Association of sedentary time with risk of cardiovascular diseases and cardiovascular mortality: A systematic review and meta-analysis of prospective cohort studies.

Given the high prevalence of cardiovascular disease (CVD), we meta-analysed CVD relative risk (RR) in relation to high vs. low categories of self-reported and objectively assessed sedentary behaviours from cohort studies; in a sub-sample (n = 4 studies), the theoretical substitution of one hour spent sedentary with the same amount of time spent in light-intense physical activity was evaluated. Based on 19 studies (60,526 fatal and non-fatal CVD, 1,473,354 individuals and 13,559,139 persons-year) we estimated a 30% increased CVD risk for high vs. low categories of sedentary behaviour (RR = 1.29, confidence interval (CI) = 1.22;1.37). Every hour spent sedentary corresponds to a 5% increased fatal and non-fatal CVD risk (RR = 1.05, CI = 1.02;1.07). Dose-response meta-analysis revealed that sedentary behaviour is statistically significantly associated to fatal and non-fatal CVD risk following a J-shaped relation. Substituting one hour spent sedentary with physical activity of light intensity reduced the risk of fatal and non-fatal CVD events by one-fifth (RR =0.84, CI = 0.73;0.97). In meta-regression analysis, potential influential factors such as age, sex, and medical condition did not essentially alter the results.

20-Year trends of hospitalisation among people with dementia: a region-wide retrospective cohort study from Lombardy, Italy.

OBJECTIVES: The aim of this study was to investigate the trends of hospitalisations among people with dementia, linking region-wide hospital and demographic health records. STUDY DESIGN: A retrospective cohort study was conducted using hospitalisation health records from the Lombardy region in Italy. METHODS: The study included people aged ≥65 years with a diagnosis of dementia who were hospitalised between 2002 and 2020 in Lombardy, which is the most populated region in Italy with 10 million inhabitants. Using data on resident population, this study computed rates of hospitalisation by calendar year, age, sex and cause of hospitalisation. RESULTS: In total, 340,144 hospitalised patients with dementia were included in the study. The rate of hospitalisation was 100.6 per 10,000 in 2002 and progressively decreased to 65.1 per 10,000 in 2020. The average age at hospitalisation in 2002 was 78.9 years for men and 81.8 years for women, which increased to 82.0 years and 84.2 years, respectively, in 2020. Respiratory diseases caused 10.4% of all hospitalisations in 2002 and grew steadily to 26.8% in 2020, becoming the leading cause of hospital admissions since 2017. CONCLUSIONS: Hospitalisation patterns for people with dementia have changed over the last 20 years, reflecting evolving epidemiological trends and the impact of healthcare policies. Region-wide administrative health record data analysis should be further utilised to explore the health needs of people with dementia and inform the planning, implementation and monitoring of effective prevention strategies in this population group.

The synergies of University Education and Primary Health Care to meet populations health needs.

Absract: In the last decades, the World Health Organization has sensitized all countries to adopt a Primary Health Care approach in their health systems. It is also important to invest in education about primary health care. Indeed, we need to spread this comprehensive culture of health, starting from university education, and continuing during the whole work-life cycle. Due the current medical model, approaching patient by specific pathology or discipline, inefficiencies have been generated due to a lack of communication and integrated management of chronicity. Public Health can build dynamic models and mechanisms that pursue the health needs expressed by populations and education plays a crucial role in enhancing a country's resilience and protecting the health of its inhabitants. All the health workers should consider all the aspects of health, beyond the specific phases of diagnosis and treatment. Continuous education and training are key elements to focus on, to satisfy our population's health needs.

Doubled mortality rate during the COVID-19 pandemic in Italy: quantifying what is not captured by surveillance.

