EASY-NET Program: Effectiveness of an Audit and Feedback Intervention in the Emergency Care for Acute Conditions in the Lazio Region.

The EASY-NET network program (NET-2016-02364191)-effectiveness of audit and feedback (A&F) strategies to improve health practice and equity in various clinical and organizational settings), piloted a novel and more structured A&F strategy. This study compared the effectiveness of the novel strategy against the sole periodic dissemination of indicators in enhancing the appropriateness and timeliness of emergency health interventions for patients diagnosed with acute myocardial infarction (AMI) and ischemic stroke in the Lazio Region. The efficacy of the intervention was assessed through a prospective quasi-experimental design employing a pre- and post-intervention (2021-2022) comparison with a control group. Participating hospitals in the Lazio Region, where professional teams voluntarily engaged in the intervention, constituted the exposed group, while the control group exclusively engaged in routine reporting activities. Effectiveness analysis was conducted at the patient level, utilizing regional health information systems to compute process and outcome indicators. The effectiveness of the intervention was evaluated using difference-in-difference models, comparing pre- and post-intervention periods between exposed and control groups. Estimates were calculated in terms of the difference in percentage points (PP) between absolute risks. Sixteen facilities for the AMI pathway and thirteen for the stroke pathway participated in the intervention. The intervention yielded a reduction in the proportion of 30-day readmissions following hospitalization for ischemic stroke by 0.54 pp in the exposed patients demonstrating a significant difference of -3.80 pp (95% CI: -6.57; -1.03; 5453 patients, 63.7% cases) in the exposed group compared to controls. However, no statistically significant differences attributable to the implemented A&F intervention were observed in other indicators considered. These results represent the first evidence in Italy of the impact of A&F interventions in an emergency setting, utilizing aggregated data from hospitals involved in the Lazio Region's emergency network.

Pregnancy outcomes in Italy during COVID-19 pandemic: a population-based cohort study.

OBJECTIVE: To compare the estimates of preterm birth (PTB; 22-36 weeks gestational age, GA) and stillbirth rates during COVID-19 pandemic in Italy with those recorded in the three previous years. DESIGN: A population-based cohort study of liveborn and stillborn infants was conducted using data from Regional Health Systems and comparing the pandemic period (March 1st , 2020-March 31st , 2021, N= 362,129) to an historical period (January 2017- February 2020, N=1,117,172). The cohort covered 84.3% of the births in Italy. METHODS: Poisson regressions were run in each Region and meta-analyses were performed centrally. We used an interrupted time series regression analysis to study the trend of preterm births from 2017 to 2021. MAIN OUTCOME MEASURES: The primary outcomes were PTB and stillbirths. Secondary outcomes were late PTB (32-36 weeks' GA), very PTB (<32 weeks' GA), and extremely PTB (<28 weeks' GA), overall and stratified into singleton and multiples. RESULTS: The pandemic period compared with the historical one was associated with a reduced risk for PTB (Risk Ratio: 0.91; 95% Confidence Interval, CI: 0.88, 0.93), late PTB (0.91; 0.88, 0.94), very PTB (0.88; 0.84, 0.91), and extremely PTB (0.88; 0.82, 0.95). In multiples, point estimates were not very different, but had wider CIs. No association was found for stillbirths (1.01; 0.90, 1.13). A linear decreasing trend in PTB rate was present in the historical period, with a further reduction after the lockdown. CONCLUSIONS: We demonstrated a decrease in PTB rate after the introduction of COVID-19 restriction measures, without an increase in stillbirths.

Changes in parental smoking during pregnancy and risks of adverse birth outcomes and childhood overweight in Europe and North America: An individual participant data meta-analysis of 229,000 singleton births.

