role in promoting vaccination. Key messages Hesitancy is associated with lifestyle choices, experience of adverse reactions and socioeconomic status, while education and employment as health professional seem not to be relevant. Whether they are health professionals or not, parents’ attitude towards their child’s vaccinations is the same.

Introduction: Tick-borne encephalitis (TBE) is an acute human arboviral infection of the central nervous system caused by a virus that is transmitted to humans mainly by tick bites. TBE is endemic in Europe and has become an increasingly important public health concern in recent years. Cases of TBE in Italy have occurred mainly in the north-east and central parts of the country. Vaccination is recommended for people who live in or visit areas at higher risk of tick bites. Objective: The aim of our study was to ascertain the burden of TBE in the Veneto Region (north-east Italy). Methods: Cases of TBE occurring in the region from January 1, 2007, to December 31, 2018, were extracted from the database of the mandatory notification system (MNS) and from hospital discharge records (HDRs) of admissions relating to a diagnostic code 063 according to the International Classification of Diseases, Ninth Revision, Clinical Modification. Capture-recapture methods were used to estimate the completeness of each data source (as a percentage of cases). Records including diagnostic codes 322.9 (Meningitis, unspecified) and 323.9 (Unspecified cause of encephalitis, myelitis, and encephalomyelitis) were also extracted from the HDR database. Municipalities were grouped by location, based on their elevation above sea level, as “mountains,” “hills,” or “lowlands”. After selecting only the municipalities where cases of TBE had occurred, the proportion of cases of TBE out of the total cases of encephalitis and meningitis identified was calculated and used to estimate the number of cases of TBE potentially occurring in the municipalities that reported none. Then the observed and adjusted TBE rates per 100,000 population were calculated. Results: During the 12 years considered, a total of 281 cases of TBE were identified; 155 emerged from the HDRs and the MNS, 89 only from the MNS database, and 37 only from the HDRs. The degree of completeness of the data was 93.0% for the MNS and HDRs combined, 80.8% for the MNS alone, and 63.6% for the HDRs alone. The observed annual rate of TBE in the Veneto in recent years was calculated at 0.48 per 100,000 population, with the highest standardized rate in the province of Belluno (5.95 per 100,000 population). A significant rising trend in the number of cases observed in the latest period (2015–2018) was apparent for the mountainous areas in the region (average annual percent changes: 43.7 [95% CI 19.0–73.5]). The number of cases peaked in the mountains in the month of June (0.89 per 100,000), in hilly areas in July (0.23 per 100,000) and in the lowlands in October (0.04 per 100,000). Conclusions: Our findings seem to confirm an underreporting of the cases of TBE and inadequate TBE surveillance in the Veneto, despite the clinical severity of the disease and the fact that it is mandatory to report all cases. The routine integration of different databases is crucial to the successful implementation and assessment of targeted prevention strategies and fundamental to public health decision-making on this issue.

BACKGROUND Reporting adverse events (AE) with a bearing on patient safety is fundamentally important to the identification and mitigation of potential clinical risks. OBJECTIVE The aim of this study was to analyze the AE reporting systems adopted at a university hospital for the purpose of enhancing the learning potential afforded by these systems. RESEARCH DESIGN Retrospective cohort study METHODS Data were collected from different information flows (reports of incidents and falls, patients' claims and complaints, and cases of hospital-acquired infection [HAI]) at an university hospital. A composite risk indicator was developed to combine the data from the different flows. Spearman's nonparametric test was applied to investigate the correlation between the AE rates and a Poisson regression analysis to verify the association among characteristics of the wards and AE rates. SUBJECTS Sixty-four wards at a University Hospital. RESULTS There was a marked variability among wards AE rates. Correlations emerged between patients' claims with complaints and the number of incidents reported. Falls were positively associated with average length of hospital stay, number of beds, patients' mean age, and type of ward, and they were negatively associated with the average Cost Weight of the Diagnosis-related group (DRG) of patients on a given ward. Claims and complaints were associated directly with the average DRG weight of a ward's patient admissions. CONCLUSIONS This study attempted to learn something useful from an analysis of the mandatory (but often little used) data flows generated on adverse events occurring at an university hospital with a view to managing the associated clinical risk to patients.

