Knowledge, experiences, and perceptions relating to obesity management among primary care physicians in the Lazio Region, Italy.

Background: Primary care providers (PCPs) play an essential role in obesity care as they represent the first contact for patients seeking weight loss interventions. Objective: This study explored the knowledge, experiences, and perceptions of PCPs in the Lazio Region of Italy in the management of obesity. Design and subjects: We conducted an anonymous survey delivered from March to July 2022 via the newsletter of Rome Provincial Order of Physicians and Dentists and at the annual meeting of the regional section of the Italian Obesity Society. Approach: The survey consisted of 24 closed-ended questions grouped into 5 sections: sociodemographic and work information; assessment of obesity; management of obesity; connections with regional Centres for Obesity Management; attitudes towards obesity. Key results: A total of 92 PCPs accessed the survey. Of those, 2.2% were excluded because they did not see any patients with obesity. A total of 68 PCPs (75.6%) had complete questionnaires and were included in this analysis. All participants reported asking their patients about their eating habits, lifestyle, and clinical complications at the first assessment. Body weight and blood pressure were measured by 98.5% of participants and 82% calculate body mass index (BMI), while a small proportion of PCPs analysed body composition and fat distribution. Over 80% prescribed laboratory tests and ECG. Approximately 40% of PCPs did not refer patients for nutritional counselling, and most prescribed a low-calorie diet. Sixty-three percent referred patients to an endocrinologist, 48.5% to a psychotherapist, and a minority to specialists for obesity complications. Twenty-three percent prescribed anti-obesity medications and 46.5% referred patients for bariatric surgery only in severe cases. Ninety-one percent stated that obesity is "a complex and multifactorial disease" and 7.4% considered obesity to be secondary to other conditions. Conclusions: Despite most PCPs adopt a correct approach to manage patients with obesity, many aspects could be improved to ensure optimal and multidisciplinary management.

Bayesian cost-effectiveness analysis of Whole genome sequencing versus Whole exome sequencing in a pediatric population with suspected genetic disorders.

Genetic diseases are medical conditions caused by sequence or structural changes in an individual's genome. Whole exome sequencing (WES) and whole genome sequencing (WGS) are increasingly used for diagnosing suspected genetic conditions in children to reduce the diagnostic delay and accelerating the implementation of appropriate treatments. While more information is becoming available on clinical efficacy and economic sustainability of WES, the broad implementation of WGS is still hindered by higher complexity and economic issues. The aim of this study is to estimate the cost-effectiveness of WGS versus WES and standard testing for pediatric patients with suspected genetic disorders. A Bayesian decision tree model was set up. Model parameters were retrieved both from hospital administrative datasets and scientific literature. The analysis considered a lifetime time frame and adopted the perspective of the Italian National Health Service (NHS). Bayesian inference was performed using the Markov Chain Monte Carlo simulation method. Uncertainty was explored through a probabilistic sensitivity analysis (PSA) and a value of information analysis (VOI). The present analysis showed that implementing first-line WGS would be a cost-effective strategy, against the majority of the other tested alternatives at a threshold of €30,000-50,000, for diagnosing outpatient pediatric patients with suspected genetic disorders. According to the sensitivity analyses, the findings were robust to most assumption and parameter uncertainty. Lessons learnt from this modeling study reinforces the adoption of first-line WGS, as a cost-effective strategy, depending on actual difficulties for the NHS to properly allocate limited resources.

Potentiality of algorithms and artificial intelligence adoption to improve medication management in primary care: a systematic review.

OBJECTIVES: The aim of this study is to investigate the effect of artificial intelligence (AI) and/or algorithms on drug management in primary care settings comparing AI and/or algorithms with standard clinical practice. Second, we evaluated what is the most frequently reported type of medication error and the most used AI machine type. METHODS: A systematic review of literature was conducted querying PubMed, Cochrane and ISI Web of Science until November 2021. The search strategy and the study selection were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and the Population, Intervention, Comparator, Outcome framework. Specifically, the Population chosen was general population of all ages (ie, including paediatric patients) in primary care settings (ie, home setting, ambulatory and nursery homes); the Intervention considered was the analysis AI and/or algorithms (ie, intelligent programs or software) application in primary care for reducing medications errors, the Comparator was the general practice and, lastly, the Outcome was the reduction of preventable medication errors (eg, overprescribing, inappropriate medication, drug interaction, risk of injury, dosing errors or in an increase in adherence to therapy). The methodological quality of included studies was appraised adopting the Quality Assessment of Controlled Intervention Studies of the National Institute of Health for randomised controlled trials. RESULTS: Studies reported in different ways the effective reduction of medication error. Ten out of 14 included studies, corresponding to 71% of articles, reported a reduction of medication errors, supporting the hypothesis that AI is an important tool for patient safety. CONCLUSION: This study highlights how a proper application of AI in primary care is possible, since it provides an important tool to support the physician with drug management in non-hospital environments.

