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During 2020, COVID-19 had a diversified distribution in Italy, the first nation in Europe to experience the outbreak of the epidemic. This was linked to geographical differences in population density and distribution of healthcare facilities, including Emergency Departments (EDs). This study aims to assess the impact of the pandemic on ED utilization in 2020 across different subpopulations and geographical locations in Italy.We used anonymized data from a survey conducted by the Italian National Institute of Statistics on 25,000 families to analyze the yearly rate of people who used EDs from 2015 to 2020. The rate of persons who accessed ED services in 2020 per 1,000 population was compared with those of the previous non-pandemic years.The number of people accessing EDs in 2020 was 32.3% lower, although this reduction was not uniform across the 21 regions / autonomous provinces. People aged 0-14 years experienced the highest reduction in ED visits. In 2020, low educational level people exhibited a steeper reduction in the use of EDs.This study shows a significant drop in EDs use especially by children; the population section mostly affected by the effects of the pandemic. This study also confirms that education and socio-economic status are important determinants of ED use. The heterogeneous reduction in ED use across the regions of Italy highlights the need to further investigate the impact of this pattern on the health of the population, as well as to define adequate preparedness strategies to face future emergencies.

The Covid-19 pandemic significantly increased the workload for the Italian Health Service. There is few information in the literature on the pediatric population and on the management of pediatric hospitals. The aim of this article is to describe the management of healthcare services during Covid-19 emergency in Regina Margherita Children's Hospital. The Regina Margherita Children's Hospital is specialized in the prevention, diagnosis and treatment of pediatric diseases. About 1000 health worker work in this Hospital and 278 hospitalization places are available.

On December 31, 2019, Chinese authorities reported to the World Health Organization the first case of what is now known as COVID-19, a respiratory syndrome caused by Severe Acute Respiratory Syndrome - Coronavirus 2 (SARS-CoV-2). Four months later, the virus caused a pandemic that has changed the lives of billions of people. In the weeks after the announcement of the first COVID-19 case, while some Asian countries (i.e. South Korea, Singapore, Taiwan) promptly equipped themselves to face a probable national outbreak, most Western nations minimized the risks posed by the virus and limited their actions to travel bans, whose effectiveness is still debated. Italy, one of the first and most severely hit countries in the Western world, was among them. However, discussions on whether to admit people coming from the outbreak epicenter in China raged immediately not only at the political level but also on the media and social media, paired with xenophobic comments on Chinese wet markets and culinary habits.

Background: Perceived health is largely dependent on multiple socio-demographic and behavioral lifestyles and healthcare related factors. This could be accentuated when gender is taken into account. The aim of this study is to explore gender-related differences in multiple socio-demographic and behavioral lifestyles and healthcare related factors associated with individual health status and to identify those responsible for changes in perceived physical and mental health among men and women in Italy. Study design: We conducted a cross-sectional retrospective study to investigate the association between multiple socio-demographic and behavioral lifestyles and healthcare related factors and individual health status of 99,479 adults in Italy, using data and information obtained from a nationwide survey. Methods: To identify the factors that correlate with the perceived physical and mental health status between males and females, we employed a censored regression analysis, a Tobit model, stratifying the analysis by gender. Results: Socio-demographic and behavioral lifestyles factors differently impact on males and females and this impact is stronger on perceived physical than mental health. The perceived physical and mental health status resulted better for men than for women. The integrated analysis of gender differences in socio-demographic and behavioral lifestyles and determinants of health revealed important inequalities, mainly related to citizenship and educational level, among the socio-demographic factors, and smoking habit and obesity, among the behavioral lifestyle factors. Conclusions: Gender imbalances mainly fall into inequality in social inclusion, educational level, and healthy lifestyle. This demonstrates how gender differences are still abundantly present in the modern Italian society. Such information should be taken into consideration by policy makers when interventions to improve the health and quality of life of the population are planned or evaluated.

Many studies reported a higher risk of COVID-19 disease among patients on dialysis or with kidney transplantation, and the poor outcome of COVID-19 in these patients. Patients in conservative management for chronic kidney disease (CKD) have received attention only recently, therefore less is known about how COVID-19 affects this population. The aim of this study was to provide evidence on COVID-19 incidence and mortality in CKD patients followed up in an integrated healthcare program and in the population living in the same catchment area. The study population included CKD patients in conservative management recruited in the Emilia-Romagna Prevention of Progressive Renal Insufficiency (PIRP) project, followed up in the 4 nephrology units (Ravenna, Forli, Cesena and Rimini) of the Romagna Local Health Authority (Italy) and alive at 1.01.2020. We estimated the incidence of COVID-19, its related mortality and the excess mortality within the PIRP cohort as of 31.07.2020. COVID-19 incidence in CKD patients was 4.09% (193/4,716 patients), while in the general population it was 0.46% (5,195/1,125,574). The crude mortality rate among CKD patients with COVID-19 was 44.6% (86/193), compared to 4.7% (215/4,523) in CKD patients without COVID-19. The excess mortality of March-April 2020 was +69.8% than the average mortality of March-April 2015-19 in the PIRP cohort. In a cohort mostly including regularly followed up CKD patients, the incidence of COVID-19 disease and COVID-19 related mortality were about ten times higher than those of the general population. The incidence of COVID-19 among CKD patients was strongly related to the spread of the infection in the community, while its lethality is associated with the underlying kidney condition and comorbidities. For this reason, it is urgent to offer a direct protection to CKD patients by prioritizing their vaccination.

Background The recent COVID-19 epidemic is showing how the response of the scientific literature is fundamental in the first days following the onset of a new epidemic. Quantifying which studies have a greatest impact can help researchers and policymakers in controlling the epidemic. The aim of this study is to describe the early scientific production in response to the COVID-19 epidemic through a scientometric analysis. Methods The study consisted of: 1) review of the scientific literature produced in the 30 days since the first paper related to COVID-19 has been published on Pubmed; 2) Identification of papers' Digital Object Identifiers (DOI) and analysis of related metrics with the construction of a 'Computed Impact Score' (CIS) that represents a unifying score over heterogeneous bibliometric indicators. The CIS takes into account all the bibliometric indicators both traditional (i.e. counting of citations) and alternative (i.e. altmetrics). In this study we use the altmetrics provided by Plum Analytics (PlumX). All bibliometric indicators for the selected papers have been collected by using their corresponding DOIs as the key for querying Scopus API, which integrates PlumX. On top of those indicators we compute the CIS. The papers with higher CIS are discussed and presented. Results 239 papers have been included in the study. A threshold for CIS of t = 1.04 (i.e.95% quantile) allowed us to record 8 papers as potentially impactful. The 8 papers are: 6 case reports, 1 methodological study, 1 editorial. First authors come from China (n = 6), USA (n = 1) and Germany (n = 1). The main topics are: case/s description (n = 5), outbreak investigation (n = 2) and 1 genomic study. Conclusions The early response of the scientific literature during an epidemic does not follow a pre-established pattern. Tracing the traditional and non-traditional metrics measures of papers can help to understand and evaluate the impact of literature on the scientific community and general population. Key messages The dynamic of the scientific community represents an important aspect of the early response to the onset of a new epidemic, which must be studied also to increase systems’ preparedness. In a connected digital world, tracing metrics measures of scientific papers can identify those with the greatest impact and help professionals to correctly inform the population.

