The bigger, the better? A systematic review on the impact of mergers on primary care organizations.

BACKGROUND: Primary care services are the first point of contact in a healthcare system; in the last years, many mergers and reconfigurations have taken place in this setting. The aim of this study is to summarize the literature evidence on the relationship between the increase in the size of these organizations and their performance. METHODS: A systematic review of the literature was carried out querying EMBASE, MEDLINE and Web of Science databases, from their inception to January 2020. Articles which quantitatively assessed outcomes and process indicators of merger/structural reorganization of primary care organizations and qualitative articles that assessed staff perception and satisfaction were included in the review. RESULTS: A total of 3626 articles was identified and another study was retrieved through snowball search; 11 studies were included in the systematic review. Studies about lipid profile evaluation and emergency admissions for chronic conditions showed moderate evidence in supporting the merging of primary care organizations; conversely, clinical outcome studies did not reach a sufficient level of evidence to support merging actions. A moderate evidence of a negative effect on patient's perspective was found. CONCLUSION: Actually, there is no strong evidence in favour or against merging of primary care organizations without equivocation. This review supports the possibility to identify indicators for evaluating a merging process of primary care organizations and for adopting eventual remedies during this process. Further efforts should be made to identify additional indicators to assess merge actions among primary care organizations.

Orbital metastases from breast cancer: A single institution case series.

BACKGROUND AND OBJECTIVES: Among orbital tumors, metastatic lesions have a prevalence of 1% to 13%; on the other hand, breast cancer is the most common malignancy causing orbital metastases. The aim of this study is to present our experience dealing with orbital metastases caused by breast cancer, to assess characteristics and clinic-pathological data of patients suffering from this rare occurrence and to find indexes related with their prognosis and survival. METHODS: Records of 28 patients diagnosed with orbital metastases from breast cancer at the Department of Ophthalmology, Humanitas Clinical and Research Centre of Milano over a 27-year period (1992-2018) were retrieved and analyzed. RESULTS: Mean patients' age at breast cancer diagnosis was 56.29 ± 14.63 years. Mean time interval between breast cancer diagnosis and orbital metastasis occurrence was 5 ± 4.17 years. All lesions were estrogen receptor-positive; 79% of patients harbored progesterone receptor-positive lesions. Interestingly, the majority of deceased patients presented orbital lesions with MIB-1 index >50% (P = .0265) and had concomitant lung metastases (P = .0452). CONCLUSIONS: The occurrence of orbital metastasis from breast cancer represents a challenging finding. Patients' clinical picture can include exophthalmos, edema, tumefaction, proptosis and/or diplopia. Significant symptomatic improvement can be achieved through surgery and other adjuvant treatments, such as radiation therapy and chemotherapy.

Intraoperative sonography for nonpalpable breast lesions: Additional indications for a consolidate technique.

This prospective study evaluated the intraoperative ultrasound scan (IUSS) for nonpalpable breast lesions' detection. A total of 108 consecutive female patients underwent surgery using IUSS: Frozen sections demonstrated clear margins in 95.5% of neoplastic patients. Only four (4.5%) patients underwent local re-excision in the same operation. IUSS demonstrated to be quick, accurate, useful, effective, and safe for the intraoperative management of neoplastic nonpalpable breast lesions when performed by a surgeon who has undergone US training, particularly for people in whom alternative approaches can show some limitations due to contraindications or because of scheduling constraints, costs, and patient discomfort.

Parathyroid Autotransplantation During Thyroid Surgery: A Novel Technique Using a Cell Culture Nutrient Solution.