BACKGROUND: Fetal smoke exposure is a common and key avoidable risk factor for birth complications and seems to influence later risk of overweight. It is unclear whether this increased risk is also present if mothers smoke during the first trimester only or reduce the number of cigarettes during pregnancy, or when only fathers smoke. We aimed to assess the associations of parental smoking during pregnancy, specifically of quitting or reducing smoking and maternal and paternal smoking combined, with preterm birth, small size for gestational age, and childhood overweight. METHODS AND FINDINGS: We performed an individual participant data meta-analysis among 229,158 families from 28 pregnancy/birth cohorts from Europe and North America. All 28 cohorts had information on maternal smoking, and 16 also had information on paternal smoking. In total, 22 cohorts were population-based, with birth years ranging from 1991 to 2015. The mothers' median age was 30.0 years, and most mothers were medium or highly educated. We used multilevel binary logistic regression models adjusted for maternal and paternal sociodemographic and lifestyle-related characteristics. Compared with nonsmoking mothers, maternal first trimester smoking only was not associated with adverse birth outcomes but was associated with a higher risk of childhood overweight (odds ratio [OR] 1.17 [95% CI 1.02-1.35], P value = 0.030). Children from mothers who continued smoking during pregnancy had higher risks of preterm birth (OR 1.08 [95% CI 1.02-1.15], P value = 0.012), small size for gestational age (OR 2.15 [95% CI 2.07-2.23], P value < 0.001), and childhood overweight (OR 1.42 [95% CI 1.35-1.48], P value < 0.001). Mothers who reduced the number of cigarettes between the first and third trimester, without quitting, still had a higher risk of small size for gestational age. However, the corresponding risk estimates were smaller than for women who continued the same amount of cigarettes throughout pregnancy (OR 1.89 [95% CI 1.52-2.34] instead of OR 2.20 [95% CI 2.02-2.42] when reducing from 5-9 to ≤4 cigarettes/day; OR 2.79 [95% CI 2.39-3.25] and OR 1.93 [95% CI 1.46-2.57] instead of OR 2.95 [95% CI 2.75-3.15] when reducing from ≥10 to 5-9 and ≤4 cigarettes/day, respectively [P values < 0.001]). Reducing the number of cigarettes during pregnancy did not affect the risks of preterm birth and childhood overweight. Among nonsmoking mothers, paternal smoking was associated with childhood overweight (OR 1.21 [95% CI 1.16-1.27], P value < 0.001) but not with adverse birth outcomes. Limitations of this study include the self-report of parental smoking information and the possibility of residual confounding. As this study only included participants from Europe and North America, results need to be carefully interpreted regarding other populations. CONCLUSIONS: We observed that as compared to nonsmoking during pregnancy, quitting smoking in the first trimester is associated with the same risk of preterm birth and small size for gestational age, but with a higher risk of childhood overweight. Reducing the number of cigarettes, without quitting, has limited beneficial effects. Paternal smoking seems to be associated, independently of maternal smoking, with the risk of childhood overweight. Population strategies should focus on parental smoking prevention before or at the start, rather than during, pregnancy.

[Access to the Emergency Department in the time of COVID-19: an analysis of the first three months in the Lazio Region (Central Italy)]. / L'accesso al pronto soccorso ai tempi del COVID-19: un'analisi dei primi tre mesi nella regione Lazio.

OBJECTIVES: to evaluate the impact of the SARS-CoV-2 epidemic on the access to the emergency services of the Lazio Region (Central Italy) for time-dependent pathologies, for suspected SARS-CoV-2 symptoms, and for potentially inappropriate conditions. DESIGN: observational study. SETTING AND PARTICIPANTS: accesses to the emergency departments (EDs) of Lazio Region hospitals in the first three months of 2017, 2018, 2019, and 2020. MAIN OUTCOME MEASURES: total number of accesses to the emergency room and number of specific accesses for cardio and cerebrovascular diseases, for severe trauma, for symptoms, signs, and ill-defined conditions, and for symptoms related to pneumonia. RESULTS: in the first 3 months of 2019, there were 429,972 accesses to the EDs of Lazio Region; in the same period of 2020, accesses arise to 353,806, (reduction of 21.5%), with a 73% reduction in the last three weeks of march 2020 as compared with the corresponding period of 2019. Comparing the first 3 months of the 2017-2019 with 2020, the accesses for acute coronary syndrome and acute cerebrovascular disease decreased since the 10th week up to more than 57% and 50%, respectively. The accesses due to symptoms, signs, and ill-defined conditions, proxy of potentially inappropriate conditions, decreased since the 8th week, with a maximum reduction of 70%. Access to severe trauma decreased by up to 70% in the 11th week. The accesses for pneumonia increased up to a 70% increment in the 12th week. CONCLUSIONS: the evaluation of accesses to emergency services during the SARS-CoV-2 epidemic can provide useful elements for the promotion and improvement of the planning, for the management of critical situations, and for the reprogramming of the healthcare offer based on clinical and organizational appropriateness.

A blended training programme for healthcare professionals aimed at strengthening territorial networks for the prevention and contrast of gender-based violence.