Background The proportion of migrants among incident patients with chronic kidney disease (CKD) in the Emilia-Romagna region is steadily increasing. Inequalities in access to health services and in outcomes between non-migrant and migrant patients already known in the literature are found also for those affected by CKD. We compared migrants' groups and Italian patients to provide evidence which may be useful to public health professionals and nephrologists for migrant patients' management. Methods Italian and migrant patients followed up in PIRP (a regional project devised to delay progression to kidney failure in subjects with CKD) were identified. Migrants were grouped by geographical area of origin and compared to Italians by means of descriptive statistics and survival analysis. Results As of 30.4.2020, migrants account for 3.1% (n = 955/30523) of all PIRP patients and 4.2% (n = 481/11335) of prevalent patients; their proportion among incident patients grew from 1.0% in 2004 to 5.5% in 2019. All areas of origin were adequately represented, from 6.4% of East Asia to 26.1% of East Europe. Wide differences were found for: age at first visit (Italians=73.1 years vs. Sub-Saharians=47.7), proportion of males (75.0% for South Asians to 49.6% of East Europeans), diabetes (from 45.1% in East Asians to 19.4% in Sub-Saharians), comorbidities and type of nephropathy. Italians had the smallest median annual eGFR decrease (-1.0 ml/min), while the largest were found in migrants from East Asia (-2.2) and Arab States (-2.5). 5-year survival to renal death (dialysis or transplantation) was lower in South Asians (51.4%) than in Latino-Americans (85.3%) and Italians (85.0%). Conclusions Migrant chronic kidney disease patients have widely different features and outcomes compared to non-migrants and among migrant subgroups. Our findings pave the way to further investigation, whose results may be essential to tailor surveillance and treatment programs on specific groups of migrants. Key messages Among chronic kidney disease patients, non-migrants and migrants exhibit different clinical characteristics and outcomes, and thus require different surveillance and treatment approaches. Future research should analyze the causes of disparities between migrant and non-migrant chronic kidney disease patients, specifically focusing on those related to inequalities in access to healthcare.

Background In the past few years more than 30,000 asylum seekers arrived in Emilia-Romagna region. Guidelines were developed to screen the newly arrived, mainly focused on communicable diseases (CDs). However, asylum seekers who are out of the institutional reception system do not have access to such screenings. In order to assess the implementation and reach of these guidelines with respect to the target population, in 2019 a mixed-method survey was carried out. Methods A questionnaire with 35 closed and 11 open questions, based on a synthesis of the regional and national guidelines, was carried out with referents of the regional clinics that provide healthcare to asylum seekers. The collected questionnaires were processed through descriptive statistical analysis for the closed questions and text analysis for the open questions. Results Questionnaires were collected from 14 clinics. All clinics provide first visit and screening for CDs upon arrival, following the regional guidelines. However, enrolment in the national healthcare system was found to be delayed for periods of up to 6 months, resulting in discontinuity of care. Administrative and cultural barriers in accessing health and social services were repeatedly reported, the latter often linked to lack of cultural mediation services. Financial barriers were also reported, particularly with respect to dental care and pharmaceuticals. Results also show that asylum seekers within the institutional reception system can more easily overcome the reported barriers compared to those out of the system. Such inequality in accessing healthcare is reported also for the TB screening process. Conclusions Even if access to healthcare for asylum seekers is regulated by norms and guidelines, barriers are consistently reported. Moreover, asylum seekers within or outside the reception system face different barriers in accessing healthcare services. Such local evidence can be very relevant to inform actions that improve health equity. Key messages Even if access to healthcare for asylum seekers is regulated by law, barriers are consistently reported and impact disproportionately on those who are out of the institutional reception system. A mixed-method approach that generates local evidence on the barriers that asylum seekers face in accessing healthcare and on their causes is key to inform actions that improve health equity.

Background Notification of confirmed or suspected cases of Malaria is compulsory in Italy. It is essential to optimize control measures in case of imported and indigenous events, considering that the main local vector, Anopheles labranchiae, is still present in Italy. Methods Descriptive analysis of malaria cases notified from Bologna local health authority (AUSL) from January 2000 to December 2019. Results In the period 2000-2019, out of the 248 Malaria cases notified to the AUSL, 161 were males, and 87 were females, with median age of 33 (IQR: 42-25). All the cases were sporadic and travel-related. The main reasons for travelling were: return to the country of origin (n = 139, 56,0%), tourism (n = 39, 15,7%), work (n = 30, 12,1%), and immigration (n = 13, 5,2%). 86 (34,7%) cases were born in Italy, 43 (17,3%) in Nigeria, 27 (10,9%) in Cameroon, and 17 (6,9%) in Ghana. The cases were imported from Nigeria (n = 56, 22,9%), Cameroon (n = 30, 12,2%), Ghana (n = 26, 10,6%), Ivory Coast (n = 24, 9,8%). Most of the cases were not taking any drug for Malaria chemoprophylaxis (n = 214, 86,6%), 20 cases (8,1%) properly completed the prophylaxis, while 13 cases (5,3%) started chemoprophylaxis but they didn't complete it. The etiological agent identified was Plasmodium falciparum in 176 cases (71,0%), P. vivax in 26 cases (10,5%). Among the former cases 49 (32,2%) were contracted in Nigeria, 29 (19,1%) in Cameroon, 23 (15,1%) in Ghana, 20 (13,2%) in Ivory Coast, 10 (6,6%) in Senegal. 11 (68,8%) cases of P. vivax were contracted in Pakistan. Conclusions Epidemiological data collected from Bologna AUSL are consistent with those described from Istituto Superiore di Sanità: the majority of cases was comprised of foreigners, the great majority of cases was imported from Africa. P. Falciparum was prevalent in Africa while P. vivax was prevalent in Asia. Key messages The knowledge of the epidemiological situation allows public health workers to advise international travelers focusing on those most at risk of contracting Malaria. Periodic assessment of local epidemiology is necessary to evaluate if data are consistent with those described from international literature.