Introduction: Many studies have been published, but none have pooled the useful evidence available in the literature to produce guidelines and health policies promoting healthy eating styles to prevent breast cancer (BC). The present study aimed to summarize the evidence produced to date, taking a judicious, critical approach to the quality of the studies analyzed. Methods: An umbrella review method was adopted, which is a systematic review of second-level studies, meta-analyses and literature reviews. Results: In all, 48 studies were considered: 32 meta-analyses, 4 pooled analyses, 5 systematic reviews, and 7 qualitative reviews. A higher intake of total meat, or red or processed meats, or foods with a high glycemic index, or eggs would seem to be associated with a higher risk of BC. Some foods, such as vegetables, would seem instead to have an inverse association with BC risk. One meta-analysis revealed an inverse association between citrus fruit and mushroom consumption and BC. Some nutrients, such as calcium, folate, vitamin D, lignans and carotenoids, also seem to be inversely associated with BC risk. The evidence is still conflicting as concerns exposure to other dietary elements (e.g., polyunsaturated fatty acids, dairy foods). Conclusion: Nutrition is one of the most modifiable aspects of people’s lifestyles and dietary choices can affect health and the risk of cancer. Overall, adhering to a healthy eating style may be associated with a significant reduction in the risk of BC.

Six cases of serogroup C invasive meningococcal disease were identified in Treviso district, Veneto region, Italy between December 13 and 15, 2007. The afflicted patients were found to have attended the same Latin-dance clubs on the same nights, and chemoprophylaxis was provided to potentially exposed individuals. Despite these efforts, 2 cases caused by the same meningococcal strain subsequently occurred in the same area, without any apparent epidemiological correlation to the initial cases. This may have resulted from a failure to neutralize the meningococcal carrier/s. The root cause analysis method applied to public health emergency preparedness was used to analyze the response to this critical incident. The root cause analysis revealed a need to develop regional guidelines for the classification and management of a meningococcal outbreak and for developing risk-communication strategies that include the identification of appropriate channels of communication for differing segments of the population. (Disaster Med Public Health Preparedness. 2019;13:368–371)

Background Demographic changes and chronicity are posing new challenges to health care systems. Our study aimed to examine how effectively the three different types of proactive primary care models adopted by three different regional health care systems in Italy were improving the quality of diabetes management by general practitioners. Methods A coordinated Italian nationwide project to compare systematically the new proactive organizational models implemented at regional and local level (the MEDINA Project) involved several regions and their local health units (LHUs). A quasi-experimental study was conducted on a large dataset obtained by processing administrative databases. A combined indicator was developed to assess the quality of care delivered by primary care physicians, based on adherence to recommendations concerning patient monitoring and treatment. Result The study concerned 602 Italian general practitioners (GPs), 174 of them female, who were caring for a total of 753,366 patients (47,575 of them diabetic). Analyzing a total score, representing global adherence to a quality management of patients with diabetes, confirmed that GPs who had adopted the new model of care for their diabetic patients obtained better results than those who had not, so the new policy was generally effective. Conclusion Our study showed that introducing new, proactive primary care models could sustain efforts made around the world to guarantee good-quality chronic disease management in the primary care setting.