OBJECTIVES: It is important to quantify the true burden of coronavirus disease 2019 (COVID-19) in different countries, to enable informed decisions about imposing and relaxing control measures. COVID-19 surveillance data fails in this respect, as it is influenced by different definitions, control policies and capacities. This article aims to quantify excess mortality and estimate the distribution between COVID-19 and non-COVID-19 causes of death. STUDY DESIGN: Observational study and mathematical modelling. METHODS: Publicly available data from multiple institutional sources were used and an in-depth analysis was carried out of deaths from all causes between 2015 and 2020 in Italy at the national, regional and local level. Excess mortality over time and space was first explored, followed by an assessment of how this related to COVID-19 surveillance and, ultimately, assuming a fixed male:female ratio, a model was developed and applied to estimate the proportions of COVID-19 and non-COVID-19 excess mortality in 2020. RESULTS: In Italy, the mortality rate doubled in March and April 2020 compared with data from 2015 to 2019 (+109%, when considering municipalites with >10.000 inhabitants), with excess mortality reaching >600% in large municipalities in northern areas. Notified COVID-19 deaths accounted for only 43.5% (regional range: 43-62%) of excess mortality. It is estimated that more than two-thirds of excess deaths that were not captured by surveillance are non-COVID-19 deaths, which could be a result of the excess burden on the health systems, in addition to reduced demand and supply of other non-COVID healthcare services. CONCLUSIONS: The impact of COVID-19 during the early stages of the pandemic is much larger than official figures have reported. Monitoring excess mortality helps to capture the full effect of the COVID-19 pandemic, which differs between regions in Italy and which might have resulted in significant indirect effects on the well-being of the population. In addition, the COVID-19 pandemic has also resulted in significant indirect effects on the well-being of the population.

Application of the "immunization islands" model to improve quality, efficiency and safety of a COVID-19 mass vaccination site.

Abstract: After SARS-CoV-2 vaccines development came at an unprecedented speed, ensuring safe and efficient mass immunization, vaccine delivery be-came the major public health mandate. Although mass-vaccination sites have been identified as essential to curb COVID-19, their organization and functioning is challenging. In this paper we present the planning, implementation and evalua-tion of a massive vaccination center in Lombardy - the largest Region in Italy and the most heavily hit by the pandemic. The massive hub of Novegro (Milan), managed by the Gruppo Ospedaliero San Donato, opened in April 2021. The Novegro mass-immunization model was developed building a la-yout based on the available scientific evidence, on comparative analysis with other existing models and on the experience of COVID-19 immunization delivery of Gruppo Ospedaliero San Donato. We propose a "vaccine islands" mass-immunization model, where 4 physicians and 2 nurses operate in each island, with up to 10 islands functioning at the same time, with the capacity of providing up to 6,000 vaccinations per day. During the first week of activity a total of 37,900 doses were administered (2,700/day), most of them with Pfizer vaccine (85.8%) and first doses (70.9%). The productivity was 10.5 vaccines/hour/vaccine station. Quality, efficiency and safety were boosted by ad-hoc personnel training, quality technical infrastructure and the presence of a shock room. Constant process monitoring allowed to identify and promptly tackle process pitfalls, including vaccine refusals (0.36%, below expectations) and post-vaccinations adverse reactions (0.4%). Our innovative "vaccine islands" mass-immunization model might be scaled-up or adapted to other settings. The Authors consider that sharing best practices in immunization delivery is fundamen-tal to achieve population health during health emergencies.

Four Italian experiences on vaccination policies: results and lessons.

INTRODUCTION: In 2018 the Council of Europe adopted a Recommendation on strengthened cooperation against vaccine preventable diseases. Among EU Member States, Italy has a long-lasting tradition of immunization policies implemented in the context of the National Health Service over the last forty years. METHODS: We identify, report and critically appraise four immunization strategies implemented in Italy in recent years and quantitatively assess their impact on coverage rates and other selected indicators. RESULTS: First: the regional law that suspended mandatory vaccination in the Veneto Region in 2007 to stimulate a proactive approach to vaccine uptake was not successful. Second: a strengthened political commitment started in 2014 brought to the release of an innovative and updated National Immunization Prevention Plan and to encouraging increase in vaccine confidence and vaccination uptake. Third: the success of social media influencers is exemplified by the case of Roberto Burioni, professor of microbiology, who in 2015 started a personal social media campaign to contrast anti-vaccinists. Fourth: The new 2017 Italian law extending mandatory vaccinations has successfully impacted on vaccine coverage which increased by more than 1% and 4% for polio and MMR vaccines, respectively, in the first six months since its entering into force, and has continued to raise in 2018. CONCLUSION: Our data and real-life case studies offer to the broader European public health community a solid basis for discussion and ground to evaluate similar polices implemented in different European settings, with the common goal to share best practices and promote the culture of immunization.