Background Recent events highlight how emerging and re-emerging pathogens are actually becoming global challenges for public health. In December 2019, a novel coronavirus (SARS-CoV-2) has emerged. This has suddenly turned out into a global health concern which has led to a very high number of papers published in the scientific literature. Aim of this research is to focus on the bibliometric aspects in order to give researchers a glimpse on what is published in the first 30-days of a global epidemic outbreak. Methods We searched MEDLINE (PubMed) electronic database in order to find all relevant studies in the first 30-days from the first publication (which appeared on Pubmed at 14/01/2020), meaning the period 15/01/2020-13/02/2020. We used the following search string: coronavirus* OR Pneumonia of Unknown Etiology OR Covid-19 OR nCoV. We placed a language restriction for English, but no publication status or study design limit was put in place for our search. Results From the initial 462 identified articles, 234 articles were found as pertinent and read in extenso in order to classify them. The vast majority of papers come from China, UK and USA. 66.2% of the papers were Editorials, comments, letters or other kind of mainly reported data. 10.7% of papers were secondary literature papers (mainly narrative reviews). The remaining 23.1% were original primary studies. Only 17.5% of the sources used data which were directly collected on the field. Conclusions Almost all of data came from China. Even if some preferential channels were guaranteed for publishing those results in the most important journals, it appears that the vast majority of publication in scientific literature in the first 30-days of an epidemic outbreak is based more on reported data and comments, and only a small fraction of the papers have primary data collected in the field. Nevertheless the whole international literature depends on that type of data sources in the early days of the epidemic. Key messages This is the first bibliometric research in Pubmed Database on the first 30 days of publications regarding the novel Coronavirus (2019-nCoV) outbreak of 2019. The vast majority of publication in the first 30-days of an epidemic outbreak are reported data or comments, and only a small fraction of the papers has directly collected data.

Background In Italy, recent changes in migration flows posed complex public health challenges. The Emilia-Romagna region (ERR) was one of the first regions to adopt specific policies addressing the health of newly arrived asylum seekers. In our study, we analysed the regional health system response comparing it to the regional and national guidelines, in order to assess its strengths and its critical areas. Methods In 2019, we conducted a survey among the referents of the regional clinics that provide healthcare to asylum seekers, in order to learn about local policies, challenges and best practices. A questionnaire with 35 closed and 11 open questions was administered and analysed through descriptive statistical analysis and text analysis. Results Regional policies showed good responsiveness and Local Health Authorities (LHAs) adhered to the guidelines. A special permit was introduced to grant asylum seekers access to healthcare, which also allowed integration of health data into the regional health information system. However, data integration was done in only 2 clinics out of 14. Instances of discretion in issuing the special permit were reported, due to ambiguity in the rules and inadequate training of office workers. Policies and LHAs protocols focused greatly on the arrival phase and on Communicable Diseases (CDs) surveillance. Other areas - such as protection of vulnerable groups, health promotion, NCDs - were prioritized in the national guidelines, but unevenly considered throughout the region, also due to lack of resources. Some clinics responded autonomously to these gaps with local resources. Conclusions The ERR health response to the influx of asylum seekers was rapid but incomplete. Interventions focused more on CDs surveillance than on responding to asylum seekers' health needs in terms of quality, access and equity. Areas to be strengthened include protection of vulnerable groups, health promotion and NCDs, together with coordination and long-term planning. Key messages The Emilia-Romagna region health response to the influx of asylum seekers reflects an emergency approach focused on communicable diseases, while NCDs and health promotion are relatively neglected. The health system in Emilia-Romagna needs to be strengthened in its capacity to respond to asylum seekers’ health needs. Health policies and practices should be planned to ensure equity and quality.

Background The US is the least regulated firearm market in the Western world and firearm violence is a major public health issue. Firearms account for 40,000 deaths in the US annually, which is higher than other high-income countries. Although most of the gun-related deaths in the US are the result of suicide attempts and self-inflicted injuries, nearly 40% of them come from accidents, assaults, or police intervention. Methods We measured the number of non-self-inflicted firearm-related ED visits, by including patients discharged with diagnostic ICD-9-CM (ICD-10 for 2016) codes of accidents, assaults or legal intervention resulting in firearm injuries between 2006-2016. We used data from the Healthcare Cost and Utilization Project (HCUPnet). From the CDC Wide-ranging Online Data for Epidemiologic Research we obtained data on non-suicidal firearm-related deaths over the period 2006-2017. To identify the cause of death we used the ICD-10 codes. Temporal changes of rates of ED visits and deaths were evaluated using Joinpoint Software. Results In 2006 there were a total of 79,998 ED visits with a diagnostic code of firearm-related injury, and this number showed a non-significant 2.7% annual decline between 2006-2013 (p = 0.06) followed by a significant 19.4% annual increase between 2013-2016 (p Conclusions Data showed steady rates until 2013 and a striking increasing trend starting from 2013. Firearm-related deaths followed the same trends. Our data show that in the last four detectable years there has been a new concerning wave of gun violence and consequently a higher number of fatalities. Analysis limitations: we used national-level aggregate data and coding accuracy may be not consistent nationwide. Key messages In the last four detectable years there has been a new concerning wave of gun violence and consequently a higher number of fatalities nationwide. The US firearm related deaths epidemic urges for new policies and preventive measures, such as stricter background checks and restrictions on guns ownership.

Background Amenable mortality is an indicator that measures the extent to which health services contribute to the improvement of the health of a population. It can also highlight geographical and socioeconomic inequalities. Therefore, it is used to assess quality and performance of health care systems, both at national and subnational level. The Italian National Health Service sets the essential levels of care (Livelli Essenziali di Assistenza, LEA), a health-benefit package for all citizens. Because every region is responsible for providing the LEA and can offer additional health care, monitoring the performance of the Regional Health Services (RHSs) is of increasing interest. Methods We used Nolte and McKee's list of amenable conditions to analyze the temporal trend of the standardized mortality rate (per 100.000) in Italy from 2006 to 2015, overall and by gender. We also examined the standardized rate at regional level by comparing the two-year periods 2006/7 and 2014/5, overall and by gender. Results Between 2006 and 2015, the overall mortality rate decreased from 81 to 68 per 100.000 population; this reduction was more pronounced in men (91 to 76 per 100.000, -16.5%) than in women (72 to 62 per 100.000, -13.9%). The decreasing trend in amenable mortality affected Italian regions differently, with northern regions showing steeper reductions as compared to southern regions. As a result, 2014/5 was the first time men's mortality in North Italy (68 per 100.000) was lower than women's mortality in South Italy (72 per 100.000). Conclusions The overall reduction of amenable mortality shows that Italy's health care services keep contributing to the improvement of population health. Nevertheless, by analyzing RHS performance we saw that differences in organization of care lead to differences in health care quality and performance across regions. Deaths amenable to health care services contribute to inequalities between Northern and Southern Italy. Key messages Because universal health coverage is necessary but not sufficient to reduce health inequalities, investing into better-quality services should be recognized as a priority. Amenable mortality can highlight areas of intervention to reduce inequalities in the provision of health care services.