INTRODUCTION: Parathyroid autotransplantation is an easy procedure with a low complication rate. We adopted the transplantation into the sternocleidomastoid muscle, which allows an easier and time-saving surgical procedure using the same surgical incision. METHODS: In this study, we retrospectively reviewed the records of 396 consecutive patients, who underwent total thyroidectomy for benign thyroid disease. In all cases in which a parathyroid was damaged or inadvertently removed, the gland was transplanted; before the autotransplantation, the parathyroid tissue was put in a cell culture nutrient solution for 5 min, afterward fragmented, and then was transplanted in the sternocleidomastoid muscle. To demonstrate a beneficial effect of the cell nutrient solution step, we compared data of transplanted patients with a control group of cases (n = 190) undergoing a standard immediate autotransplantation. RESULTS: We divided patients in two main groups: group A (n = 160) including subjects that underwent one or more parathyroid gland autotransplantation using the cell nutrient solution, and group B (n = 236) concerning those who were not transplanted. Among patients, 62 hypocalcemias occurred, 40 in the group A and 22 in the group B (P < 0.001): 91.9 % were transient and 8.1 % (5 patients) definitive, all pertaining to the group B. Among controls (group C), 42 hypocalcemias occurred (P = 0.616 vs. group A and P = 0.002 vs. group B) and 3/42 became definitive (P = 0.096 vs. group A and P = 0.121 vs. group B). All differences concerning pre- and postoperative calcium values were statistically significant (P < 0.001). CONCLUSIONS: We recommend the routine parathyroid autotransplantation, when a vascular damage is certain or suspected, in order to reduce the rate of permanent hypoparathyroidism, using a cell culture nutrient solution before gland transplantation.

Maxillofacial and concomitant serious injuries: An eight-year single center experience.

PURPOSE: Maxillofacial injuries are frequently associated with multiple trauma and can determine functional and aesthetic bad outcomes. The severity of maxillofacial injuries may be considerable and can divert clinicians' attention from other concomitant injuries which is less evident but potentially life-threatening. The aim of this study was to find out the concomitant injuries in patients referred to the Emergency Department (ED) of the University Hospital of Messina (North-East Sicily, Italy) for maxillofacial traumas. METHODS: We retrospectively evaluated data of 240,833 patients admitted at the ED of the University Hospital of Messina from January 2008 to December 2015 because of maxillofacial injuries leading to hospitalization and surgical treatment. Patients who primarily received treatment care at different institutions, pediatric trauma patients and adult patients who were transferred in accordance with pre-existing agreements in case of paucity of beds were excluded. Finally we included 447 (0.2%) patients over the 8 years. Data were evaluated with emphasis on epidemiology (age, gender, mechanism of trauma), primary survey and abnormalities and pattern of trauma. RESULTS: The most frequent cause of maxillofacial trauma was road accidents (319 patients, 71.4%), among which motorcycle ones were prevalent. The maxillofacial injured who presented major lesions were 98 patients and minor lesions occurred in 349 patients; 443 (99.1%) patients underwent maxillofacial surgery, immediate or delayed depending on the severity of concomitant injuries (χ2 = 557.2, p < 0.0001). Five concomitant neglected lesions were found to be associated with severe maxillofacial traumas (χ2 = 17.13, p < 0.0001 vs minor lesions). All of the neglected lesions occurred in paucisymptomatic patients who showed painless abdomen, no hemodynamic instability, no signs of hematoma of anterior and posterior abdominal wall or other suspicious clinical signs and symptoms. CONCLUSION: Among the patients admitted firstly in other surgical wards different from the Maxillofacial Surgery Unit, diagnosis was more difficult, especially for blunt abdominal traumas, in which patients showed only vague and nonspecific symptoms concealing serious and life-threatening injuries. We recommend the routine use of whole body CT scan, when the maxillofacial injuries appear prevalent, mainly in patients affected by maxillofacial major lesions.

Hypothyroid myopathy: A peculiar clinical presentation of thyroid failure. Review of the literature.

