[Prevention of HPV cancer related through HPV-9: state of the art, potential benefits and open issues]. / HPV-9 e prevenzione dei tumori HPV correlati: stato dell'arte, potenziali benefici e problemi aperti.

HPV vaccines currently marketed in Italy (bivalent and quadrivalent against HPV 16-18 and HPV and 6,11,16,18 respectively) are an extraordinary tool for the primary prevention of HPV related diseases, particularly of the cervical cancer. Although the implementation of the organized vaccination programs has already translated (for some endpoint) in confirmation of clinical efficacy, remains excluded a significant proportion of the diseases linked to non-vaccine HPV types. The new nonavalent vaccine (HPV9), of impending commercialization, represents an evolution of the quadrivalent, the composition of which are added five high-risk HPV types (HPV 31,33,45,52,58). The high clinical-immunological efficacy in experimental trials against the new genotypes (> 96% for CIN2 +), and the equivalence immunogenic to the four already present in the previous vaccine, will render the use of HPV9 a tool able to control in an even more effective HPV disease. The potential of the new vaccine is linked to the reduction of the HPV cancer burden by 2-20% according to anatomical site, with major benefits for cervical cancer, vulvo-vaginal, penile and more limited benefits for anal tumours. Moreover, the potential benefits could be also linked to the reduction of incidence of pre-neoplastic lesions arising in the lower-genital tract, especially in the cervix (CIN2-3), so often cause lengthy and expensive diagnostic and therapeutic procedures. In the face of this broad provision of benefit from HPV9 vaccine, we have also to consider all the variables related to its introduction in the vaccination calendars: the market price, the schedule of administration (currently in three doses) and data regarding the cost-effectiveness. The authors recognize the new vaccine (currently registered only in the US) a lot of potential in the prevention of HPV-related diseases.

Developing communication tools on rotavirus vaccination to support family paediatricians in Italy.

BACKGROUND: Universal rotavirus (RV) vaccination for newborns was introduced in Italy in 2018, but national vaccination coverage is still suboptimal. Effective communication between the family paediatrician (FP) and parents/caregivers is essential to promote vaccination acceptance. This project aimed to support FPs in communicating RV vaccination to parents/caregivers through the development and implementation of demonstrative videos and training modules. METHODS: A working group composed of two FPs, two communication professionals, a medical expert from GSK and a clinical psychologist, was formed to establish the key scientific information to be communicated to parents/caregivers and develop the demonstrative videos. Four videos depicting four communication styles (I to IV) were developed based on the Social Styles Theory. Thirty FPs were then asked to pilot test the videos and provide feedback. In addition, two training modules with scientific information were developed to learn how to respond to parents'/caregivers' objections. RESULTS: A total of 23 FPs provided feedback after using one or more videos at least five times. Twenty FPs (87.0 %) used mostly-one style, and most (60.0 %) used Style IV. Overall, the feedback was positive, as the majority of FPs (82.6 %, n = 19/23) indicated that the proposed videos were 'useful' or 'extremely useful' for introducing the RV vaccination to parents/caregivers in their actual practice. Based on this feedback, shorter versions of each video were also produced, and two training modules were developed to support FPs in responding to parental objections. Most FPs 75 % (n = 9/12) found Module 1 'very useful', and all found Module 2 'very useful' (100 %, n = 12/12). CONCLUSIONS: The communication tools developed were well appreciated by the FPs and are expected to support FPs in communicating RV vaccination thereby increasing its coverage. Practicing RV communication may also prove beneficial for FPs to communicate other critical topics to parents/caregivers.

Fourteen years' clinical experience and the first million babies protected with human live-attenuated vaccine against rotavirus disease in Italy.

Rotavirus (RV) causes up to half of hospital and community acute gastroenteritis (AGE) cases in young children in Italy. Two RV vaccines, available since 2006, are human RV (HRV) and human bovine RV (HBRV). This report looks back at the implementation of RV vaccination with HRV in Italy, and at HRV current and future perspectives. Initial regional policies led to national implementation by 2018, after scientific societies' disease awareness efforts. Following vaccination, RV hospitalizations declined significantly, and cost savings were observed. The two-dose HRV vaccine is easily administered during compulsory vaccine visits, helping increase coverage. Intussusception, a serious event in children <1 year, was reported in Italy with a rate of 33-40 per 100,000 infants. RV vaccination presents a low increased risk of intussusception after the first dose, estimated at 0.6 cases per 100,000 doses in Italy in 2019. Parents should be aware of the intussusception risk and symptoms to ensure prompt treatment. It is widely recognized that the vaccination benefits (large numbers of RV hospitalizations prevented) outweigh the risk. HRV introduction in Italy was supported by epidemiologic burden studies, healthcare provider opinions, and congress debates, which significantly contributed to implementation of RV universal routine infant vaccination in Italy.

Parents' insights after pediatric hospitalization due to rotavirus gastroenteritis in Italy.