Nudging Interventions on Alcohol and Tobacco Consumption in Adults: A Scoping Review of the Literature.

Background: The World Health Organization identified alcohol and tobacco consumption as the risk factors with a greater attributable burden and number of deaths related to non-communicable diseases. A promising technique aimed to modify behavioral risk factors by redesigning the elements influencing the choice of people is nudging. Methodology: A scoping review of the literature was performed to map the literature evidence investigating the use of nudging for tobacco and alcohol consumption prevention and/or control in adults. Results: A total of 20 studies were included. The identified nudging categories were increasing salience of information or incentives (IS), default choices (DF), and providing feedback (PF). Almost three-quarters of the studies implementing IS and half of those implementing PF reported a success. Three-quarters of the studies using IS in conjunction with other interventions reported a success whereas more than half of the those with IS alone reported a success. The PF strategy performed better in multi-component interventions targeting alcohol consumption. Only one DF mono-component study addressing alcohol consumption reported a success. Conclusions: To achieve a higher impact, nudging should be integrated into comprehensive prevention policy frameworks, with dedicated education sessions for health professionals. In conclusion, nudge strategies for tobacco and alcohol consumption prevention in adults show promising results. Further research is needed to investigate the use of nudge strategies in socio-economically diverse groups and in young populations.

Impact of the Covid-19 pandemic on palliative care provision by a hospital-based unit: results from an observational study.

Background Palliative care is a key approach in improving the quality of life of patients and their families facing the end-of-life care process. It is widely regarded as a public-health concern, especially considering the rapidly increasing end-of-life care needs worldwide. Its provision has been highly challenged by the COVID-19 pandemic emergency. Objective This study aims to analyse whether and to what extent the provision of Palliative Care to non-COVID patients provided by a hospital-based unit has changed during the COVID-19 pandemic. Material and methods A retrospective observational study was performed. All non-COVID patients admitted from October 1, 2019 to September 30, 2020 and evaluated by the hospital-based Palliative Care team were considered. Three time periods were considered: pre-lockdown, lockdown and post-lockdown. A trend analysis and multiple linear and logistic regressions to study and quantify the statistical significance of the associations were performed. Results A statistically significant positive linear trend of the number of hospitalized patients in need of Palliative Care was found over the study period. Compared to pre-lockdown, the rest of the study period presented more female and elderly patients, the length of stay and the number of patients discharged to a Hospice setting were significantly reduced. The waiting time did not change in lockdown but decreased in post-lockdown and the mortality rate was not significantly different. Also, the average number of Palliative Care consultations per patient significantly increased in the lockdown and post-lockdown. Discussion First, the significant admissions drop between the start of the pandemic and the following study period is in line with recent literature. The consequent rebound registered may be attributed to the high pressure from outside requiring admission and care. Second, the significantly older age of patients found during the lockdown than before the lockdown could be attributed to a "selection effect" of young patients, more able to delay hospitalization than the elderly, also in line with recent literature. Third, the shorter waiting time for Palliative Care activation the post-lockdown compared to the pre-lockdown period could be due to both increased hospital efficiency and to the greater pressure to discharge patients during the post-lockdown period. Also, the significant reduction in the lockdown and post-lockdown of the length of stay after Palliative Care activation could be explained considering both the greater receptivity of healthcare services outside the hospital, such as Hospices, and the greater pressure on hospital wards to discharge. Fourth, the unchanged in-hospital mortality rate remained over the entire period could be an indication of the high quality of care provided by this hospital setting to fragile patients, which is to be noted especially considering the average mortality rate registered during pandemic context in healthcare facilities. Conclusions The study aimed to quantify the impact of the COVID-19 on the provision of Palliative Care by a hospital-based team. We believe it might represent an innovative contribution and we hope similar research will be produced in order build the evidence for future challenges in this field.

The Impact of Tumor Boards on Breast Cancer Care: Evidence from a Systematic Literature Review and Meta-Analysis.

Breast cancer is the most common malignancy in women, with a complex clinical path that involves several professionals and that requires a multidisciplinary approach. However, the effectiveness of breast cancer multidisciplinary care and the processes that contribute to its effectiveness have not yet been firmly determined. This study aims to evaluate the impact of multidisciplinary tumor boards on breast cancer care outcomes. A systematic literature review was carried out through Scopus, Web of Science and Pubmed databases. The search was restricted to articles assessing the impact of MTB implementation on breast cancer care. Fourteen studies were included in the review. The most analyzed outcomes were diagnosis, therapy and survival. Four out of four studies showed that, with implementation of an MTB, there was a change in diagnosis, and all reported changes in the treatment plan after MTB implementation. A pooled analysis of three studies reporting results on the outcome "mortality" showed a statistically significant 14% reduction in mortality relative risk for patients enrolled versus not enrolled in an MTB. This study shows that MTB implementation is a valuable approach to deliver appropriate and effective care to patients affected by breast cancer and to improve their outcomes.