Background In 2017, under the supervision of the European Centre for Disease Prevention and Control (ECDC), a list of competencies and knowledge and skill statements for EU professionals working in Public Health Emergency Preparedness (PHEP) systems were identified and integrated into a Competency Model. Building on these efforts, a PHEP competency-based training toolkit was developed, pilot tested and finalized with the goal of providing a standardized training resource for experts involved in response to cross-border threats to health. Objectives Led by the ECDC, an international research team drafted a preliminary version of a curriculum consisting of five modules, with a list of targeted competencies, learning objectives, reading and training methods including case studies and simulation exercises. In May 2018, the curriculum was pilot tested in a 3.5-day training course at the University of Bologna, Italy. The participants included 20 representatives from 8 EU Member States. An evaluation strategy, combining both quantitative and qualitative methods, was designed to assess the impact of the training on participants’ applied knowledge and competence. Results Overall, the participants’ feedback on the pilot course was positive, with scores from 4.0 to 4.8 out of 5 for all the items considered. Several suggestions were made both by the trainers and the trainees to enhance the effectiveness of the learning activities, and the curriculum was integrated into a training toolkit with more exercises, teaching materials and a guide for facilitators. Conclusions This European Public Health Emergency Preparedness Training Toolkit is the first EU competency-based toolkit intended to help Member States improve their response to public health emergencies through standardized training. Designed for individuals working in strategic positions at the national level, its general approach, modular structure and content are relevant and can be tailored to a wider range of professionals. Key messages To improve PHEP in the EU, competency-based curricula and standardized training programs and resources for health professionals are needed. By enhancing the overall public health professionals’ experience and competency, the European PHEP Training Toolkit represents a step towards strengthening preparedness and response systems in the EU.

Background Crowdfunding (CF) is the practice of financing a project by raising money from a large number of people. Many patients use online CF platforms to fund medical needs, whether unmet by their healthcare service - therefore to be sought elsewhere -, or when unable to afford them. CAR-T (Chimeric antigen receptor T-cells) is an innovative therapy approved to treat several types of lymphoma and with potential to treat many other cancers. CAR-T is available in most countries through clinical trials only and its diffusion is limited by high costs. Gofundme is a CF platform ’leader in online medical fundraising’. The objective of this study is to shed some light on the phenomenon of CF for CAR-T therapy, describing the campaigns started on Gofundme. Methods We extracted data from CAR-T campaigns started in Europe and publicly available on Gofundme until March 2019. Data related to each campaign has been analyzed and reported through descriptive analyses. Results Since 2017, 26 CAR-T treatment campaigns have been started. Due to the privacy policy of the platform, we were able to retrieve data from only 12 of them; 3 campaigns were closed, thus not disclosing enough data to be included. Nine campaigns were studied: 4 from Italy, 4 from the UK, 1 from Spain. The United States were the main destination. The median campaign goal was 180k€. The number of campaign shares on social media and the percentage of goal raised seemed to be linked. Conclusions CF is unquestionably a good expression of the Internet: it channels empathy towards important causes, providing tangible help. However, when applied to healthcare - especially to experimental treatments -, several questions arise. Patients affected by treatment resistant cancers may be prone trying new treatments to keep the hope alive, even when indication is missing or scientific evidence is lacking. Policymakers should monitor healthcare related CF campaigns, both for equity and safety reasons. Key messages Policymaker should monitor healthcare related CF campaigns, both for equity and safety reasons. Healthcare related crowdfunding campaigns could be interpreted as an indicator of unmet medical needs.

Background General elections represent a peculiar moment in which clear positions on relevant topics are more likely to emerge. Therefore, they may serve as a reference point to monitor policy development and to verify decision makers’ accountability. The aim of this study is to systematically examine the proposals on health issues in the manifestos of the 38 parties running in the 2018 Italian general election, comparing them with the contents shared on social media. Methods All the electoral manifestos published on the websites of each party and of the Italian Ministry of the Interior were collected and independently assessed by four evaluators. A list of 48 health themes grouped into 13 main domains into was then consensually created and used to classify the reported proposals. Parties’ official social media accounts (Facebook and Twitter) were subsequently screened for selected keywords to determine the frequency and the content of health-related posts. Results Thirty out of 38 parties included a specific section on health in their programmes or generally addressed healthcare topics. The most covered themes were health promotion and lifestyles, self-sufficiency of fragile populations, management of private healthcare and health workforce, although implementation strategies varied greatly and only in a few cases it was possible to compare them. On social media, health related posts represented less than 1% of the contents shared by any party during the election campaign. Conclusions In the 2018 Italian election campaign the majority of the parties’ manifestos explicitly addressed health issues but, apart from a few exceptions, significant differences were present in the themes and in the proposed solutions, mostly generic. On social media health was almost neglected. Despite its social relevance, health played a marginal role in the 2018 Italian election campaign.

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Introduzione Due recenti metanalisi (Duaso, 2014; Duaso, 2016) hanno dimostrato che lo status di fumatore dei professionisti sanitari influenza negativamente l’approccio nel consigliare la cessazione del fumo. Altre evidenze di letteratura indicano che una quota di medici ritiene che la promozione della cessazione del fumo richieda troppo tempo e sia inefficace (Vogt, 2005). Secondo i dati della sorveglianza condotta dall’Istituto Superiore di Sanità italiano (PASSI, 2018) solo il 51,4% dei fumatori dichiara di aver ricevuto il consiglio di smettere di fumare da un medico o da un operatore sanitario. Nell’ambito dei progetti di promozione della salute sostenuti dall’Istituto per la Sicurezza Sociale (ISS) di San Marino, il presente studio vuole indagare le abitudini tabagiche dei suoi professionisti sanitari. Materiali e metodi È stata condotta una survey rivolta ai dipendenti dell’ISS San Marino mediante la distribuzione di un questionario cartaceo auto-somministrato, costituito da una parte iniziale contenente le informazioni anagrafiche e da cinque domini: abitudine al fumo, cessazione del fumo, valutazione dei percorsi anti-fumo, opinione circa la presa in carico dei fumatori, opinione sulla validità dei metodi di disassuefazione tabagica. Risultati Sono stati distribuiti circa 1.000 questionari a medici, infermieri e personale tecnico/amministrativo dell’ISS e sono state raccolte le risposte di 352 dipendenti. I partecipanti al questionario hanno un’età media di 45,3 anni e sono per il 72,6% femmine. Il 55,9% dichiara di non aver mai fumato (NF), il 23,3% fuma attualmente (F) ed il 21,3% è ex-fumatore (EF). L’abitudine tabagica presenta differenze significative tra i due generi per quanto riguarda lo stato di NF (57,9% donne, 50% uomini) e lo stato di EF (19% donne, 26,6% uomini); praticamente identica inveca la quota di fumatori nei due generi: 23,1% tra le donne e 23,4% tra gli uomini. L’83,8% dei fumatori ha dichiarato di aver pensato di smettere di fumare e il 53,7% di questi prenderebbe in considerazione un percorso presso un Centro Antifumo (CA). Alla domanda “Pensa che valga la pena impiegare tempo e risorse nel trattamento del fumatore?” hanno risposto 324 partecipanti. La maggior parte ha risposto “Sempre” (media tra i gruppi 79,6%; NF 82,3%; F 70%; EX 84,1%). Per quanto riguarda la domanda “Secondo lei quali metodi potrebbero essere efficaci per smettere di fumare?” hanno risposto in 343: “Breve colloquio motivazionale individuale” è il metodo che ha ricevuto il maggior numero di risposte positive (63,4%), seguito da “Eventi formativi” (62,4%), “Terapie di gruppo” (62,1%), “Terapia farmacologica” (42%) ed infine “Multe e sanzioni” (38,4%). Conclusioni Evidenze in letteratura (DoH, 2009) mostrano che la popolazione tende ad accettare meno favorevolmente le indicazioni di professionisti sanitari che non seguono un corretto stile di vita. Dal momento che circa un quarto dei dipendenti dell’ISS attualmente fuma e che la maggior parte di questi ha pensato di smettere di fumare, potrebbe essere utile attuare un programma di cessazione tabagica rivolto ai dipendenti; questo permetterebbe di migliorare il loro stato di salute e li renderebbe un veicolo più efficace di educazione ai corretti stili di vita. Uno strumento utile potrebbe essere la creazione di un Centro Antifumo dove implementare i metodi di cessazione tabagica che sono stati valutati come i maggiormente efficaci dai dipendenti intervistati, in cui prendere in carico anche i cittadini e i pazienti con patologie croniche motivati a smettere di fumare.