The prevention of doping and the improper use of drugs and food supplements in sports and physical activities: a survey on the activity of the prevention departments of Italian local health authorities.

INTRODUCTION: Doping is an important public health problem widespread not only among elite athletes, but also among amateur and recreational athletes and the general population. In Italy the introduction of doping prevention within the Essential Levels of Care (LEA) with the DPCM 12/1/2017 represents a crucial step towards the implementation of education and health promotion interventions. In this context, the Departments of Prevention (DP) of the Local Health Authorities (LHA) have to play a fundamental role, becoming the cultural and operational reference on this issue. As part of the "Doping prevention: development of a permanent educational tool coordinated by the National Health Service Prevention Departments" project, funded by the Italian Ministry of Health, a survey was conducted on the activities carried out by the DP regarding doping prevention and improper use and abuse of drugs and food supplements in sports and physical activities, as a basis for the harmonization of organizational structures and prevention programs and the creation of a collaboration network at a regional and national level. METHODS: A semi-structured questionnaire consisting of 11 questions, prepared on an electronic platform, was sent to the DP of all the Italian LHA. RESULTS: A total of 38 DP out of 131 (29%) completed the questionnaire, with representation from all regions. 42.1% of DP carried out or are still running programs for the prevention of doping, a percentage that decreases to 27% considering the programs for the prevention of misuse and abuse of drugs and food supplements in sports and in physical activities; in less than half of the DP, 37.5% and 41.7%, respectively, dedicated funds have been allocated. The professionals most involved in prevention of doping are the Specialists in Sport Medicine (81.3%) followed by Specialists in Hygiene (43.8%) and Psychologists (37.5%), while Health Care Assistants (50%) are the professionals most involved in the prevention of the improper use of drugs and food supplements, followed by Specialists in Hygiene and Specialists in Sport Medicine (40%). Most of the DP (71.9%) believe that the introduction of programs to prevent and counteract doping in the LEA will have repercussions on their approach against doping. CONCLUSIONS: The survey, although conducted on a limited sample, has provided an important framework relating to programs for the prevention of doping and the misuse and abuse of drugs and food supplements in sports and in the physical activities carried out by DP. A remarkable heterogeneity has been highlighted, both at national and regional level. It is urgent to provide DP with homogeneous and effective organizational models and adequate operational tools, paying particular attention to the training of all the professionals involved. It is also essential to implement permanent monitoring tools.

Childhood vaccine coverage in Italy after the new law on mandatory immunization.