Cancers: What Are the Costs in Relation to Disability-Adjusted Life Years? A Systematic Review and Meta-Analysis.

Cancers currently represent a leading cause of morbidity and mortality, and precisely estimating their burden is crucial for evidence-based decision-making. This study aimed at understanding the average costs of cancer-related disability-adjusted life years (DALYs) and highlighting possible differences in economic estimates obtained with diverse approaches. We searched four scientific databases to identify all the primary literature simultaneously investigating cancer-related costs and DALYs. In view of the different methodologies, studies were divided into two groups: those estimating costs starting from DALYs, and those independently performing cost and DALY analyses. The latter were pooled to compute costs per disease-related DALY: meta-analytic syntheses were performed for total costs and indirect costs, and in relation to the corresponding gross domestic product (GDP) per capita. The quality of included studies was assessed through the Quality of Health Economic Studies instrument. Seven studies were selected. Total and indirect pooled costs per DALY were, respectively, USD 9150 (95% CI: 5560-15,050) and USD 3890 (95% CI: 2570-5880). Moreover, the cost per cancer-related DALY has been found to be, on average, 32% (95% CI: 24-42%) of the corresponding countries' GDP per capita. Costs calculated a priori from DALYs may lead to results widely different from those obtained after data retrieval and model building. Further research is needed to better estimate the economic burden of cancer in terms of costs and DALYs.

The impact of tumor board on cancer care: evidence from an umbrella review.

BACKGROUND: Tumor Boards (TBs) are Multidisciplinary Team (MDT) meetings in which different specialists work together closely sharing clinical decisions in cancer care. The composition is variable, depending on the type of tumor discussed. As an organizational tool, MDTs are thought to optimize patient outcomes and to improve care performance. The aim of the study was to perform an umbrella review summarizing the available evidence on the impact of TBs on healthcare outcomes and processes. METHODS: Pubmed and Web of Science databases were investigated along with a search through citations. The only study design included was systematic review. Only reviews published after 1997 concerning TBs and performed in hospital settings were considered. Two researchers synthetized the studies and assessed their quality through the AMSTAR2 tool. RESULTS: Five systematic reviews published between 2008 and 2017 were retrieved. One review was focused on gastrointestinal cancers and included 16 studies; another one was centered on lung cancer and included 16 studies; the remaining three studies considered a wide range of tumors and included 27, 37 and 51 studies each. The main characteristics about format and members and the definition of TBs were collected. The decisions taken during TBs led to changes in diagnosis (probability to receive a more accurate assessment and staging), treatment (usually more appropriate) and survival (not unanimous improvement shown). Other outcomes less highlighted were quality of life, satisfaction and waiting times. CONCLUSIONS: The study showed that the multidisciplinary approach is the best way to deliver the complex care needed by cancer patients; however, it is a challenge that requires organizational and cultural changes and must be led by competent health managers who can improve teamwork within their organizations. Further studies are needed to reinforce existing literature concerning health outcomes. Evidence on the impact of TBs on clinical practices is still lacking for many aspects of cancer care. Further studies should aim to evaluate the impact on survival rates, quality of life and patient satisfaction. Regular studies should be carried out and new process indicators should be defined to assess the impact and the performance of TBs more consistently.

Efficacy of continuous neuromonitoring in thyroid surgery: preliminary report of a single-center experience.

BACKGROUND: The continuous intraoperative nerve monitoring (CIONM) technique seems to be acknowledged as a useful tool to prevent impending nerve injury, because it constantly provides valuable real-time information. Aim of the study is to evaluate the impact of the CIONM technique on functional outcome i.e., recurrent laryngeal nerve (RLN) palsy, compared to the traditional surgical procedure. METHODS: From January to December 2016, 197 patients who underwent thyroid surgery were included in this retrospective study: 94 patients had CIONM procedure and 103 traditional technique, according to the order of the operating room list. RESULTS: A total of 8 patients showed a damage to left or right vocal cord: 3 patients after CIONM procedure, and 5 patients after traditional surgical procedure. After matching for propensity score, 188 patients were eventually considered and 7 RLN palsy were identified: 3 in CIONM and 4 in traditional surgical procedure. The analysis performed on the matched propensity score sample showed a non-significant difference between the two procedures. CONCLUSIONS: In our experience no significant differences in functional outcomes were found between the use of CIONM and the standard technique.