MeDALL (Mechanisms of the Development of ALLergy; EU FP7-CP-IP; Project No: 261357; 2010-2015) has proposed an innovative approach to develop early indicators for the prediction, diagnosis, prevention and targets for therapy. MeDALL has linked epidemiological, clinical and basic research using a stepwise, large-scale and integrative approach: MeDALL data of precisely phenotyped children followed in 14 birth cohorts spread across Europe were combined with systems biology (omics, IgE measurement using microarrays) and environmental data. Multimorbidity in the same child is more common than expected by chance alone, suggesting that these diseases share causal mechanisms irrespective of IgE sensitization. IgE sensitization should be considered differently in monosensitized and polysensitized individuals. Allergic multimorbidities and IgE polysensitization are often associated with the persistence or severity of allergic diseases. Environmental exposures are relevant for the development of allergy-related diseases. To complement the population-based studies in children, MeDALL included mechanistic experimental animal studies and in vitro studies in humans. The integration of multimorbidities and polysensitization has resulted in a new classification framework of allergic diseases that could help to improve the understanding of genetic and epigenetic mechanisms of allergy as well as to better manage allergic diseases. Ethics and gender were considered. MeDALL has deployed translational activities within the EU agenda.

Background: Vaccine hesitancy is a considerable issue in European countries and leads to low coverage rates. After a long debate, Italy has made vaccination mandatory for admission to its schools.Methods: In the NAVIDAD study (a cross-sectional multicentre study), a 63-item questionnaire was administered to 1820 pregnant women from 15 Italian cities. The questionnaire assessed the interviewee's opinion on mandatory vaccines, as well as their socioeconomic status, sources of information about vaccines, confidence in the Italian National Healthcare Service (NHS), and intention to vaccinate their newborn.Results: Information sources play a key role in determining the opinion on restoration of mandatory vaccines; in particular, women who obtained information from anti-vaccination movements are less likely to accept the vaccines (OR: 0.35, 95% CI: 0.21-0.58, p < 0.001). Women who had confidence in healthcare professional information agreed more on mandatory vaccination than did the other women (OR: 2.66, 95% CI: 1.62-4.36, p < 0.001); those who perceived that healthcare professionals have economic interest in child immunization and who declared that healthcare providers inform only on vaccinations benefits not on risks were less likely to agree on compulsory vaccination (OR: 0.66, CI 95%: 0.46-0.96, p = 0.03; OR: 0.66, CI 95%: 0.46-0.95, p = 0.03, respectively).Conclusion: Information sources and confidence towards health professionals are the main determinants of acceptance of mandatory vaccine restoration. To increase the acceptability of the restoration and reduce vaccine hesitancy, these aspects need to be strengthened.

Background. Results from the World Health Survey indicate that physical health multimorbidity is significant increased across the depression and the psychosis spectrums worldwide. However, no research evidence is available on physical multimorbidity in patients with mental health problems in Italy. We investigated physical multimorbidity and pharmacological treatments among patients being treated by Italian community mental health services and the associated risk of hospitalization over 18 months. Materials and Methods. This retrospective study is based on linkage of data retrieved from the mental health information system, the hospital discharge records database and the pharmacological prescription databases. Patients living in Emilia-Romagna, Italy and treated by mental health services as of 1/1/2015 were extracted. A total of 17 physical health conditions and 9 pharmacological treatments for the cardiovascular system and thyroid problems were assessed. The association of psychiatric diagnoses and physical multimorbidity with hospitalization was analysed using multivariable Poisson regression models. Results. The study sample includes 8615 patients (59.2% male, mean age 40.3 years). Depression (33.4%), schizophrenia (17.6%) and personality disorder (13.3%) were the most frequent psychiatric diagnoses. Physical comorbidity, i.e. the presence of at least one physical health condition, was found in 19.2% of cases, and multimorbidity (≥2 physical conditions) in 6.5%. Patients treated pharmacologically for physical conditions were 39.6%. Personality disorders, substance use disorders and physical multimorbidity were associated with an increased risk of hospitalization during the follow-up. Conclusions. Physical multimorbidity is found in 6.5% of patients with mental disorders and is associated with an increased risk of hospitalization. Given that physical health multimorbidity can increase the mortality risk, early interventions to reduce it in mental healthcare are warranted.