Background Genital warts are one of the most common forms of sexually-transmitted disease, but their epidemiology has yet to be thoroughly elucidated. The present study was designed to shed light on the prevalence of clinically-confirmed, self-reported genital warts (GWs) in a representative sample of the university population. Methods In 2015, a cross-sectional survey was conducted on 11,096 individuals approached at the Students Information Bureau where they came to enroll for a university degree course. Participants completed an anonymous, self-administered questionnaire providing information on their sociodemographic characteristics, sexual behavior, and any history of clinically-diagnosed genital warts. Multivariate logistic regression was then used to identify any factors associated with the disease. Results Our analysis was conducted on 9259 questionnaires (83.4%). Participants were a mean 21.8 ± 4.8 years of age, and 59.6% were female. Overall, 124 individuals (1.3%, 95%CI: 1.0–1.6) reported having been diagnosed with genital warts: 48 men (1.3%, 95%CI: 0.9–1.6), and 76 women (1.4% 95%CI: 1.1–1.7). Overall, 22.5% of the sample were vaccinated (1.3% of the males and 36.8% of the females). The group of respondents aged 30 years or more had the highest incidence of genital warts (males: 5.6%, 95%CI: 2.5–8.6; females: 6.9%, 95%CI: 3.4–10.4). The independent risk factors associated with a history of disease were (for both genders) a history of other sexually-transmitted diseases, and ≥2 sex partners in the previous 24 months. A protective role emerged for routine condom use. Additional risk factors associated with genital warts in males concerned men who have sex with men, bisexuality vis-à-vis heterosexuality, and smoking. Conclusions The findings emerging from our study help to further clarify the epidemiology of genital warts in young people, and may be useful to public health decision-makers. This study showed that genital warts occur in men as well as women, and suggests that both genders should be monitored for this disease to ascertain the effects of the free HPV vaccination offered to all girls in the Veneto in their 12th year of life since 2008, and to all boys of the same age since 2015.

To assess the burden of herpes zoster (HZ) by analyzing HZ-related hospital admissions. We conducted a population-based descriptive cross-sectional study on all hospitalizations for HZ among the resident population admitted to all public and accredited private hospitals in the Veneto Region (north-east Italy) during the years 2008–2016. HZ hospitalizations were identified from the International Classification of Diseases codes in the hospital discharge records. During the period considered, we identified 3566 HZ-associated admissions, 194 (5.4%) of which were readmissions within 30 days. A complicated HZ diagnosis was mentioned for 44.4% of the patients admitted once and for 65.9% of those admitted twice. In the sample as a whole, 27.0% of patients had at least one comorbidity. Overall, our analysis revealed a gradual increase in hospitalizations with age for both genders, reaching a hospitalization rate for the population over 80 years old of 51.2 × 100,000 for males and 52.8 × 100,000 for females. The average hospitalization rate for HZ-related conditions during the years 2008–2016 was 7.7 per 100,000 population. Postherpetic neuralgia was diagnosed in 8.2% of hospitalizations, with no difference between the genders. The estimated overall cost of HZ-related conditions was approximately €2.7 million a year. This study suggests that the burden of HZ and its impact on quality of life are of critical relevance to public health decision-making.

Background In 2016, 362 753 migrants reached Europe by sea. Most of migrants come from high tuberculosis (TB) burden countries and travel in conditions that increase the risk for communicable diseases. The goal of WHO End TB Strategy is to end global epidemic by 2035. Management of latent TB infection (LTBI) in low TB incidence countries is thus essential. Nevertheless, a lack of uniformity in policies and procedures for LTBI screening in Europe is perceived. The aim of this study was to estimate the LTBI prevalence in migrants by Mediterranean Sea. Methods A cross-sectional study was conducted, involving 1038 migrants. Since a gold standard method is not available, LTBI prevalence was assessed in four alternative scenarios with different thresholds and diagnostic tools: (i) TST ≥ 5 mm; (ii) TST ≥ 10 mm; (iii) TST ≥ 5 mm plus IGRA; and (iv) TST ≥ 10 mm plus IGRA. TST = tuberculin skin test; IGRA = interferon-gamma release assay. Results The four scenarios returned the following prevalence: (i) TST ≥ 5 mm: 40%; (ii) TST ≥ 10 mm: 33%; (iii) TST ≥ 5 mm plus IGRA: 27%; and (iv) TST ≥ 10 mm plus IGRA: 25%. Moreover, a positive association was found between the proportion of IGRA positive patients and the size of TST induration site. No patient who reported TST ≥ 18 mm tested IGRA negative. Conclusions Prevalence varied substantially in the investigated scenarios. Significant differences were noted according with the nationality of migrants, probably attributable to different Bacillus Calmette-Guerin vaccination coverage rates in the countries of origin or different exposition to non-tuberculous mycobacteria infection. Data about the nationality can suggest the need of a tailored approach according to migrants' area of origin.