Abnormalities in thyroid function are common endocrine disorders that affect 5-10 % of the general population, with hypothyroidism occurring more frequently than hyperthyroidism. Clinical symptoms and signs are often nonspecific, particularly in hypothyroidism. Muscular symptoms (stiffness, myalgias, cramps, easy fatigability) are mentioned by the majority of patients with frank hypothyroidism. Often underestimated is the fact that muscle symptoms may represent the predominant or the only clinical manifestation of hypothyroidism, raising the issue of a differential diagnosis with other causes of myopathy, which sometimes can be difficult. Elevated serum creatine kinase, which not necessarily correlates with the severity of the myopathic symptoms, is certainly suggestive of muscle impairment, though it does not explain the cause. Rare muscular manifestations, associated with hypothyroidism, are rhabdomyolysis, acute compartment syndrome, Hoffman's syndrome and Kocher-Debré-Sémélaigne syndrome. Though the pathogenesis of hypothyroid myopathy is not entirely known, proposed mechanisms include altered glycogenolytic and oxidative metabolism, altered expression of contractile proteins, and neuro-mediated damage. Correlation studies of haplotype, muscle gene expression and protein characterization, could help understanding the pathophysiological mechanisms of this myopathic presentation of hypothyroidism.

The role of PET/CT in the management of patients affected by head and neck tumors: a review of the literature.

The management of head and neck tumor (HNSCC) has been changing over the years, especially due to the aid of imaging techniques that help physicians to attain a correct diagnosis. These techniques represent a valuable tool to help tailor treatment and during follow-up of patients affected by malignancies. The aim of this review is to summarize the results of the most recent and relevant studies about the use of PET imaging in HNSCCs. This review is divided into six chapters: (1) The role of PET/CT in the pre-treatment phase; (2) PET/CT and radiotherapy planning; (3) PET/CT in the post-treatment setting; (4) PET/CT and SUVmax for prediction of prognosis; (5) miscellanea on the utility of PET in specific HNSCCs; (6) non-FDG PET tracers used in HNSCC. Promising results have been obtained so far. Despite the encouraging outcomes, more investigations are needed to warrant the value of this technique, especially in the pre-treatment setting.

Perceptions of Tobacco Price Policy among Students from Sapienza University of Rome: Can This Policy Mitigate Smoking Addiction and Its Health Impacts?

Tobacco use is one of the main risk factors for non-communicable diseases. Avoiding youth initiation and treating addiction are fundamental public health issues to ensure better health. Among tobacco control policies, increasing tobacco price is the single most effective intervention. It reduces tobacco consumption, especially among youths, while representing a government financing source. This study aimed to assess the agreement with the proposal of a one-euro increase in tobacco price earmarked to health issues among students at Sapienza University. Two convenience samples were surveyed, five years apart, on World No Tobacco Days. Smoking habits, agreement with the proposal and reasons for it were collected. Results from the 208 questionnaires (107 in 2014, 101 in 2019) showed 46.6% of agreement with the proposal (53.3% in 2014, 39.2% in 2019, p = 0.044). Main predictive factor for agreement was being a non-smoker (OR = 6.33 p < 0.001), main reason (64.8%) was it could trigger smokers to quit or reduce consumption. Several factors might have influenced this finding, including the introduction of novel tobacco products and their increased advertisement on social media. In 2024, European Union is planning to update the Tobacco Taxation Directive which could greatly contribute to the reduction of non-communicable diseases and premature deaths.

Relationships between serum levels of vitamins and papillary thyroid cancer: a single center case-control study.

Background: Vitamins are involved in various human physiological and biochemical mechanisms due to their antioxidant properties and their ability to enhance the immune response. Deficiency of some serum vitamins has been reported to be associated with an increased risk of developing cancer, including thyroid cancer. However, medical literature dealing with cholecalciferol supplementation was not able to show the potential of this intervention in cancer prevention. The aim of this paper is to highlight the association between lower serum vitamins levels and papillary thyroid cancer occurrence. Methods: This case-control study was conducted between September 2018 and October 2019. Cases were defined as patients with histologically diagnosed papillary thyroid cancer who underwent thyroidectomy were retrospectively recruited and serum levels of various vitamins were assessed by examining their relationships with clinical, pathological and molecular data (n=51). Controls matched on sex and thyroid surgery were randomly selected from the same population (n=49). Results: In this study, serum concentrations of vitamins A and E in neoplastic patients were significantly lower than in controls (1.40 vs. 1.78, P<0.003 and 23.9 vs. 29.1, P<0.003, respectively). Serum concentrations of vitamin D and methylmalonic acid were borderline significantly low (15.6 vs. 17.9, P=0.06 and 100.3 vs. 110.4, P=0.055, respectively), while homocysteine was statistically similar in the two groups. Furthermore, serum vitamin levels were compared with the pathological characteristics of cancer patients, and vitamin D concentrations were significantly lower in BRAF-positive than in BRAF-negative neoplastic patients (8.2 vs. 16.0, P=0.021). On the other hand, no significant differences were observed in the correlation between serum levels of vitamins and other pathological characteristics, in particular with regard to lymph node metastases. Conclusions: In conclusion, albeit with the analysis of a limited sample, this study highlighted the phenomenon that deficiencies in vitamins A and E can be associated with a higher frequency of occurrence of papillary thyroid cancer.