Most of the severe cases of acute gastroenteritis in infants and children under 5 globally are caused by rotavirus infection. There are nearly 15,000 rotavirus gastroenteritis (RVGE) hospitalizations in Italy each year, which could be reduced by available rotavirus vaccines. In addition to the economic and societal burden, RVGE hospitalization could impact families negatively. The aim of this survey was to obtain parents' insights after hospitalization of their child for RVGE. Parents, of 500 children aged 0-5 years, were interviewed about their experience of RVGE hospitalization and asked to rate their stress on different items and overall. Most children (32.6%) were hospitalized aged 12-23 months, and 6.8% were <6 months old. Family pediatricians referred 56.2% of cases to hospital, and 25.8% went based on their parents' decision. During hospitalization, mean parental stress scores (out of 10, with 10 as highest stress) ranged from 6.6 to 8.4. The highest scores were for child malaise (8.42, SD 1.00), vomiting/diarrhea (8.07, SD 0.97), stress for the family in general (7.82, SD 0.90), parental stress (7.68, SD 0.93) and child dehydration (7.18, SD 1.02). The overall stress for the family was graded as 'high' by 67.2% of parents. Geographical areas and stress level were related (p = 0.0071), being the "high" stress score not an evenly distributed variable (p < 0.0001). Most children (91.8%) were not vaccinated against rotavirus, as most parents (74.5%) were not aware of vaccination availability. Parental distress due to RVGE hospitalization appears to be significant (93.6% reporting high/medium stress) and there is an important lack of awareness among parents about rotavirus vaccination. More education on RVGE for families in Italy should be warranted.

The 2016 Lifetime Immunization Schedule, approved by the Italian scientific societies: A new paradigm to promote vaccination at all ages.

Medical scientific societies have the core mission of producing, pooling and disseminating solid and updated scientific information. We report the successful experience of the partnership of four national Medical Scientific Societies active in Italy in producing scientific advice on vaccines and vaccination. In particular, i) the Italian Society of Hygiene, Preventive Medicine and Public Health; SitI, ii) the Italian Society of Paediatrics; SIP, iii) the "Italian Federation of General Practitioners"; FIMP, and iv) the Italian Federation of General Medicine FIMMG) have worked together since 2012 to produce shared evidence-based recommendations on vaccination schedules, namely the "Lifetime Immunization Schedule" which introduced for the first time in Italy a life-course approach to vaccination. The 2014 edition of the "Lifetime Immunization Schedule" was used as a basis to develop the 2017-2019 Italian National Prevention Plan, approved by The Italian Ministry of Health in February 2017. In this report, we present the structure, content and supporting evidence of the new 2016 "Lifetime Immunization Schedule" and we expand on the influential role of medical scientific societies in researching and advocating for effective and safe vaccination programmes' implementation at the national level.

Monitoring adherence to guidelines of antibiotic use in pediatric pneumonia: the MAREA study.

BACKGROUND: Children are the most vulnerable population exposed to the use of antibiotics often incorrectly prescribed for the treatment of infections really due to viruses rather than to bacteria. We designed the MAREA study which consisted of two different studies: i) a surveillance study to monitor the safety/efficacy of the antibiotics for the treatment of pneumonia (CAP), pharyngotonsillitis and acute otitis media in children younger than 14 yrs old, living in Liguria, North-West Italy and ii) a pre-/post-interventional study to evaluate the appropriateness of antibiotic prescription for the treatment these infections. In this paper, we show only results of the appropriateness study about the antibiotic prescription for the treatment of pneumonia. METHODS: Patients included in this study met the following inclusion criteria: i) admission to the Emergency/Inpatient Dpt/outpatient clinic of primary care pediatricians for pneumonia requiring antibiotics, ii) informed written consent. The practice of prescribing antibiotics was evaluated before-and-after a 1 day-educational intervention on International/National recommendations. RESULTS: Global adherence to guidelines was fulfilled in 45%: main reason for discordance was duration (shorter than recommended). Macrolide monotherapy and cephalosporins were highly prescribed; ampicillin/amoxicillin use was limited. 61% of patients received >1 antibiotic; parenteral route was used in 33%. After intervention, i) in all CAP, cephalosporin prescription decreased (-23%) and the inappropriate macrolide prescriptions was halved and, ii) in not hospitalized CAP (notH-CAP), macrolides were prescribed less frequently (-25%) and global adherence to guidelines improved (+39%); and iii) in H-CAP antibiotic choice appropriateness increase. CONCLUSION: Prescribing practices were sufficiently appropriate but widespread preference for multidrug empirical regimens or macrolide in monotherapy deserve closer investigation.

Why, when and for what diseases pregnant and new mothers "should" be vaccinated.

Immunological and serological changes that occur during pregnancy can alter the susceptibility of both the mother and the fetus against various infectious diseases. The pregnant woman has an altered immune response and, for some pathologies, is at increased risk of infection and of developing complications and serious outcomes. In addition, maternal infections can result in congenital anomalies, malformations or severe neonatal diseases. Vaccination of pregnant women can therefore have a double goal: to protect the mother from diseases that could have an impact on her health and to avoid infection/disease transmission to the fetus or the newborn. Despite the potential benefits of immunization in pregnant women, it is still evident reluctance and/or refusal of vaccinations by health professionals as well as by pregnant women, who are wary of the real advantages linked to vaccines. For these reasons a group of experts has evaluated the latest scientific evidence reported in the international literature on this relevant topic.