OBJECTIVES: a blended training programme combining residential meetings (de visu) and distance training course (DTC) have been developed in order to provide the key elements for prevention, individuation, and care of women victims of violence. DESIGN: the Project involved the identification and testing of a systematic methodology of blended training addressed to social and health operators of 28 Emergency Room (ER) Units in 4 Italian regions (Lombardy - Northern Italy, Lazio - Central Italy, Campania and Sicily - Southern Italy). Tuscany region (Central Italy) collaborated through experts in the field from the Grosseto Task Force. This training approach specifically aimed to increase the professional competences for diagnosis, management and treatment of gender-based violence, as well as to strengthen multidisciplinary territorial networks against violence. SETTING AND PARTICIPANTS: in this Project, 28 ERs in the four Italian regions mentioned above were selected because of their involvement in managing gender-based violence. This selection was performed by a coordinator, one for each region, who also coordinated the recruitment of personnel to be involved in the training programme. The programme has therefore been proposed to social and health operators and police officers in the ERs recruited. In each ER, two referents were identified (a doctor and a nurse) in order to ensure a constant connection between the course participants and the experts involved in the management of the Project and the DTC platform. MAIN OUTCOME MEASURES: evaluation of the increase of knowledge relatively to gender-based violence issue in the ER professionals who have concluded the blended training programme. A systematic analysis and comparison of all accesses concerning women aged ≥14 years in the period 1 July-31 December 2014 (before the blended training programme) and in the period 1 July-31 December 2016 (after the blended training program). RESULTS: among the 866 registered professionals, 636 participants (73.5%) completed the course, 202 (23.3%) professionals did not complete it, 21 (2.4%) did not pass the certification test, and 7 (0.8%) participated as Auditors. Among the participants who completed the course, most of them (70.8%) were females; the average age was 45 for both males and females. The most represented professional role was the nurse (61%), followed by the medical doctor (27.2%). Based on our data, in the post-training period, an increased number of cases of violence were correctly recorded in comparison to the pre-training period. CONCLUSION: the Project allowed to define a training strategy for health professionals of the ERs who respond daily to the health needs of women who are victims of violence. The blended training programme combining residential meetings (de visu) and distance training course has been developed in order to provide the key elements for prevention, individuation, and care of women victims of violence. The observed improvement in the recording and management of cases of gender-based violence is probably due to a greater competence in the awareness and use of specific diagnostic codes by ER professionals.

Social network analysis to characterize women victims of violence.

BACKGROUND: In Europe, it is estimated that one third of women had experienced at least one physical or sexual violence after their 15. Taking into account the severe health consequences, the Emergency Department (ED), may offer an opportunity to recognize when an aggression is part of the spectrum of violence. This study applies Social Network analysis (SNA) to ED data in the Lazio region with the objective to identify patterns of diagnoses, within all the ED accesses of women experiencing an aggression, that are signals for gender-based violence against women. We aim to develop a risk assessment tool for ED professionals in order to strength their ability to manage victims of violence. METHODS: A cohort of 124,691 women aged 15-70 with an ED visit for aggression between 2003 and 2015 was selected and, for each woman, the ED history of diagnoses and traumas was reconstructed. SNA was applied on all these diagnoses and traumas, including also 9 specific violence diagnoses. SNA community detection algorithms and network centrality measures were used to detect diagnostic patterns more strongly associated to violence. A logistic model was developed to validate the capability of these patterns to predict the odds for a woman of having an history of violence. Model results were summed up into a risk chart. RESULTS: Among women experiencing an aggression, SNA identified four communities representing specific violence-related patterns of diagnoses. Diagnoses having a central role in the violence network were alcohol or substance abuse, pregnancy-related conditions and psychoses. These high-risk violence related patterns accounted for at most 20% of our cohort. The logistic model had good predictive accuracy and predictive power confirming that diagnosis patterns identified through the SNA are meaningful in the violence recognition. CONCLUSIONS: Routine ED data, analyzed using SNA, can be a first-line warning to recognize when an aggression related access is part of the spectrum of gender-based violence against women. Increasing the available number of predictors, such procedures may be proven to support ED staff in identifying early signs of violence to adequately support the victims and mitigate the harms.

Association of Gestational Weight Gain With Adverse Maternal and Infant Outcomes.