BACKGROUND: The Italian National Immunization Prevention Plan (PNPV) identifies vaccines actively offered free of charge to target populations within the National Health Service. Despite this, childhood immunization coverage has been declining in Italy in recent years. As a response, the Italian Parliament in July 2017 approved law n. 119 extending mandatory childhood vaccines from four to ten, this stimulating a lively debate at both the scientific and policy level. METHODS: We analysed and critically interpreted 2000-2017 Italian national childhood immunization coverage trends, by different vaccine, target population, birth cohort and by Region. In particular, in order to preliminarily assess the impact of the new law, we computed percentage changes in 2016-2017 vaccine coverage for both mandatory and recommended vaccine programs. Data were provided by the Directorate General of Health Prevention of the Italian Ministry of Health. RESULTS: In 2017 national-level vaccine coverage at 24 months of age was 94.5% for Polio and 91.7% for Measles, this representing, respectively 1.2% and 4.4% increase, as compared to 2016. Conjugate Pneumococcal and Meningococcal C vaccines coverage increased, respectively, by +2.5% and +2.4% between 2016 and 2017. National-level polio vaccine coverage remained above the 95% PNPV coverage target between 2000 and 2013 and has remained below since then. In particular, it has had been steadily declining between 2011 and 2016 (-2.8%). Measles coverage remained well below the 95% coverage target for the entire study period. In recent times, it declined by 4.8% between 2011 and 2015 with the lowest coverage rate reported for year 2015 (85.3%). There is high heterogeneity in coverage within Regions for both mandatory and recommended vaccines. CONCLUSION: Preliminary data show that childhood immunization coverage increased since the approval of the new law on mandatory vaccination. Nonetheless, as additional data are accumulating and will make it possible to further assess the impact of the new law, strengthened efforts are needed in Italy to promote informed and proactive vaccine uptake.

Knowledge, experiences, and attitudes toward Mantoux test among medical and health professional students in Italy: a cross-sectional study.

BACKGROUND: The World Health Organization's Action Framework for tuberculosis elimination in low-tuberculosis incidence countries includes the screening for active and latent tuberculosis in selected high-risk groups, including health care workers. In this context, medical and health profession students, exposed to nosocomial tuberculosis transmission during training and clinical rotations, are target populations for tuberculosis screening. No updated data are available on tuberculosis screening practice and knowledge of medical and health profession students in Italy. METHODS: Within the activities Italian Study Group on Hospital Hygiene of the Italian Society of Hygiene, Preventive Medicine and Public Health, we carried out a multicentre cross-sectional study to assess knowledge, attitude and practices on tuberculosis prevention and control among Medical, Dentistry, Nursing and other health professions' students. Students were enrolled in the study on a voluntary basis and were administered a previously piloted structured questionnaire. Logistic regression models were applied to explore knowledge on tuberculosis prevention by selected socio-demographic variables and University-based tuberculosis prevention practice. RESULTS: Students of seventeen Universities across Italy participated in the study, and 58.2% of them received compulsory tuberculin skin test either at enrollment or while attending clinical practice. A total of 5,209 students filled the questionnaire. 37.7% were medicine and dentistry students (Group 1), 44.9% were nursing students (Group 2) and 17.4% were other health professions' students (Group 3). Age and gender had different distributions by groups, as well as knowledge and practice on tuberculin skin test. 84.4% of the study population (95% CI = 83.3-85.3) was aware of the existence of the tuberculin skin test, 74.4% (95% CI = 73.2-75.6) knew what is the first-level screening test for latent tuberculosis and only 22.5% (95% CI = 21.4-23.6) knew how to proceed after a positive tuberculin skin test result. Overall, knowledge on tuberculosis prevention was higher in Group 2 and lower Group 3, as compared to Group 1. CONCLUSION: In Italy, the knowledge on tuberculosis screening among University students is generally good. To reduce some of the criticalities found among the different study courses, it would be appropriate to harmonize both the regulations on tuberculosis screening practices for admission to University courses, and the educational activities on the topic of tuberculosis, to be extended to all workers involved in health care setting.

Human papillomavirus 9-valent vaccine for cancer prevention: a systematic review of the available evidence.