Growing evidence underlines the pivotal role of infant gut colonization in the development of the immune system. The possibility to modify gut colonization through probiotic supplementation in childhood might prevent atopic diseases. The aim of the present systematic review and meta-analysis was to evaluate the effect of probiotic supplementation during pregnancy and early infancy in preventing atopic diseases. PubMed, Embase and Cochrane Library were searched for randomized controlled trials evaluating the use of probiotics during pregnancy or early infancy for prevention of allergic diseases. Fixed-effect models were used, and random-effects models where significant heterogeneity was present. Results were expressed as risk ratio (RR) with 95% confidence interval (CI). Seventeen studies, reporting data from 4755 children (2381 in the probiotic group and 2374 in the control group), were included in the meta-analysis. Infants treated with probiotics had a significantly lower RR for eczema compared to controls (RR 0.78 [95% CI: 0.69-0.89], P = 0.0003), especially those supplemented with a mixture of probiotics (RR 0.54 [95% CI: 0.43-0.68], P

Udgivelsesdato: 2008-Nov BACKGROUND: Studies on pet ownership as a risk or protective factor for asthma and allergy show inconsistent results. This may be on account of insufficient adjustment of confounding factors. AIM: The objective of this study was to describe determinants of cat and dog ownership in European families with and without allergies. METHODS: Within the EU-funded network of excellence GA(2)LEN, we performed meta-analyses with data from 12 ongoing European birth cohort studies on asthma and allergy. Each of the birth cohort studies enrolled between 485 and 4089 children. Pet ownership, allergic status (asthma, allergic rhinitis, eczema) of parents and siblings, parental education, access to ground floor, and number of people living at home were assessed by questionnaires. RESULTS: Among the 25 056 families from seven European countries cats (14.9%) were more common than dogs (12.0%). Allergic family history significantly reduced the odds to own a cat (adjusted combined random-effect OR 0.91; 95% CI 0.85-0.99), or dog (0.90; 0.86-0.94). A higher parental educational level had even more pronounced effects on cat (0.84; 0.71-0.98), and dog ownership (0.61; 0.54-0.70). Elder siblings reduced the odds to own cats, but not dogs. Convenient ground access significantly increased the odds, whereas crowding at home was not associated with cat or dog ownership. CONCLUSIONS: The chances to own a cat or dog were significantly reduced in allergic families, in parents with a higher educational level, and in homes without convenient ground access. In addition to parental allergies, social and housing factors should be considered as potential confounders in studies on pet exposure and allergic diseases.

Allergic diseases (asthma, rhinitis and atopic dermatitis) are complex. They are associated with allergen-specific IgE and non-allergic mechanisms that may coexist in the same patient. In addition, these diseases tend to cluster and patients present concomitant or consecutive diseases (multimorbidity). IgE sensitization should be considered as a quantitative trait. Important clinical and immunological differences exist between mono or polysensitized subjects. Multimorbidities of allergic diseases share common causal mechanisms that are only partly IgE-mediated. Persistence of allergic diseases over time is associated with multimorbidity and/or IgE polysensitization. The importance of the family history of allergy may decrease with age. This review puts forward the hypothesis that allergic multimorbidities and IgE polysensitization are associated and related to the persistence or re-occurrence of foetal Type 2 signalling. Asthma, rhinitis and atopic dermatitis are manifestations of a common systemic immune imbalance (mesodermal origin) with specific patterns of remodelling (ectodermal or endodermal origin). This paper proposes a new classification of IgE-mediated allergic diseases that allows the definition of novel phenotypes in order to (i) better understand genetic and epigenetic mechanisms, (ii) better stratify allergic preschool children for prognosis, and (iii) propose novel strategies of treatment and prevention.

BACKGROUND: The Global Allergy and Asthma European Network (GA2LEN) is a consortium of 26 leading European research centres committed to establish a European research area of excellence in the field of allergy and asthma. AIM: One of the GA2LEN work packages was designed to identify and compare the existing European birth cohort studies on asthma and atopic diseases. The present review compares their subjective and objective outcomes as well as exposure variables. METHODS: A common database was established to assess study characteristics of observational birth cohort studies designed to examine asthma and atopic diseases. Data were collected by visiting most of the participating research teams and interviewing all relevant study personnel. For each study, the type of objective/subjective outcome parameters and potentially influential factors were recorded precisely for every time point during follow-up. RESULTS: Eighteen birth cohort studies on asthma and atopic diseases were identified in eight European countries. Thirteen studies collected data on specific immunoglobulin E (IgE) to various inhalant and food allergens, whereas 12 performed skin prick tests (many at several time points during follow up). Several studies measured lung function, but across the cohorts no comparable standard procedures were used. For subjective evaluation of asthma and allergic rhinitis most studies applied the ISAAC questionnaire (sometimes modified), whereas the assessment of eczema was rather heterogeneous across the studies. CONCLUSION: This GA2LEN initiative established a unique common database of 18 European birth cohorts on asthma and atopic diseases. For selected cohorts, it seems that pooling data and performing common analyses may be possible to examine associations between certain exposure variables (e.g. pet ownership, tobacco smoke exposure and day-care) and selected outcome measures for atopy, asthma or allergic rhinitis (e.g. sensitization assessed by IgE or skin prick tests, doctor's diagnosis of asthma, parental perception regarding asthma/wheezing or hay fever symptoms).

Background The rising prevalence of chronic diseases and management of multimorbidity represent a main challenge for health care systems worldwide, as it correlates with high use of health services resources over time. Prevalence estimates of multimorbidity vary widely among countries, as neither a widely accepted definition has been stated nor standard approach for measuring the phenomenon has been established so far. The aim of this study was to describe the prevalence of multimorbidity in Emilia-Romagna region (Northern Italy). Methods Multimorbidity was defined as the presence of two or more chronic conditions. To assess multimorbidity, patients (aged ≥ 18 years) were classified according to Charlson's algorithm, integrated with some categories retrieved from Elixhauser's list. The prevalence of multimorbidity was calculated using information on hospitalizations and drug therapies retrieved from administrative databases between 2008 and 2012. Results From 2008 to 2012, 905707 persons living in Emilia-Romagna region had one chronic condition (prevalence of 24.4%), whereas 604856 had multimorbidity (prevalence of 16.3%). The prevalence of multimorbidity was higher in men and increased with age: by age 60 years, half of the population had at least one chronic disease, and by the age 70 years 30% had multimorbidity. The most prevalent chronic condition was hypertension (35.6%), followed by diabetes (7.6%), cancer (4.9%), stroke (4.0%) and heart failure (3.4%). The prevalence of one chronic disease and that of multimorbidity was lower in immigrants than in Italian citizens, probably due to a “healthy immigrant effect”. However, in immigrants the age-standardized prevalence of multimorbidity was higher than the prevalence of one chronic disease. Conclusions Multimorbidity occurred in a high percentage of Emilia-Romagna population, especially in the elderly. The analysis also revealed a different prevalence of multimorbidity by citizenship, implying a different burden of health care by citizenship and suggesting that more efforts are needed to guarantee migrant-sensitive health care. Future perspectives include retrieving information on mental health, to provide a strong evidence base for the care and management of patients with multimorbidity.