Importance: Both low and high gestational weight gain have been associated with adverse maternal and infant outcomes, but optimal gestational weight gain remains uncertain and not well defined for all prepregnancy weight ranges. Objectives: To examine the association of ranges of gestational weight gain with risk of adverse maternal and infant outcomes and estimate optimal gestational weight gain ranges across prepregnancy body mass index categories. Design, Setting, and Participants: Individual participant-level meta-analysis using data from 196 670 participants within 25 cohort studies from Europe and North America (main study sample). Optimal gestational weight gain ranges were estimated for each prepregnancy body mass index (BMI) category by selecting the range of gestational weight gain that was associated with lower risk for any adverse outcome. Individual participant-level data from 3505 participants within 4 separate hospital-based cohorts were used as a validation sample. Data were collected between 1989 and 2015. The final date of follow-up was December 2015. Exposures: Gestational weight gain. Main Outcomes and Measures: The main outcome termed any adverse outcome was defined as the presence of 1 or more of the following outcomes: preeclampsia, gestational hypertension, gestational diabetes, cesarean delivery, preterm birth, and small or large size for gestational age at birth. Results: Of the 196 670 women (median age, 30.0 years [quartile 1 and 3, 27.0 and 33.0 years] and 40 937 were white) included in the main sample, 7809 (4.0%) were categorized at baseline as underweight (BMI <18.5); 133 788 (68.0%), normal weight (BMI, 18.5-24.9); 38 828 (19.7%), overweight (BMI, 25.0-29.9); 11 992 (6.1%), obesity grade 1 (BMI, 30.0-34.9); 3284 (1.7%), obesity grade 2 (BMI, 35.0-39.9); and 969 (0.5%), obesity grade 3 (BMI, ≥40.0). Overall, any adverse outcome occurred in 37.2% (n = 73 161) of women, ranging from 34.7% (2706 of 7809) among women categorized as underweight to 61.1% (592 of 969) among women categorized as obesity grade 3. Optimal gestational weight gain ranges were 14.0 kg to less than 16.0 kg for women categorized as underweight; 10.0 kg to less than 18.0 kg for normal weight; 2.0 kg to less than 16.0 kg for overweight; 2.0 kg to less than 6.0 kg for obesity grade 1; weight loss or gain of 0 kg to less than 4.0 kg for obesity grade 2; and weight gain of 0 kg to less than 6.0 kg for obesity grade 3. These gestational weight gain ranges were associated with low to moderate discrimination between those with and those without adverse outcomes (range for area under the receiver operating characteristic curve, 0.55-0.76). Results for discriminative performance in the validation sample were similar to the corresponding results in the main study sample (range for area under the receiver operating characteristic curve, 0.51-0.79). Conclusions and Relevance: In this meta-analysis of pooled individual participant data from 25 cohort studies, the risk for adverse maternal and infant outcomes varied by gestational weight gain and across the range of prepregnancy weights. The estimates of optimal gestational weight gain may inform prenatal counseling; however, the optimal gestational weight gain ranges had limited predictive value for the outcomes assessed.

Maternal body mass index, gestational weight gain, and the risk of overweight and obesity across childhood: An individual participant data meta-analysis.

BACKGROUND: Maternal obesity and excessive gestational weight gain may have persistent effects on offspring fat development. However, it remains unclear whether these effects differ by severity of obesity, and whether these effects are restricted to the extremes of maternal body mass index (BMI) and gestational weight gain. We aimed to assess the separate and combined associations of maternal BMI and gestational weight gain with the risk of overweight/obesity throughout childhood, and their population impact. METHODS AND FINDINGS: We conducted an individual participant data meta-analysis of data from 162,129 mothers and their children from 37 pregnancy and birth cohort studies from Europe, North America, and Australia. We assessed the individual and combined associations of maternal pre-pregnancy BMI and gestational weight gain, both in clinical categories and across their full ranges, with the risks of overweight/obesity in early (2.0-5.0 years), mid (5.0-10.0 years) and late childhood (10.0-18.0 years), using multilevel binary logistic regression models with a random intercept at cohort level adjusted for maternal sociodemographic and lifestyle-related characteristics. We observed that higher maternal pre-pregnancy BMI and gestational weight gain both in clinical categories and across their full ranges were associated with higher risks of childhood overweight/obesity, with the strongest effects in late childhood (odds ratios [ORs] for overweight/obesity in early, mid, and late childhood, respectively: OR 1.66 [95% CI: 1.56, 1.78], OR 1.91 [95% CI: 1.85, 1.98], and OR 2.28 [95% CI: 2.08, 2.50] for maternal overweight; OR 2.43 [95% CI: 2.24, 2.64], OR 3.12 [95% CI: 2.98, 3.27], and OR 4.47 [95% CI: 3.99, 5.23] for maternal obesity; and OR 1.39 [95% CI: 1.30, 1.49], OR 1.55 [95% CI: 1.49, 1.60], and OR 1.72 [95% CI: 1.56, 1.91] for excessive gestational weight gain). The proportions of childhood overweight/obesity prevalence attributable to maternal overweight, maternal obesity, and excessive gestational weight gain ranged from 10.2% to 21.6%. Relative to the effect of maternal BMI, excessive gestational weight gain only slightly increased the risk of childhood overweight/obesity within each clinical BMI category (p-values for interactions of maternal BMI with gestational weight gain: p = 0.038, p < 0.001, and p = 0.637 in early, mid, and late childhood, respectively). Limitations of this study include the self-report of maternal BMI and gestational weight gain for some of the cohorts, and the potential of residual confounding. Also, as this study only included participants from Europe, North America, and Australia, results need to be interpreted with caution with respect to other populations. CONCLUSIONS: In this study, higher maternal pre-pregnancy BMI and gestational weight gain were associated with an increased risk of childhood overweight/obesity, with the strongest effects at later ages. The additional effect of gestational weight gain in women who are overweight or obese before pregnancy is small. Given the large population impact, future intervention trials aiming to reduce the prevalence of childhood overweight and obesity should focus on maternal weight status before pregnancy, in addition to weight gain during pregnancy.