In 2014, the Food and Drug Administration approved a new human papillomavirus 9-valent vaccine (9vHPV), targeting nine HPV types: HPV types 6, 11, 16, and 18, which are also targeted by the quadrivalent HPV vaccine (qHPV), plus five additional high cancer risk HPV types (HPV types 31, 33, 45, 52, and 58). The aim of the current study was to systematically retrieve, qualitatively and quantitatively pool, as well as critically appraise all available evidence on 9vHPV from randomized controlled trials (RCTs). We conducted a systematic review of the literature on 9vHPV efficacy, immunogenicity and safety, as well as a systematic search of registered, completed, and ongoing RCTs. We retrieved and screened 227 records for eligibility. A total of 10 publications reported on RCTs' results on 9vHPV and were included in the review. Sixteen RCTs on 9vHPV have been registered on RCT registries. There is evidence that 9vHPV generated a response to HPV types 6, 11, 16 and 18 that was non-inferior to qHPV. Vaccine efficacy against five additional HPV type-related diseases was directly assessed on females aged 16-26 years (risk reduction against high-grade cervical, vulvar or vaginal disease = 96·7%, 95% CI 80·9%-99·8%). Bridging efficacy was demonstrated for males and females aged 9-15 years and males aged 16-26 years (the lower bound of the 95% CIs of both the geometric mean titer ratio and difference in seroconversion rates meeting the criteria for non-inferiority for all HPV types). Overall, 9vHPV has been proved to be safe and well tolerated. Other RCTs addressed: 9vHPV co-administration with other vaccines, 9vHPV administration in subjects that previously received qHPV and 9vHPV efficacy in regimens containing fewer than three doses. The inclusion of additional HPV types in 9vHPV offers great potential to expand protection against HPV infection. However, the impact of 9vHPV on reducing the global burden of HPV-related disease will greatly depend on vaccine uptake, coverage, availability, and affordability.

The impact of bariatric surgery on health outcomes, wellbeing and employment rates: analysis from a prospective cohort study.

PURPOSE: Morbid obesity is associated with several comorbidities that often impair patients' ability to obtain and keep a job and that, eventually, could hinder their fitness to work. This study aimed at determining whether the employment status of morbidly obese patients may be positively affected by bariatric surgery. METHODS: A total of 30 morbidly obese patients who underwent Roux-en-Y gastric bypass (RYGB) from March 2014 to March 2015 were prospectively evaluated. All patients underwent a pre-operative assessment including the collection of personal and occupational data and the evaluation of musculoskeletal system. All evaluations were repeated at the end of a 24-month follow up. RESULTS: After RYGB, employment rates increased from 15/30 (50.0%) to 25/30 (83.3%, p = 0.012). Patients who were working at the end of follow-up referred lower rates of comorbidities, in particular of musculoskeletal complaints (4/25 vs. 4/5, p < 0.001), and presented significantly increased scores of energy/vitality at SF-36 assessment. CONCLUSIONS: Our study suggests that RYGB can increase employment rates, increasing tolerance to effort and reducing prevalence and severity of obesity-related symptoms and complaints.

The Italian National Health Service expenditure on workplace prevention and safety (2006-2013): a national-level analysis.

BACKGROUND: The World Health Organization (WHO) stated that countries' health policies should give high priority to primary prevention of occupational health hazards. Scant data are available on health expenditure on workplace prevention and safety services and on its impact on occupational health outcomes in Italy and in other European countries. STUDY DESIGN: objective of the present study was to systematically retrieve, analyse and critically appraise the available national-level data on public health expenditure on workplace prevention and safety services as well as to correlate them with occupational health outcomes. METHODS: National-level data on total public health expenditure on prevention services, its share spent on workplace prevention and safety services as well as on number of workers receiving appropriate health surveillance were derived from the national public health expenditure monitoring system over a 8-year study period (2006-2013). An analytic approach was adopted to explore the association between health expenditure and occupational health services supply. RESULTS: The Italian National Health Service spends almost € 5 billion per year on preventive care, of which 13.3% are spent on workplace prevention and safety programmes (€ 645 million, € 10.6 per capita). There is wide heterogeneity between Italian regions. CONCLUSIONS: Our findings are useful for health systems and policies analysis, national and international comparisons as well as for health policy makers to plan, implement and monitor occupational health prevention programmes.

Meningococcal serogroup B vaccine in Italy: state-of-art, organizational aspects and perspectives.