Food Selectivity in Children with Autism Spectrum Disorder: A Statistical Analysis in Southern Italy.

This paper focuses on autism spectrum disorder (ASD) and food selectivity, both of which are prevalent in the pediatric population. In this context, the authors paid attention to food selectivity and its possible correlation with the atypicality of sensory processes, outlining the useful rehabilitation treatments to draw on. This research included the parents or caregivers of pediatric patients diagnosed with autism spectrum disorder and placed within a therapeutic clinic. The sample is composed of 111 children, males and females, aged between 2 and 10 years, and includes 60 children diagnosed with autism and 51 children with normotypical development, similar in characteristics but without the disorder. The standardized questionnaire, "Brief Autism Mealtime Behavior Inventory", was developed to examine behavior during meals, especially in children with ASD. The "Brief Sensory Profile", and the "Child Oral and Motor Proficiency Scale", were also administered. The results obtained from the analysis lead to evidence of eating and food selectivity difficulty. Additionally, our study demonstrates that food selectivity can be caused by extreme sensory modulation and sensory problems related to the smell, texture, color, and temperature of food. In fact, the results obtained emphasize the correlation between food selectivity and the sensory domains of taste and smell. Furthermore, this research highlights a correlation between motor skills and eating skills, particularly regarding food selectivity, which is closely associated with atypical and disruptive behaviors during meals.

Parathyroid carcinoma presenting as normocalcemic hyperparathyroidism.

Parathyroid carcinoma (PC) is a rare malignancy, with an indolent but progressive course. Long-term survival is largely dependent on the extent of the primary surgical resection. Hence, pre- or intraoperative suspicion of malignancy is of great importance. We describe the case of a 62-year-old woman with a 2-year history of asthenia and mental depression. Her past medical history was significant for osteoporosis. A diagnosis of primary normocalcemic hyperparathyroidism was established and the patient underwent surgery. PC was suspected intraoperatively because of the size and appearance of the parathyroid mass (a grayish, lobulated 3.5 cm mass). Thus, aggressive surgery (en bloc resection) was performed, along with bilateral neck exploration. Pathological examination of the specimens confirmed the suspicion of PC, demonstrating vascular invasion and extracapsular infiltration into adjacent soft tissue. Immunohistochemical staining revealed an elevated Ki-67 score (8.43%; cut-off value 5%). The mean area of silver-stained nucleolar organizer regions (AgNOR) was high (4.972 µm(2)), indicating an elevated proliferation rate. Serum calcium and parathyroid hormone levels normalized postoperatively, and the patient's 5-year outcome was good. The present case provides evidence that parathyroid malignancy cannot be excluded a priori based on normocalcemic hyperparathyroidism, emphasizing the variability in clinical presentation. Moreover, Ki-67 expression and AgNOR analysis confirmed their additional value in complementing the histological evaluation of a parathyroid malignant mass.

Effect of the mandatory vaccination law on measles and rubella incidence and vaccination coverage in Italy (2013-2019).