Gestational weight gain charts for different body mass index groups for women in Europe, North America, and Oceania.

BACKGROUND: Gestational weight gain differs according to pre-pregnancy body mass index and is related to the risks of adverse maternal and child health outcomes. Gestational weight gain charts for women in different pre-pregnancy body mass index groups enable identification of women and offspring at risk for adverse health outcomes. We aimed to construct gestational weight gain reference charts for underweight, normal weight, overweight, and grades 1, 2 and 3 obese women and to compare these charts with those obtained in women with uncomplicated term pregnancies. METHODS: We used individual participant data from 218,216 pregnant women participating in 33 cohorts from Europe, North America, and Oceania. Of these women, 9065 (4.2%), 148,697 (68.1%), 42,678 (19.6%), 13,084 (6.0%), 3597 (1.6%), and 1095 (0.5%) were underweight, normal weight, overweight, and grades 1, 2, and 3 obese women, respectively. A total of 138, 517 women from 26 cohorts had pregnancies with no hypertensive or diabetic disorders and with term deliveries of appropriate for gestational age at birth infants. Gestational weight gain charts for underweight, normal weight, overweight, and grade 1, 2, and 3 obese women were derived by the Box-Cox t method using the generalized additive model for location, scale, and shape. RESULTS: We observed that gestational weight gain strongly differed per maternal pre-pregnancy body mass index group. The median (interquartile range) gestational weight gain at 40 weeks was 14.2 kg (11.4-17.4) for underweight women, 14.5 kg (11.5-17.7) for normal weight women, 13.9 kg (10.1-17.9) for overweight women, and 11.2 kg (7.0-15.7), 8.7 kg (4.3-13.4) and 6.3 kg (1.9-11.1) for grades 1, 2, and 3 obese women, respectively. The rate of weight gain was lower in the first half than in the second half of pregnancy. No differences in the patterns of weight gain were observed between cohorts or countries. Similar weight gain patterns were observed in mothers without pregnancy complications. CONCLUSIONS: Gestational weight gain patterns are strongly related to pre-pregnancy body mass index. The derived charts can be used to assess gestational weight gain in etiological research and as a monitoring tool for weight gain during pregnancy in clinical practice.

Meat consumption reduction in Italian regions: Health co-benefits and decreases in GHG emissions.