Cutaneous melanoma is a major concern in terms of healthcare systems and economics. The aim of this study was to estimate the direct costs of melanoma by disease stage, phase of diagnosis, and treatment according to the pre-set clinical guidelines drafted by the AIOM (Italian Medical Oncological Association). Based on the AIOM guidelines for malignant cutaneous melanoma, a highly detailed decision-making model was developed describing the patient's pathway from diagnosis through the subsequent phases of disease staging, surgical and medical treatment, and follow-up. The model associates each phase potentially involving medical procedures with a likelihood measure and a cost, thus enabling an estimation of the expected costs by disease stage and clinical phase of melanoma diagnosis and treatment according to the clinical guidelines. The mean per-patient cost of the whole melanoma pathway (including one year of follow-up) ranged from €149 for stage 0 disease to €66,950 for stage IV disease. The costs relating to each phase of the disease's diagnosis and treatment depended on disease stage. It is essential to calculate the direct costs of managing malignant cutaneous melanoma according to clinical guidelines in order to estimate the economic burden of this disease and to enable policy-makers to allocate appropriate resources.

INTRODUCTION Patients with complex health care needs (PCHCN) are individuals who require numerous, costly care services and have been shown to place a heavy burden on health care resources. It has been argued that an important issue in providing value-based primary care concerns how to identify groups of patients with similar needs (who pose similar challenges) so that care teams and care delivery processes can be tailored to each patient subgroup. Our study aims to describe the most common chronic conditions and their combinations in a cohort of elderly PCHCN. METHODS We focused on a cohort of PCHCN residing in an area served by a local public health unit (the "Azienda ULSS4-Veneto") and belonging to Resource Utilization Bands 4 and 5 according to the ACG System. For each patient we extracted Expanded Diagnosis Clusters, and combined them with information available from Rx-MGs diagnoses. For the present work we focused on 15 diseases/disorders, analyzing their combinations as dyads and triads. Latent class analysis was used to elucidate the patterns of the morbidities considered in the PCHCN. RESULTS Five disease clusters were identified: one concerned metabolic-ischemic heart diseases; one was labelled as neurological and mental disorders; one mainly comprised cardiac diseases such as congestive heart failure and atrial fibrillation; one was largely associated with respiratory conditions; and one involved neoplasms. CONCLUSIONS Our study showed specific common associations between certain chronic diseases, shedding light on the patterns of multimorbidity often seen in PCHCN. Studying these patterns in more depth may help to better organize the intervention needed to deal with these patients.

Background Streptococcus pneumoniae (SP) is a major cause of morbidity and mortality worldwide in all age groups. Serious diseases often caused by pneumococci include pneumonia, meningitis and bacteremia. Objective The aim of this work was to estimate the hospitalization rate for SP in the Veneto region by investigating pneumococcal-related discharges. Material and methods This was a retrospective study based on hospital discharge data collected from 2008 to 2012 in the Veneto Region (north-east Italy). All hospitalizations for diseases potentially associated with SP were identified by searching the hospital discharge records, then the proportions of hospital admissions for pneumonia, meningitis and septicemia attributable to the infection were calculated. Comorbidities were also graded according to the Charlson Comorbidity Index (CCI). Data were analyzed using the chi square test and Student's t-test for unpaired data, as appropriate. Significant trends over the years considered were examined in terms of average annual percent changes (AAPC). A p value, Highlights • Estimated hospitalization rate was higher in children and the elderly • Overall fatality rate was 11.0%. • Economic burden of SP-HA was around €14.8 million a year in Veneto Region.