Neisseria meningitidis causes severe invasive meningococcal diseases (IMDs) in humans including meningitis and septicemia, responsible for serious clinical conditions and leading to life-long disabilities and death. Serogroup B dominates IMDs burden in Italy, accounting for over 60% of total cases. On January 2013 the European Medicine Agency (EMA) licensed the first serogroup B meningococcal (MenB) vaccine in Europe. A number of European countries and Regions have introduced the new MenB vaccine in their immunization schedule, including Italy. In this paper we present the state of art, related critical issues and future perspectives of MenB vaccine introduction in Italy, in the context of the most recent available epidemiological data. In particular, we systematically assess the ongoing processes in the 8 Italian regions and one autonomous province that have already introduced MenB vaccine. With the new 2014-2018 National Vaccine Prevention Plan including active MenB vaccine offer about to be adopted, it is of fundamental importance to gather further evidence on MenB vaccine clinical effectiveness, duration of protection and cost-effectiveness. Italian regions are called to organize and manage MenB immunization programs. Careful consideration will need to be devoted on timing, doses, and co-administration with other vaccines but also to economic assessments and strengthened communication to the general public. Our data will help to plan, implement and evaluate MenB immunization programmes in other Italian and international settings.

Advocacy communication, vaccines and the role of scientific societies.

In 1986 the Ottawa Charter underlined the importance of advocacy in health. This article analyzes the role of advocacy in Public Health making the case of immunization, whose coverage rates are decreasing in many countries. An effective advocacy action could counteract the growing phenomenon of the vaccine hesitancy within both the general population and an increasing share of healthcare providers as well as contrast antivax movements' action. We identify who are the advocates focusing on Italy and on the crucial role of scientific societies which share the responsibility of making the latest scientific evidence and most effective infectious diseases' control strategies available to health policy makers. The Italian Society of Hygiene (SItI) has been actively engaged for several years in a number of initiatives of advocacy communication and vaccines including research, training, media exposure and a dedicated website portal (vaccinarSì).

Diagnostic validity of comorbid bipolar disorder and obsessive-compulsive disorder: a systematic review.

OBJECTIVE: At least 50% of bipolar disorder (BD) patients have an additional diagnosis, one of the most difficult to manage being obsessive-compulsive disorder (OCD). Defining the nosology of BD-OCD comorbidity has important clinical implications, given that treatments for OCD can worsen BD outcomes. METHOD: A systematic review was conducted on: i) BD-OCD comorbidity lifetime prevalence and ii) on standard diagnostic validators: phenomenology, course of illness, heredity, biological markers, and treatment response. Relevant papers published through March 30th 2013 were identified searching the electronic databases MEDLINE, Embase, PsycINFO, and the Cochrane Library. RESULTS: Sixty-four articles met inclusion criteria. Lifetime comorbidity prevalence was 11-21% in BD patients and 6-10% in OCD patients. Compared to non-comorbid subjects, BD-OCD has a more episodic course of OC symptoms (up to 75% vs. 3%), typically with worsening during depression (78%) and improvement during mania/hypomania (64%), as well as a higher total mean number of depressive episodes (8.9±4.2 vs. 4.1±2.7) and perhaps more antidepressant-induced mania/hypomania (39% vs. 9%). CONCLUSION: In this first systematic review of BD-OCD comorbidity, it appears that OC symptoms are usually secondary to BD, rather than representing a separate disease.

Transition to retirement impact on risk of depression and suicidality: results from a longitudinal analysis of the Survey of Health, Ageing and Retirement in Europe (SHARE).