INTRODUCTION: Animal agriculture has exponentially grown in recent decades in response to the rise in global demand for meat, even in countries like Italy that traditionally eat a Mediterranean, plant-based diet. Globalization related dietary changes are contributing to the epidemic of non-communicable diseases and to the global climate crisis, and are associated with huge carbon and water footprints. The objective of the study is to assess inequalities in health impacts and in attributable greenhouse gases-GHG emissions in Italy by hypothesizing different scenarios of reduction in red and processed meat consumption towards healthier consumption patterns more compliant with the recommendations of the Mediterranean food pyramid. METHODS: We used demographic and food consumption patterns from national surveys and risk relationships between meat intake and cardiovascular and colorectal cancer mortality from IARC and other meta-analyses. From the baseline data (year 2005-2006, average 406 gr/week beef and 245 gr/week processed meat), we considered hypothetical meat reduction scenarios according to international dietary guidelines such as the Mediterranean pyramid targets. For each geographical area (Northwest, Northeast, Centre, and South) and gender, we calculated the number of avoidable deaths from colorectal cancer, and cardiovascular disease among the adult population. Moreover, years of life gained by the adult population from 2012 to 2030 and changes in life expectancy of the 2012 birth cohort were quantified using gender-specific life tables. GHG emission reductions under Mediterranean scenario were estimated only for beef by applying the Global Warming Potential (GWP) coefficient to total consumption and to a low carbon food substitution in adult diet. RESULTS: The deaths avoidable (as percentage change compared to baseline) according to the three reduction scenarios for beef consumption were between 2.3% and 4.5% for colorectal cancer, and between 2.1% and 4.0% for cardiovascular disease; higher benefits would be observed in Northwestern areas and among males. In parallel, 5% and 6.4% of colorectal cancer and CVD deaths would be avoided if the Italian population ate the advised quantity of processed meat. Life table analysis suggests that the scenario that is fully compliant with the Mediterranean diet model would save 5 million years of life lost prematurely among men and women over the next 18 years and would increase average life expectancy of future generations by over 7 months. Considering the environmental impact, emissions associated with the actual total intake of beef range from 12,900 to 21,800 Gg CO2 eq; emissions saved according to the Mediterranean scenario are in the range 8000-14000 Gg CO2 eq per year. The per capita reduction is 263 KgCO2eq/year/person with higher reductions in Northwestern and Central areas. CONCLUSIONS: In Italy, scenarios for reducing beef consumption are consistent with significant health and environmental co-benefits on current and future generations. Results support introducing policies to promote healthier behavior towards red and processed meat in the adult population within an overall balanced and healthy dietary pattern. Interventions should address gender, vulnerable population groups, and geographical differences in order to be more effective.

Gestational age and hospital utilization: three-years follow-up of an area-based birth cohort.

OBJECTIVE: To investigate differences by gestational age in emergency department visits and re-hospitalizations during the three years following childbirth discharge. METHODS: We performed a historical cohort study in Lazio Region, Italy, for infants born in 2007-2008 to resident mothers. Health administrative data were used. Analysis was performed by multinomial logistic regression. RESULTS: Of 90 545 infants, more than 50% had at least one emergency department visit, and 18.8% at least one re-hospitalization. After the exclusion of infants with congenital anomalies, relative risk ratios of re-hospitalization and, to a lesser extent, of emergency department visits increased by decreasing gestational age; the two events were also higher for mothers ≤35 years of age, with low education and of Italian nationality. Residency outside the metropolitan area was associated with an increased risk of re-hospitalization and a decreased risk of emergency department visits. CONCLUSION: During the three years following childbirth discharge, re-hospitalizations and, to a lesser extent, emergency department use are inversely related to gestational age at birth; socio-demographic factors have an effect on the risk of infant use of hospital resources independent of gestational age.

Breastfeeding initiation rates among immigrant women in central Italy between 2006 and 2011.

OBJECTIVE: This study was aimed at evaluating differences in breastfeeding initiation rates by maternal place of birth among women giving birth in one of 14 hospitals in Lazio, Italy, between 2006 and 2011. METHODS: The data on 14 hospitals for this study were taken from a survey on healthy newborns carried out during the month of October each year. It collected information on maternal characteristics and infant feeding during the hospital stay. The exposure variable was maternal place of birth. The outcome variable was infant feeding during hospital stay classified as exclusive breastfeeding, predominant breastfeeding (PBF), complementary feeding or formula feeding. Both a descriptive analysis and a logistic regression on infant feeding (exclusive/PBF versus partial or non-breastfeeding) by maternal place of birth were carried out. The logistic regression model was adjusted for confounding factors. A random effect model was used to take into account the correlation of data among the hospitals. RESULTS: Among the 6505 mothers included in this study, 18.7% were born in non-industrialized countries. Overall, 64.9% of mothers exclusively breastfed their babies, with lower prevalence among Asiatic mothers. The logistic model confirmed that breastfeeding was lower among infants born to Asian mothers (OR: 0.52; 95% CI: 0.35-0.77) compared with other groups, taking into account the effect of the other variables included in this model. Intracluster correlation was equal to 26%, showing that the hospital's model of care is a strong predictor of the initiation of breastfeeding. CONCLUSIONS: These data are useful for targeting disadvantaged groups when promoting breastfeeding.

Health care costs and functional outcomes of road traffic injuries in the Lazio region of Italy.