HPV (human papillomavirus) is the virus most often responsible for sexually transmitted infections. The burden of HPV-related diseases on hospital resources represents a major public health problem. The aim of this study was to assess the economic burden of HPV-related diseases (anal cancer, genital cancer, genital warts, oropharyngeal cancer) on hospital resources in two Italian regions. A retrospective, non-randomized, observational study was developed in the Marche and Veneto Regions, based on patients receiving hospitalization between 2008 and 2011. All hospitalizations were identified through administrative archives, according to the International Classification of Diseases (ICD-9 CM) to which a defined tariff was assigned. We identified 5299 hospitalized patients in Veneto and 1735 in the Marche Region. The mean annual hospitalization rate was 49.44 per 100,000 individuals in Veneto and 48.41 in Marche. The total mean annual cost attributable to HPV-related diseases was €5.78 (SD 0.80) million in Veneto and €2.24 (SD 0.17) million in Marche. Costs associated with genital cancer amounted to €1.61 million in Veneto and €1.06 million in Marche (28% and 47% of the total mean annual cost, respectively). Oropharyngeal cancer accounted for 36% in Veneto (€2.08 million) and 28% in Marche (€632,645). Hospitalization costs related to anal cancer were €882,567 in Veneto and €377,719 in Marche; genital warts accounted for €1.19 million in Veneto and €171,406 in Marche. Finally, the mean cost per patient was €4364 in Veneto and €5176 in Marche. The present work estimated the cost of HPV-related diseases for hospitalized patients in two Italian regions. The considerable estimated annual economic burden is a powerful driver for the governance of the public health sector.

Background Epidemiology of Neisseria meningitidis has been changing since the introduction of universal vaccination programmes against meningococcal serogroup C (MenC) and meningococcal serogroup B (MenB) has now become dominant. This study aimed to analyse the cases reported in institutional data recording systems to estimate the burden of invasive meningococcal diseases (IMDs) and assess the effectiveness of surveillance in Veneto region (Italy). Methods Analysis was performed from 2007 to 2014 on data recorded in different systems: Mandatory Notification System, National Surveillance of Invasive Bacterial Diseases System and Laboratories Surveillance System (LSS), which were pooled into a combined surveillance system (CSS) and hospital discharge records (HDRs). A capture-recapture method was used and completeness of each source estimated. Number of cases with IMD by source of information and year, incidence of IMD by age group, case fatality rate (CFR) and distribution of meningococcal serogroups by year were also analysed. Results Combining the four data systems enabled the identification of 179 confirmed cases with IMD, achieving an overall sensitivity of 94.7% (95% CI: 90.8% to 98.8%), while it was 76.7% (95% CI: 73.6% to 80.1%) for CSS and 77.2% (95% CI: 74.1% to 80.6%) for HDRs. Typing of isolates was done in 80% of cases, and 95.2% of the typed cases were provided by LSS. Serogroup B was confirmed in 50.3% of cases. The estimated IMD notification rate (cases with IMD diagnosed and reported to the surveillance systems) was 0.48/100 000 population, and incidence peaked at 6.2/100 000 in children aged

Rectal resection is technically one of the most demanding laparoscopic procedures, requiring additional training and expertise of both surgeons and institutions. The literature has shown that laparoscopic procedures can be appropriate for the treatment of rectal cancer (RC), in terms of safety, outcome and efficiency, but results may not always be directly transferable to the general population. This study aimed to investigate the use of laparoscopic rectal cancer resections in a north-eastern Italian region (the Veneto) and to see how the characteristics of patients and hospitals are associated with the use of laparoscopy. This was a retrospective cohort study based on administrative data collected from 2007 to 2014 in the Veneto region (north-east Italy). In the period considered (2007–2014), 4953 rectal resections were performed for RC in Veneto hospitals, accounting for 35% of the total 14,243 surgical procedures involving the rectum, and resulting in 76,739 days in hospital [mean length of stay—post-operative (MLOS) 15.5 ± 11.1 days]. Patients were a mean 67.9 ± 11.7 years old (68 ± 12.7 for women, 67.9 ± 11 for men), while the subgroup of patients undergoing laparoscopic procedures was on average 2 years younger (66.5 ± 11.8 vs 68.8 ± 11.5; p