Despite the introduction of the trivalent vaccine (measles, mumps, rubella) more than 20 years ago, measles outbreaks have occurred in Europe, including Italy, due to its underutilization. In Italy mandatory vaccination was established in 2017 (Decree Law 119/2017). This study aimed at evaluating the impact of mandatory vaccination and determining the trend in vaccination coverage for measles and rubella in Italy. We retrieved data from the Annual Status Update, a form sent annually by the Italian National Verification Committee to the Regional Verification Committee for Europe, from 1st January 2013 to 31st December 2019. Since the beginning of 2013, 14,788 cases of measles have been reported, ranging from 256 (3.9 x 1,000,000) to 5,397 (88.4 x 1,000,000) compared to 259 rubella cases for the same period. From 2013 to 2015, vaccination coverage decreased for the first dose of measles (90.4% to 85.3%) and rubella vaccine (90.3% to 85.2%), but then it increased significantly, reinforced by the Italian Decree Law, reaching 94.4% in 2019. The trend for the second dose showed a decrease from 2013 to 2016 (84.1% to 82.2% for measles and 83.7% to 82.0% for rubella), but then increased significantly and reached 90.2% in 2019 for measles and 90.0% for rubella. The mandatory vaccination law has resulted in a significant increase in vaccination coverage for measles and rubella in Italy, and demonstrates encouraging progress toward the 95% target and the restriction of measles transmission. Special attention should be paid to maintaining and further improving vaccination coverage.

Development of Histologically Verified Thyroid Diseases in Women Operated for Breast Cancer: A Review of the Literature and a Case Series.

BACKGROUND: The possible relationships between breast and thyroid diseases have been reported in the literature. The purpose of our study was to evaluate the occurrence of histologically verified thyroid pathologies in women who were diagnosed with breast cancer and, after mastectomy/quadrantectomy complemented by oncological treatment, were thyroidectomized based on their periodic thyroid evaluation. PATIENTS AND METHODS: Our series consist of 31 women with a mean age of 62.9 ± 10.9 years (range, 45-81) treated for breast cancer (18 right-sided, 11 left-sided, and 2 bilateral), of whom 29 were thyroidectomized, since two women who developed Graves' disease refused thyroidectomy. These 31 women belong to a cohort of 889 women who referred to the Breast Surgery Unit of our university hospital during the period January 2010 through December 2020. RESULTS: The mean time interval between breast cancer and thyroid pathologies was 48.1 ± 23.4 months (range, 12-95). The final diagnosis at histopathology was infiltrating ductal breast carcinoma in 26 women (with 2/26 patients having bilateral carcinoma) and infiltrating lobular breast carcinoma in the other 5 women. Ten of the twenty-nine thyroidectomized women (34.5%) had a thyroid malignancy on histology: five papillary carcinomas, three papillary micro-carcinomas and two follicular carcinomas. Two of the five women with papillary carcinoma also had histological evidence of chronic lymphocytic thyroiditis/Hashimoto's thyroiditis, which was also detected in another five women with benign thyroid diseases. CONCLUSIONS: We suggest that breast cancer survivors should be made aware of the possible increased risk of thyroid pathologies (including thyroid malignancy) so that they can undergo screening and follow-up.

Adverse effects related to tattoos in the community setting: a systematic review.

BACKGROUND: Tattoos were historically associated with deviant behaviours or religious and other social purposes, but in the last decades, they have gained increasing popularity and have become a mainstream. The aim of this systematic review is to assess the literature evidence about decorative tattoos complications, considering both infective and non-infective risks. METHODS: This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement. We searched the following electronic bibliographic databases: PubMed, Scopus and Web of Science (science and social science citation index). RESULTS: The literature search resulted in 6473 studies. A total of 207 full articles were considered potentially relevant and were reviewed independently by researchers. After full-text evaluation, 152 of 207 articles were excluded, as they did not meet selection criteria. The remaining 55 studies were included in the systematic review and their quality assessment was performed. Ten studies reported microbiological complications, 37 reported non-microbiological effects and eight reported either microbiological and non-microbiological complications. CONCLUSIONS: Several well-known and uncommon risks are associated with tattooing and tattoo after-care. Public health authorities could take into account health education programmes for tattooists and customers in order to prevent health complications in people with tattoos. PROSPERO REGISTRATION NUMBER: CRD42020177972.