The economic consequences of road traffic injuries (RTIs) are very important in terms of health care costs. The aim of this study is to provide estimates of health care costs of non-fatal RTIs and to estimate functional outcomes using in-hospital rehabilitation data. We identified all emergency department (ED) visits related to RTI during 2008 and then linked them with hospital discharges and rehabilitation admissions, health care costs following RTI were estimated from the integrated database. We performed an epidemiological evaluation of RTI with a comprehensive description of functional outcomes at 6 months. Health care costs have been estimated at about €80 million with a per person cost of €522. About 18% of the total cost was due to rehabilitation treatments. In multivariate analysis the variables that correlated better with higher total health care costs were: older age, injury severity, presence of spinal lesion. Patients requiring rehabilitation were: the elderly, patients suffering from a spinal cord injury and leg injuries. This study provides consistent health care cost estimates of RTI using administrative databases and it shows a picture of functional outcomes after RTI. Further research is needed for the estimation of other components of the total cost of RTI.

[Reduction of meat consumption and greenhouse gas emissions associated with health benefits in Italy]. / Riduzione del consumo di carne e delle emissioni di gas serra e benefici per la salute in Italia.

BACKGROUND: the reduction in red meat consumption has been proposed as one of the climate change mitigation policies associated to health benefits. In the developed world, red meat consumption is above the recommended intake level. OBJECTIVES: the aim is to evaluate health benefits, in term of mortality decline, associated to different bovine meat consumption reduction scenarios and the potential reduction in greenhouse gas (GHG) emissions. DESIGN: meat consumption in Italy has been estimated using the Italian National Food Consumption Survey INRAN-SCAI (2005-2006) and the Multipurpose survey on household (2012) of the Italian National Institute for Statistics. Colorectal cancer and stoke mortality data are derived from the national survey on causes of death in 2012. Bovine meat consumption risk function has been retrieved from systematic literature reviews. Mean meat consumption in Italy is equal to 770 grams/week; gender and geographical variations exist: 69 per cent of the adult population are habitual bovine meat consumers; males have an average intake of over 400 grams/week in all areas of Italy (with the exception of the South), while females have lower intakes (360 grams per week), with higher consumption in the North-West (427 gr) and lower in the South of Italy. Four scenarios of reduction of bovine meat consumption (20%, 40%, 50% e 70%, respectively) have been evaluated and the number of avoidable deaths by gender and area of residence have been estimated. GHG emissions attributed to bovine meat adult consumption have been estimated to be to 10 gigagrams CO2-eq. RESULTS: from low to high reduction scenario, the percentage of avoidable deaths ranged from 2.1% to 6.5% for colorectal cancer and from 1.6% to 5.6% for stroke. Health benefits were greatest for males and for people living in the North-Western regions of Italy. CONCLUSIONS: in Italy, in order to adhere to bovine meat consumption recommendations and to respect EU GHG emission reduction targets, scenarios between 50% and 70% need to be adopted.

[Meat consumption reduction policies: benefits for climate change mitigation and health]. / Politiche di riduzione del consumo di carne in Italia: contrasto ai cambiamenti climatici e benefici per la salute.

Agricultural food production substantially contributes to green house gas (GHG) emissions worldwide and 80% of the agricultural emissions arise from the livestock sector, in particular from ruminants. Meat consumption is generally above dietary recommendations in many countries, including Italy, and it is increasing in developing countries. Although meat is a source of essential nutrients, it provides large amounts of saturated fat, which is a known risk factor for obesity and for several diseases such as stroke, breast cancer and colon cancer. Dietary changes, with lower intake of red and processed meat, are likely to be beneficial for improving health and for the environment by reducing emissions of GHG. Data on meat consumption in Italy among adults, referred to the last ten years, shows heterogeneity among regions, with the highest consumption in the North-western regions and generally with higher consumption among males. We describe meat consumption distribution worldwide, in Europe and Italy. An assessment of the potential environmental and health co-benefits considering different reduction scenarios of red meat consumption in Italy is provided. Dietary changes can substantially lower GHG and coordinated actions are needed across public health and other sectors to promote healthy, low-emission diets.

Piccolipiù, a multicenter birth cohort in Italy: protocol of the study.