Intradermal therapy (mesotherapy) for the treatment of acute pain in carpal tunnel syndrome: a preliminary study.

BACKGROUND: The carpal tunnel syndrome (CTS) is the most common cause of severe hand pain. In this study we treated acute pain in CTS patients by means of local intradermal injections of anti-inflammatory drugs (mesotherapy). METHODS: In twenty-five patients (forty-five hands), CTS diagnosis was confirmed by clinical and neurophysiological examination prior to mesotherapy. A mixture containing lidocaine 10 mg, ketoprophen lysine-acetylsalycilate 80 mg, xantinol nicotinate 100 mg, cyanocobalamine 1,000 mcg plus injectable water was used. Sites of injection were three parallel lines above the transverse carpal ligament and two v-shaped lines, one at the base of the thenar eminence, and the other at the base of the hypothenar eminence. RESULTS: The day after the treatment, all but four patients reported a significant reduction in pain and paresthesias. After 12 months, 17 patients had a complete pain relief, eight patients reported recurrence of pain and sensory symptoms and four out of them underwent surgical treatment. CONCLUSIONS: With the obvious limits of a small-size open-label study, our results suggest that mesotherapy can temporary relieve pain and paresthesias in most CTS patients and in some cases its effect seems to be long-lasting. Further controlled studies are needed to confirm our preliminary findings and to compare mesotherapy to conventional approaches for the treatment of CTS.

Vaccination recommendations for patients with neuromuscular disease.

Neuromuscular diseases (NMDs) encompass a broad spectrum of conditions. Because infections may be relevant to the final prognosis of most NMDs, vaccination appears to be the simplest and most effective solution for protecting NMD patients from vaccine-preventable infections. However, very few studies have evaluated the immunogenicity, safety, tolerability, and efficacy of different vaccines in NMD patients; therefore, detailed vaccination recommendations for NMD patients are not available. Here, we present vaccination recommendations from a group of Italian Scientific Societies for optimal disease prevention in NMD patients that maintain high safety levels. We found that NMD patients can be classified into two groups according to immune function: patients with normal immunity and patients who are immunocompromised, including those who intermittently or continuously take immunosuppressive therapy. Patients with normal immunity and do not take immunosuppressive therapy can be vaccinated as healthy subjects. In contrast, immunocompromised patients, including those who take immunosuppressive therapy, should receive all inactivated vaccines as well as influenza and pneumococcal vaccines; these patients should not be administered live attenuated vaccines. In all cases, the efficacy and long-term persistence of immunity from vaccination in NMD patients can be lower than in normal subjects. Household contacts of immunocompromised NMD patients should also be vaccinated appropriately.

Skiing and snowboarding injuries and their impact on the emergency care system in South Tyrol: a restrospective analysis for the winter season 2001--2002.

OBJECTIVES: To evaluate the incidence and the pattern of skiing and snowboarding injuries in South Tyrol and their impact on the emergency medical system in the winter season 2001--2002 in an attempt to rationalize and improve the emergency care and assist in prevention strategies. METHODS: All medical records of patients referred to our emergency department (ED) that sustained a skiing or snow-boarding injury during the study period were retrospectively reviewed. Age, sex, local or non-local residency, type of injury, data and time of accident, type of transport to the hospital, hospital admission or ED discharge, Injury Severity Score, outcome (including mortality) were evaluated. On site mortality data were obtained from the emergency call-center registry. Ski resorts utilization was estimated from the data published by the Regional Office of Cable Transport. RESULTS: For the period analyzed approximately 2,500,000 skier and snowboarder days were recorded in the whole region of which about 500,000 were attributed to the four nearby ski resorts that refer to our hospital. Of the 1087 patients, 794 were skiers and 294 were snowboarders. Snow-boarders were younger than skiers (mean age 20 and 36 respectively, p = 0.001). Females were equally represented in the two groups. Male patients, children, senior skiers and non-local residents suffered from more severe injuries than their corresponding classes (p < 0.01, p = 0.002, p = 0.02, p = 0.000 respectively). Critical injuries (ISS > or = 25) were homogeneously spread in the groups, with the exception of the non-local resident patients that showed a higher incidence (p < 0.02). No difference in severity was found between skiers and snowboarders. The incidence was 2.05 per 1,000 skier-days. Mortality rate was 1.6 per 1,000,000 skier-days. The pattern of injury was different: snowboarders showed more forearm and wrist trauma and skiers more lower extremity injuries. 208 patients were hospitalized and the mean length of stay was 4.5 days. Head trauma and fractures were the most common diagnosis of admission. The lack of field triage led to 12% of unjustified helicopter transfer and 9.6% of avoidable ambulance transport. CONCLUSIONS: Incidence, pattern of injuries and mortality from skiing and snowboarding accidents in South Tyrol resemble those reported in other part of the world. Nevertheless, strategies for prevention are needed. The routine use of helmets should be enforced by law. Dangerous behaviors should be prosecuted. Skiers and snowboarders should be made aware that skiing beyond their technical ability can be life-threatening.