Background The Italian Ministry of Health declared oncology a priority and stressed the importance of ensuring continuity and integration in cancer care pathways. In order to monitor the quality of cancer care pathways, we need to explore patients’ experience of the continuity of care, identifying the dimensions that define continuity Methods We found 886 relevant articles in the Pubmed database from 1987 to 5 November 2013. The search strategy for the electronic database was defined using the Population, Intervention, Comparison and Outcome(s) framework (PICO) to identify keywords. Two researchers independently reviewed records identified through the search strategy, analyzing continuity dimensions, specificity and/or transversal domains Results We selected 20 articles that measure the patients’ experience of continuity of care: 7 articles including 5 questionnaires [Questionnaire by King et al. 2008; Cancer care coordination Questionnaire (Cccq); Patient Continuity of Care Questionnaire (Pccq); Medical Care Questionnaire (Mcq); Continuity and Coordination of Care Questionnaire (CCCQ)]; 6 articles evaluating the relationship between patient and his/her physician (the same across the care pathway) in terms of frequency and/or dispersion; 6 articles considering one subscale of larger scales designed to evaluate the generic cancer care service patient experience; 1 revealing four organizational indicators of care pathway continuity / discontinuity Conclusion We traced 3 transversal dimensions across the individual analyses: informational, organizational, relational continuity. It follows that in order to cater to the needs of cancer patients, we need to simultaneously focus on these three dimensions along the cancer care pathway. In line with these results, we promoted the “R.In.Cu.ORAM.i” study (Networks for Integrated Treatment of colorectal and breast cancer), in Area Vasta Romagna Area (Italy), and developed a continuity of care patient-experience continuity tool

There are several versions of the Diagnosis Related Group (DRG) classification systems that are used for case‐mix analysis, utilization review, prospective payment, and planning applications. The objective of this study was to assess the adequacy of two of these DRG systems – Medicare DRG and All Patient Refined DRG – to classify neonatal patients. The first part of the paper contains a descriptive analysis that outlines the major differences between the two systems in terms of classification logic and variables used in the assignment process. The second part examines the statistical performance of each system on the basis of the administrative data collected in all public hospitals of the Emilia–Romagna region relating to neonates discharged in 1997 and 1998. The Medicare DRG are less developed in terms of classification structure and yield a poorer statistical performance in terms of reduction in variance for length of stay. This is important because, for specific areas, a more refined system can prove useful at regional level to remove systematic biases in the measurement of case‐mix due to the structural characteristics of the Medicare DRGs classification system. Received 23 July 2001. Accepted 13 February 2002.

SUMMARY The prevalence, causal origin of and impairments associated with severe mental retardation (SMR) were investigated among all school-age children (six to 13 years) living in the city of Bologna, Italy. 90 children (57 boys, 33 girls) with IQs ≤ 50 were identified. The prevalence of SMR was 4-2 per 1000 for males, 2–5 per 1000 for females and 3–4 per 1000 for both sexes. Causal origin was prenatal for 33-3 per cent, perinatal for 14-4 per cent, combined pre- and perinatal for 5–6 per cent and postnatal for 13-3 per cent. Another 12-3 per cent of the children with IQs ≤ 50 had autism or childhood psychosis, while there was no evident cause of mental retardation for the remaining 21-1 per cent. 50 per cent had at least one associated physical or neurological impairment other than mental retardation, with epilepsy and cerebral palsy predominating. REESUMEE Etude epidemiologique du retard mental severe parmi les enfants d'âge scolaire a Bologne, en Italie La preevalence, l'origine et les incapacites resultantes associees au retard mental severe (SMR) ont ete recherchees parmi les enfants d'age scolaire (six a 13 ans) vivant a Bologne, en Italie. 90 enfants (57 garcons et 33 filles) avec Q.I. inferieur ou egal a 50 ont ete identifies. La prevalence de SMR a ete de 4,2 pour 1000 chez les garcons, 2,5 pour mille chez les filles et 3,4 pour mille dans le deux sexes. L'origine causale etait prenatale dans 33,3 pour cent des cas, perinatale pour 14,4 pour cent, combinee pre- et peri-natale pour 5,6 pour cent et post-natale pour 13,3 pour cent. Un autre groupe representant 12,3 pour cent des cas presentait en association un autisme ou une psychose infantile et il n'y avait pas de cause evidente de retard mental pour les 21,1 pour cent restants. 50 pour cent des cas presentaient au moins un trouble physique ou neurologique associe au retard, l'epilepsie et 1'I.M.C. etant predominants. ZUSAMMENFASSUNG Eine epidemiologische Studie uber geistige Retardierung bei Schulkindern in Bologna, Italien Vorkommen, Ursache und begleitende Storungen der schweren geistigen Retardierung (SMR) wurden bei allen Schulkindern (sechs bis 13 Jahre) in der Stadt Bologna (Italien) untersucht. Bei 90 Kindern (57 Jungen, 33 Madchen) wurde ein IQ ≤ 50 festgestellt. Die Haufigkeit der SMR betrug 4-2 pro 1000 Jungen, 2–5 pro 1000 Madchen und 3–4 pro 1000 fur beide Geschlechter. Die Ursache war bei 33-3 Prozent pranatal, bei 14-4 Prozent perinatal, bei 5–6 Prozent pra- und perinatal und bei 13-3 Prozent postnatal begrundet. Weitere 12-3 Prozent der Kinder mit einem IQ ≤ 50 hatten Autismus oder kindliche Psychosen, wahrend bei den restlichen 21-1 Prozent keine eindeutige Ursache fur die geistige Retardierung gefunden wurde. 50 Prozent der Kinder hatten zu der geistigen Retardierung mindestens noch eine physische oder neurologische Erkrankung, wobei Epilepsie und Cerebralparese am haufigsten vertreten waren. RESUMEN Estudio epidemiologico del retraso mental grave en escolares en Bolonia, Italia La prevalencia, la causa originaria y las alteraciones asociadas con un grave retraso mental (GRM) fueron investigados en escolares (de seis a 13 anos de edad) que vivian en la ciudad de Bolonia, Italia. Se identificaron 90 nifios (57 varones y 35 hembras) con un CI ≤ 50. La prevalencia de GRM era del 4-2 por 1000 en varones y 2–5 en hembras y 3–4 por 1000 en ambos sexos. El origen causal era prenatal en el 33,3 por ciento, perinatal en el 14,4 por ciento, combinado pre-y perinatal en el 5–6 por ciento y postnatal en el 13,3 por ciento. Otro 12,3 por ciento de nifios con CI ≤ 50 tenia autismo o psicosis infantil, mientras que no existia causa evidente de retraso mental en el restrante 21,1 por ciento. El 50 ciento tenia por lo menos una alteracion asociada fisica o neurologica, ademas del retraso mental, con predominio de la paralisis cerebral infantil y la epilepsia.

The immune competence of the T lymphocyte system was studied in 28 noninstitutionalized subjects with Down's syndrome (DS) and were compared with sex- and age-matched healthy controls. The ability of enriched T lymphocytes to respond to 3 different T cell stimulants revealed a selective impairment of T lymphocyte subset(s). Subjects with DS showed normal responsiveness in allogeneic mixed lymphocyte reactions, but their response to phytohemagglutinin and in autologous mixed lymphocyte reactions was severely impaired. Non-T cells from DS subjects stimulated equally well both normal and DS allogeneic T lymphocytes. The blood concentration of serum thymic factor in the majority of DS subjects was much lower than that found in age-matched healthy controls. These data support the hypothesis that a deficiency of the T-dependent regulatory system is an intrinsic feature of DS and confirm the precocious aging of the immune system in these subjects.