AIMS: Depression is among the main contributors to older adults' mental health burden. Retirement, one of the major life transitions, has been claimed to influence mental health substantially. Following up on a previous meta-analysis, the study aims to assess from a longitudinal perspective short- and long-term impacts of transitioning to retirement on depression risk and suicidality in older adults across Europe. METHODS: We conducted a longitudinal study using data from the Survey of Health, Ageing and Retirement in Europe (SHARE), collected between 2004 and 2020 in 27 European countries plus Israel. To estimate relative risks (RR) and 95% confidence intervals (95% CIs) for depression and suicidality at seven time intervals before and after retirement, we fitted adjusted generalized estimating equation models for repeated measures. RESULTS: We included 8,998 individuals employed at baseline and retired at follow-up (median follow-up time: 9 years; maximum: 16 years). Compared to the year of retirement, the risk of depression was 11% lower in the following year (RR 0.89; 95% CI 0.81-0.99), 9% lower after 2 years (RR 0.91; 95% CI 0.82-1.00) and after 3 years (RR 0.91; 95% CI 0.81-1.01). Significant estimates remained among females, married individuals, those with an intermediate or higher level of education, former manual workers and those who retired at or before their country's median retirement age. A significant increase in depressive symptoms emerged from the tenth year after retirement among former non-manual workers (RR 1.21; 95% CI 1.05-1.40) and late retirees (RR 1.37; 95% CI 1.16-1.63). No heterogeneity emerged among strata. As for suicidality, we reported an increase in risk only 5 years or more after retirement, namely +30% 5-9 years after retirement (RR 1.30; 95% CI 1.04-1.64) and +47% 10 or more years after retirement (RR 1.47; 95% CI 1.09-1.98). Sensitivity analyses excluding subjects who reported a diagnosis of depression over the study period and those retirees who declared to receive a disability pension confirmed the results obtained in the overall analysis. CONCLUSIONS: Longitudinal adjusted data suggest an independent effect of retiring associated with a reduction in depression and suicidality risk in the short run, with its effect decreasing in the long run. Such trends are particularly evident among selected subgroups of elderly populations. If greater flexibility in pensionable age may help prevent depression late in life, the transition to retirement is to be accompanied by targeted health promotion interventions. In an ageing society, welfare policies should be evaluated, considering their long-term impact on mental health.

The community pharmacy model for colorectal cancer screening: Policy insights from a national programme.

BACKGROUND: In Italy, a recent national project has expanded local collaboration between colorectal (CRC) screening programmes and pharmacies to the national level. OBJECTIVE: The objective of this study is to provide an overview of the existing agreements between regional authorities and pharmacy owners in Italy regarding CRC screening programmes, to make internationally available the most qualifying elements of the collaboration. METHODS: We analyzed the agreements, in force on 01/08/2021, arranged between the Regions and their respective pharmacy owners, describing the process phases addressed such as the faecal occult blood test pathway and supplementary activities provided by the pharmacies together with the CRC screening kit delivery. RESULTS: Agreements were received from 18 Regions (86% of the total). The amount of money paid for each kit varies a lot, with a range from 0 to 18 EUR. The number of process phases covered by the agreements ranged from a maximum of 16 (out of 18) to a minimum of 0. The processes most frequently covered were the supply/delivery of kits and education/awareness of CRC screening (68.8%). Less covered processes were warehouse management and awareness of other healthcare initiatives (12.5%), and delivery of preparation for intestinal cleansing (6.3%). CONCLUSIONS: Arrangements between pharmacies and CRC screening programmes in Italy vary widely and lack a unified model. Collaboration quality standards should be set at the national/international level.

Environmental risk factors for amyotrophic lateral sclerosis: methodological issues in epidemiologic studies.

The exact role of environmental risk factors in the etiology of the neurodegenerative disease amyotrophic lateral sclerosis (ALS) is still unknown. Their hypothetical contribution ranges from a minimal impact to a major role. Among the environmental factors strictu sensu (i.e., not life-style factors) suspected to play a role in ALS etiology, we consider pesticides, the metalloid selenium, some heavy metals, magnetic fields and cyanobacteria. However, the possibility exists that these factors exert their activity only in genetically susceptible persons and only after long-term exposures, thus further hampering epidemiologic studies. The recent availability of powerful tools such as population-based ALS registries for case ascertainment and clustering detection, and of environmental modeling techniques and of geographical information systems, may yield unique opportunities for offering insight into the etiology of the disease.