There is a paucity of information on extrahepatic autoimmune (EHA) conditions associated with primary biliary cirrhosis (PBC) and on the impact of EHA conditions on PBC patients’ survival. Our goal was to assess the association between PBC and other autoimmune diseases and the impact of EHA conditions on the natural history of PBC. We took advantage of 361 consecutive PBC patients enrolled between 1975 and 2012 (22 males, 339 females; mean follow-up 8 ± 6.9 years). Any associated EHA conditions, PBC histological stage at diagnosis, biochemical data, physiological history, and extrahepatic malignancies developing during the follow-up were recorded. Survival was analyzed by means of Kaplan-Meier curves. Importantly, 221 patients (61.2 %) had at least one EHA conditions: 45 patients (20.4 %) had Hashimoto thyroiditis; 7 (3.2 %) had Graves’ thyroiditis; 65 (29.4 %) had Raynaud’s phenomenon; 124 (56.1 %) had Sjogren’s syndrome; 8 (3.6 %) had systemic lupus erythematosus; 22 (9.9 %) had scleroderma; 22 (9.9 %) had rheumatoid arthritis; 18 (8.1 %) had cutaneous autoimmune diseases; 8 (3.6 %) had vasculitis; 5 (1.4 %) had celiac disease; and 25 (13.1 %) had other EHA conditions. The proportion of patients with associated EHA conditions enrolled during representative periods (1975–1980, 1981–1990, 1991–2000, 2001–2010, 2011–2012) remained stable. No differences emerged between patients with versus without EHA conditions in terms of mean age at PBC diagnosis, antimitochondrial antibody (AMA), or antinuclear antibody (ANA) positivity, histological stage at diagnosis, smoking habits, alcohol consumption, or BMI >25. Multiple logistic regression analysis showed that only female gender was significantly associated with positivity for EHA conditions (OR 4.8; 95 % CI 1.6–13.7, p = 0.004). The mean survival after the diagnosis of PBC was much the same in patients with and without EHA conditions. In conclusion, EHA conditions are often associated with PBC, especially in female patients, but they do not reduce patient survival.

ObjectivesThe aim of this study was to elucidate the pathway of associations linking gambling, alcohol intake, smoking habit, cannabis consumption between each other and with demographic and socioeconomic variables.Setting and participantsA survey was conducted in 2017 on a representative sample of 15 602 Italian 14-year-olds to 17-year-olds attending 201 secondary schools.Outcome measuresStructural Equation Models analysis was used to assess the pathway between gambling, alcohol intake, smoking, cannabis consumption, demographics and socioeconomic factors.ResultsIrrespective of socioeconomic or demographic variables, gambling is positively associated with alcohol and cannabis consumption, while cannabis consumption is predicted by smoking and by alcohol intake, smoking is predicted by alcohol intake. Adolescents with a higher weekly income are more at risk of gambling, drinking alcohol and smoking, while the degree of economic dissatisfaction was positively associated with alcohol intake, cannabis consumption and smoking. Maternal employment appeared to be positively associated with adolescents’ smoking, alcohol intake and cannabis consumption.ConclusionsThis is one of the first studies to shed light on the pathways of associations connecting various health-risk behaviours among adolescents with demographic and socioeconomic factors.

BACKGROUND Cholangiocarcinoma (CCA) and gallbladder cancer are the second cause of liver malignancy after hepatocellular carcinoma. Epidemiological data point to an increase in the incidence of CCA in both western and eastern countries; however, data on more recent years are lacking. AIMS The aim of this study was to elucidate the more recent epidemiology of CCA and gallbladder carcinoma in north-east Italy using automatically collected regional data on hospital admissions over a 10-year period. MATERIALS AND METHODS We performed a retrospective analysis of the Veneto region (north-east Italy) database of patients' hospital discharge records, identifying cases with the following codes: intrahepatic cholangiocarcinoma (155.1), primary gallbladder cancer (156.0), and primary extrahepatic biliary tract cancer (156.1). Hospitalizations were recorded according to the surgical or medical procedures involved (based on International Classification of Diseases-9 procedure codes), and only the first hospitalization was considered for the 2005-2009 period. RESULTS The number of hospitalizations for biliary tumors as a whole has remained stable over the past 10 years. The hospitalization rate of intrahepatic CCA is increasing; this cancer is more frequent in males than in females. The hospitalization rate for gallbladder cancer is increasing with age. However, the figures for extrahepatic CCA have remained stable over the past 10 years. The duration of survival was significantly longer for patients who underwent radical surgery than for those who did not. CONCLUSION Efforts are needed to prevent CCA, bearing in mind the emerging conditions associated with its onset. Secondary prevention of these tumors will substantially improve the duration of survival.