BACKGROUND: The fetal and infant life are periods of rapid development, characterized by high susceptibility to exposures. Birth cohorts provide unique opportunities to study early-life exposures in association with child development and health, as well as, with longer follow-up, the early life origin of adult diseases. Piccolipiù is an Italian birth cohort recently set up to investigate the effects of environmental exposures, parental conditions and social factors acting during pre-natal and early post-natal life on infant and child health and development. We describe here its main characteristics. METHODS/DESIGN: Piccolipiù is a prospective cohort of expected 3000 newborns, who will be recruiting in six maternity units of five Italian cities (Florence, Rome, Trieste, Turin and Viareggio) since October 2011. Mothers are contacted during pregnancy or at delivery and are offered to participate in the study. Upon acceptance, their newborns are recruited at birth and followed up until at least 18 years of age. At recruitment, the mothers donate a blood sample and complete a baseline questionnaire. Umbilical cord blood, pieces of umbilical cord and heel blood spots are also collected. Postnatal follow-up currently occurs at 6, 12, and 24 months of age using on-line or postal self administered questionnaire; further questionnaires and medical examinations are envisaged. Questionnaires collect information on several factors, including mother's and/or child's environmental exposures, anthropometric measures, reproductive factors, diet, supplements, medical history, cognitive development, mental health and socioeconomic factors. Health promotion materials are also offered to parents. DISCUSSION: Piccolipiù will broaden our understanding of the contribution of early-life factors to infant and child health and development. Several hypotheses on the developmental origins of health can be tested or piloted using the data collected from the Piccolipiù cohort. By pooling these data with those collected by other existing birth cohorts it will be possible to validate previous findings and to study rare exposures and outcomes.

Use of emergency department services by women victims of violence in Lazio region, Italy.

BACKGROUND: Violence against women is a significant health problem and a hidden phenomenon, in Italy that about 31% of the women have been victims of violence once in life. Aims of this study are to describe characteristics of women victims of violence (VV) attending the EDs in the Lazio region in 2008 and to illustrate the frequency and characteristics of previous ED visits. METHODS: Using the Emergency Information System, visits of women, (15-49 years), in the 60 EDs, for a violent trauma have been analysed. For each VV identified, we considered the last episode and searched for ED attendances in a six year period (2003-08) in order to identify other visits. We performed descriptive analyses of socio-demographic and clinical factors of VV and we analyzed the impact previous ED visits. We compared ED utilization of women VV with a random sample of women with the same age distribution who gave birth in 2008. RESULTS: In 2008, 7,725 ED attendances of women VV were found (1.1% of the ED visits) corresponding to 6,936 women (prevalence = 52.0x10,000). The mean number of ED visits for each woman in five years was 5.0 (1-190). Prevalent diagnoses were contusions (45.8%), neurotic disorders (5.4%) complications of medical care (6.3%). The women were young, approximately 70% were residents in Rome or the surrounding areas. Foreign women were three times more likely to visit the ED for intentional injuries than were Italian women (114.1 vs 44.4 per 10.000). CONCLUSIONS: This study shows high prevalence of violence against women in Lazio region, Italy. Most of the women have been visited by the ED several times before the violent episode, often with traumas. ED medical and nursing staff should be prepared and trained to successfully manage victims of violence.

Impact of multiple injuries on functional and neurological outcomes of patients with spinal cord injury.

BACKGROUND: The effects of multiple injuries on the neurological and functional outcomes of patients with traumatic spinal cord injury (SCI) are debated-some groups have shown that subjects with multiple injuries have the same neurological and functional outcomes of those without them, whereas others have found that SCI patients with associated traumatic brain injury have worse functional status at admission and discharge and longer rehabilitation stays than patients without brain injury. Thus, the aim of this study was to compare the outcomes of SCI subjects with or without multiple injuries. METHODS: A total of 245 patients with a traumatic SCI during the first rehabilitation stay after the development of the lesion (202 males and 43 females; age 39.8 ± 17 years; lesion to admission time 51.1 ± 58 days) were examined on a referral basis. Patients were assessed using the following measures: American Spinal Injury Association standards, Barthel Index, Rivermead Mobility Index, and Walking Index for Spinal Cord Injury. The statistical analysis comprised Poisson regression models with relative risks and 95% confidence intervals, adjusted for the following confounders: age, sex, lesion level, and ASIA impairment scale (AIS) grade. Student's T test was used to compare the outcomes of patients divided by AIS impairment and lesion level. RESULTS: SCI patients with and without multiple injuries differed significantly with regard to the level and completeness of the lesion. Overall, patients with multiple injuries had worse functional status at admission and discharge than monotraumatic subjects. However, when adjusted for neurological features, the populations had comparable functional and neurological status at admission and discharge and similar rates of complications and discharge destinations. The separate analysis per each level of lesion/AIS grade showed that in some groups, patients with multiple injuries had a significant longer length of stay or worse functional status at rehabilitation admission (but not at discharge) than their monotraumatic counterparts. CONCLUSIONS: Multiple injuries do not affect the neurological or rehabilitative prognosis of spinal cord injuries. At discharge, patients with spinal cord injuries with and without multiple injuries achieved similar results with regard to neurological and functional improvement. Some groups of patients with multiple injuries had a longer length of stay.