6 cases of Behçet's disease are reported. Diagnosis was particularly arduous because the typical triad of symptoms (oral aphthae, genital ulcers, uveitis) was masked by secondary disturbances in other organs and systems. Immunology confirmed the presence in these patients of changes in various in vivo and in vitro tests and particularly interesting was the aspecific cutaneous hypersensitivity seen in 5 cases and enhanced lymphocyte blastic transformation. This was seen spontaneously and following PHA. On the basis of the outcome of the studies carried out and the literature data, the possibility that Behçet's disease may contain immunological changes and changes in the mechanisms that regulate quinine, complement and clotting activation is suggested. Therapeutically, confirmation was obtained of the effectiveness, at least temporarily, of corticosteroid treatment and antilymphocyte globulin was experimented for the first time in these patients. This might be used to replace the immune depressant antiblastic substances already successfully employed in patients with Behçet's disease.

Bruton type agammaglobulinemia is an X-linked disease with humoral immunological deficiency. Children with congenital agammaglobulinemia develop bacterial infections easily. We describe a 15-year-old

Background. Disparities among ethnic groups are reported in the epidemiology and outcomes of cardiovascular diseases. Given the growing prevalence of migrant populations in Italy and the “epidemic” of cardiovascular diseases, the aim of this study was to evaluate the characteristics and outcomes of patients with acute coronary syndrome (ACS) in relation to country of origin. Methods. This retrospective study includes patients living in Emilia-Romagna, Italy, and discharged from 2012 to 2014 with a diagnosis of acute myocardial infarction (AMI, STEMI and non-STEMI). Primary outcomes were percutaneous coronary intervention (PTCA) within 48 hours of admission for STEMI and 30-day all-cause mortality, and secondary outcomes 1-year adherence to post-AMI medications, major adverse cardiac and cerebrovascular event (MACCE) and all-cause mortality. The relationship between outcomes and citizenship was analyzed using multiple regression models. Potential confounders were age, gender and comorbidities recorded in the index and prior two years hospitalizations. Results. The study population comprised 23,884 patients of which 647 (2.7%) are migrants. The mean age of onset of ACS was lower among migrants than among Italians (56 vs 73 years) and immigrants had a higher prevalence of STEMI (50.1% vs 44.9%; χ2 = 6.8, p = 0.009). Compared with Italians, patients from Africa and Asia had a lower likelihood of undergoing PTCA and were less adherent to medications. Adjusted mortality rates were similar between Italians and migrants, however patients from Asia had a 62% increased probability of experiencing a MACCE at 1 year. Conclusions. Migrants with ACS were younger, less likely to undergo PTCA, and less adherent to drug treatment after discharge compared with Italians. Further studies are needed to investigate in depth the determinants of these differences and to develop organizational models tailored to the specific needs of migrant patients.

Background: Although population-based screening has the potential to reduce inequalities in breast cancer survival, evidence on this topic is controversial. The objective of this study was to evaluate whether the full implementation of a mammography screening programme in Emilia-Romagna in Italy had an impact on variations in breast cancer survival by educational level. Methods: A cohort study was performed, including all women

BACKGROUND: Registry-based studies have identified risk factors for chronic kidney disease (CKD) and for progression to end-stage renal disease. However, usually, these studies do not incorporate sequential measurements of kidney function and provide little information on the prognosis of individual patients. The aim of this study is to identify which combinations of demographic and clinical characteristics are useful to discriminate patients with a differential annual decline in glomerular filtration rate (GFR). METHODS: This observational retrospective study includes patients enlisted in the registry of the Prevention of Progressive Renal Insufficiency Project of Emilia-Romagna region (Italy) from July 2004 to June 2010, with at least four serum creatinine measurements. Classification tree analysis (CTA) was used to identify subgroups of patients with a different annual GFR decline using demographic and laboratory data collected at study entry. RESULTS: The CTA procedure generated seven mutually exclusive groups. Among patients with proteinuria, those with a baseline estimated GFR (eGFR) of >33 mL/min/1.73 m2 exhibited the fastest illness progression in the study population (-3.655 mL/min/1.73 m2), followed by patients with a baseline eGFR of 4.3 mg/dL (-2.833 mL/min/1.73 m2). Among patients without proteinuria, those aged 67 years, females had on average a stable eGFR over time, with a large variability. CONCLUSIONS: It is possible to rely on a few variables typically accessible in routine clinical practice to stratify patients with a different CKD progression rate. Stratification can be used to guide decisions about the follow-up schedule, treatments to slow progression of kidney disease, prevent its complications and to begin planning for dialysis and transplantation.

The goal of most epidemiological studies is to determine an unbiased estimate of the effect of being exposed to a given risk factor on a well defined outcome (disease, death) taking into account the effects of confounding. However, it may not be entirely clear which confounders should be adjusted for in the analysis and which should not, even after using expert knowledge. Recent developments in epidemiological theory have clearly shown that traditional methods of identifying and adjusting for confounding may be inadequate and so more recently the use of Directed Acyclic Graphs (DAGs) has been advocated. DAGs are a useful graphical tool for encoding assumptions about causality and deciding apriori which variables require adjustment in the analysis and which not. However, many clinical problems require complicated DAGs and therefore investigators may continue to use traditional practices because they are discouraged by the apparent complexity. Therefore, the purpose of this manuscript is to provide a simple overview on DAGs and how they can be used to select variables which require adjustment in the analysis.

Il fenomeno della medicalizzazione della gravidanza è attualmente uno dei problemi ostetrici più discussi e tra questi in particolare il continuo aumento del ricorso al parto cesareo.L’Italia ha uno dei valori più elevati al mondo e il primato assoluto tra tutti i paesi dell’Unione europea. Un aspetto particolare del già singolare profilo epidemiologico italiano è che la proporzione di parti cesarei, oltre ad essere in continuo aumento senza mostrare alcun accenno di inversione di tendenza, ha valori diversi nelle differenti realtà regionali. Tra queste sono soprattutto le regioni del Sud Italia, in cui attualmente quasi un parto su due avviene con taglio cesareo, che complessivamente riportano, dal 1993, le proporzioni più alte. I determinanti di questo fenomeno sono quindi complessi da analizzare e molto probabilmente intrecciati tra di loro. Oltre a ragioni economiche si riconoscono fattori di tipo organizzativo (la mancanza ad esempio di una guardia ostetrica attiva in tutti i punti nascita), carenze strutturali (non tutti i punti nascita ad esempio possono offrire, a parità di rischio ostetrico, lo stesso livello di sicurezza), fattori culturali (come la mancanza di linee-guida o percorsi nascita condivisi e basati sulle migliori evidenze scientifiche) e fattori socio-culturali .