Background Community-acquired pneumonia (CAP) is an important cause of illness and death worldwide, particularly among the elderly. Previous studies on the factors associated with mortality in patients hospitalized for CAP revealed a direct association between the type of microorganism involved, the characteristics of the patient and mortality. Vaccination status against pneumococcal disease was not considered. We conducted a retrospective analysis on the mortality rates after a first hospitalization for CAP in north-east Italy with a view to examining especially the role of anti-pneumococcal vaccination as a factor associated with pneumonia-related mortality at one year. Method Between 2012–2013, patients aged 65+ hospitalized with a primary diagnosis of CAP, identified based on International Classification of Diseases, Ninth Revision, Clinical Modification codes 481–486, were enrolled in the study only once. Patients were divided into three groups by pneumococcal vaccination status: 1) 13-valent pneumococcal conjugate vaccine (PCV13) prior to their hospitalization; 2) 23-valent pneumococcal polysaccharide vaccine (PPV23) within 5 years before hospitalization and 3) unvaccinated or PPV23 more than 5 years prior to admission. Gender, age, length of hospital stay and influenza vaccination were considered. Comorbidities were ascertained by means of a properly coded diagnosis. Every patient was followed up for 1 year and the outcome investigated was mortality for any cause and for pneumonia. Results A total of 4,030 patient were included in the study; mean age at the time of admission to hospital was 84.3±7.7; 50.9% were female. 74.2% of subjects had at least one comorbidity; 73.7% has been vaccinated against influenza. Regard to pneumococcal vaccine, 80.4% of patients were not vaccinated, 14.5% vaccinated with PPV23 and 5.1% with PCV13. The 1-year survival rates after hospitalization for pneumonia were 83.6%, 85.9% and 89.3% in the unvaccinated, PPV23 and PCV13 groups, respectively. Regression analysis indicated that the risk of death due to pneumonia increased significantly with age (adjusted OR: 1.073; 1.061–1.085), shorter hospital stay (adjusted OR: 0.981; 0.971–0.990), and male gender (adjusted OR: 1.372; 1.165–1.616). The model also confirmed the pneumococcal 13-valent conjugated vaccine as an independent protective factor for mortality-related pneumonia (adjusted OR: 0.599; 0.390–0.921). Conclusion The main finding of our observational cohort study is a high mortality rate among elderly patients admitted to hospital for pneumonia. The present study suggests a protective role for PCV13 vaccination.

Objectives Problematic use of video games (PUVG) is associated with substance use in middle school students. The aim of our study was to examine the association between PUVG and substance abuse in children and young adolescents. Methods A survey was conducted during the 2014-2015 school year in Padua (northeastern Italy). The sample consisted of 1156 students in grades 6 to 8. A multivariate logistic regression model was applied to seek associations between PUVG (dependent variable) and independent variables. Results Logistic regression showed that lifetime drunkenness, combined energy drink and alcohol consumption (lifetime), reading comics, and disrespect for rules increased the odds of PUVG, whereas playing competitive sport, eating fruit and/or vegetables daily, finding it easy to talk with fathers and being female lowered the odds of PUVG in early adolescence. Conclusions Our findings show that PUVG is more likely in young adolescents at risk of substance abuse. Prevention schemes focusing on early adolescence should be based on a multicomponent intervention strategy that takes PUVG into account.

Background A growing presence of inappropriate patients has been recognised as one of the main factors influencing emergency department (ED) overcrowding, which is a very widespread problem all over the world. On the other hand, out-of-hours (OOH) physicians must avoid delaying the diagnostic and therapeutic course of patients with urgent medical conditions. The aim of this study was to analyse the appropriateness of patient management by OOH services, in terms of their potentially inappropriate referral or non-referral of non-emergency cases to the ED. Methods This was an observational retrospective cohort study based on data collected in 2011 by the local health authority No. 4 in the Veneto Region (Italy). After distinguishing between patients contacting the OOH service who were or were not referred to the ED, and checking for patients actually presenting to the ED within 24 hours thereafter, these patients’ medical management was judged as potentially appropriate or inappropriate. Results The analysis considered 22 662 OOH service contacts recorded in 2011. The cases of potentially inappropriate non-referral to the ED were 392 (1.7% of all contacts), as opposed to 1207 potentially inappropriate referrals (5.3% of all contacts). Age, nationality, type of disease and type of intervention by the OOH service were the main variables associated with the appropriateness of patient management. Conclusions These findings may be useful for pinpointing the factors associated with a potentially inappropriate patient management by OOH services and thus contribute to improving the deployment of healthcare and the quality of care delivered by OOH services.

Non-melanoma skin cancers (NMSC) are the most common form of human skin cancer. The majority of NMSC are basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) with a BCC:SCC incidence ratio of 4:1 in immunocompetent patients. Toll-like receptors (TLRs) are transmembrane glycoproteins that recognize pathogen-associated molecular patterns and damage-associated molecular patterns, against which they activate the innate immune response and initiate the adaptive immune response. Genetic variations of these receptors can alter the immune system and are involved in evolution and susceptibility of various diseases, including cancer. Imiquimod, an agonist of TLR7, is applied topically in the treatment of premalignant and malignant skin disorders, in particular BCC. The high efficacy of this TLR7 agonist toward BCC supports a possible role of this receptor in the induction of BCC and, consequently, polymorphisms of this receptor could be responsible for a greater or lesser susceptibility to BCC. The aim of the present study was to evaluate whether the presence of the functional TLR7 rs179008/Gln11Leu promoter polymorphism conferred an increased susceptibility to BCC. A case-control study with 177 BCC cases and 158 controls was performed to highlight the possible association between this polymorphism and the susceptibility to BCC. As the TLR7 gene is localized on chromosome X, the allelic frequency of this polymorphism was analyzed separately in males and females. The analysis of the distribution of frequencies of wild-type TLR7 and variant TLR7 carrying the single-nucleotide polymorphism (SNP) rs179008 in patients with BCC and healthy subjects did not reveal any statistically significant difference between cases and controls. This study does not suggest the involvement of the SNP rs179008 of TLR7 in the susceptibility to BCC, but cannot exclude a role for TLR7 in BCC carcinogenesis considering the high efficacy of the TLR7 agonist, imiquimod, in the treatment of this neoplastic disorder.

Objective Previous research among late adolescents suggests an additive association between levels of engagement in gambling and vulnerability to substance use disorder. The aim of our research was to investigate the frequency of gambling experience in childhood and early adolescence and to examine the association between alcohol/cigarette/energy drink consumption and gambling in this young population. Methods A survey called "Pinocchio" was conducted during the 2013 to 2014 school year at primary and secondary schools in Padua (north-eastern Italy) on a sample of 1325 students in sixth to eighth grade (11-13 year olds). Multilevel analysis, taking the school-level variance into account, established an adjusted association between gambling and attitude to risk-taking among early adolescents. Results Among eighth graders, 45.8% of the boys and 35.4% of the girls reported at least 1 type of gambling. In a fully-adjusted model, having experience of gambling confers a higher likelihood of being consumers (at least once a month) of other substances (alcohol, cigarettes, energy drinks, or marijuana). Conclusion Gambling behavior is widespread among adolescents. An association with other risk-taking behavior was found in this study, and this provides further evidence of the need for a greater awareness of gambling behavior in early adolescence.