[Improving Hospital efficiency: assessment of performance of a surgical suite through root cause analysis, in a hospital in northern Italy]. / Migliorare l'efficienza dell'ospedale. Valutazione della performance di un Blocco Operatorio attraverso l'applicazione della Root Cause Analysis (RCA).

A Surgical Suite (SS) is a complex system in which different healthcare professionals work. Inefficient management could lead to waste of money and time and reduce quality of care. The aim of the study was to carry out an organizational assessment of a SS in northern Italy, in order to identify weaknesses and inadequacies related to its performance and promote strategies to increase efficiency. The study was conducted by process mapping of the working context, qualitative and quantitative analysis of patient documents and an evaluation of the critical issues using the root cause analysis (RCA) tool. The Plan Do Check Act (PDCA) method was used to implement the necessary changes. A detailed description of the staff involved, medical devices available, organization and timing of the SS was performed. Inefficiencies in the unit were caused mainly by insufficient medical devices and underusage of the radiological software Picture Archiving and Communication System (PACS). Root causes of inefficiencies were identified and classified into four areas: organization/structure, personnel, technologies and methods. In particular, critical issues were identified in: the planning processes, the heterogeneity of technical and Information technology skills and educational background of nursing staff, the presence of several computerized information systems and lack of a connection interface between the different software, the lack of internal procedures and paths and lack of continuing professional education opportunities. Two multidisciplinary working tables were launched by the hospital management in order to identify improvement strategies. The evaluation allowed us to define the root causes of SS inefficiency in this hospital, leading to a reorganization with a view to continuous improvement. An innovative aspect of the present study was the use of RCA to perform an organizational assessment in healthcare, rather than as a reactive risk management tool.

Increasing early surgery within 2 days for hip fracture: a time trend in 15 EU countries (2000-13).

OBJECTIVE: To analyse the trajectories of hip-fracture surgery rates within 2 days of admission to the hospital and the ratios of procedures initiated within the same day (Day 0) and the following day (Days 0-1) to procedures performed on the 2nd day. To study the association between socioeconomic, health input variables and early surgery. DESIGN: A pooled, cross-sectional, time-series analysis was used to evaluate secondary data from 15 European countries, during 2000-13. RESULTS: The rate of patients aged ≥65 years that were operated on within 2 days of hip-fracture has changed over time with an EU average annual increase of 0.42% (95% CI = 0.25, 0.59; P < 0.001) and with a significant linear trend. Multiple slopes from all the countries compete with this result. In contrast, the ratios of procedures initiated within the same day (Day 0) and the following day (Days 0-1) compared to procedures performed on the 2nd day are constant.No association was found between the rate of patients treated within 2 days of admission and demographic structure, health expenditure, health resources. However, the rate of patients treated within 2 days of admission is significantly associated with surgical volumes. CONCLUSIONS: As the early surgery rate is growing, policy makers should be encouraged to undertake further policies to support the quality of care, and the providers should be driven to improve their organizational effectiveness by taking actions aimed at acting on specific organizational and logistical causes that represent a barrier to early surgery.

A campaign aimed at increasing seasonal influenza vaccination coverage among post graduate medical residents in an Italian teaching hospital.

We analysed the impact of several strategies aimed at increasing influenza immunisation rates among Medical Residents (MRs) of an Italian teaching Hospital. During the 2015-16 and 2016-17 influenza seasons we carried out several interventions: ambulatory doubling where vaccination was offered, ambulatory opening hour extension, email invitations, informative materials, forum theatre and vaccination campaign conference. In addition, during the 2016-17 the OSV was carried out: MRs who go to specific wards where they perform influenza immunisation counselling and eventually vaccinate the personnel. 99/1041 (9.5%) and 184/1013 (18.2%) MRs received the vaccine in 2015-16 and in 2016-17 respectively (p < 0.0001). Significant difference was found among three specialisation areas (medicine, surgery, "services"; p < 0.001) and among years of residency (p < 0.001). The highest coverage was found among Infectious Diseases, Paediatrics, Haematology and Hygiene MRs (80%, 67%, 52% and 52% respectively) in 2016-2017 season. The highest coverage increase was found among MRs in Pneumology and Geriatrics (566% and 268%, respectively). The coverage rate has increased even though important differences among specialties persist. The study shows a significant increase in immunisation rate among MRs after the implementation of these strategies.

Organized screening programmes for breast and cervical cancer in 17 EU countries: trajectories of attendance rates.

BACKGROUND: The aim was to analyse participation trajectories in organised breast and cervical cancer screening programmes and the association between socioeconomic variables and participation. METHODS: A pooled, cross-sectional, time series analysis was used to evaluate secondary data from 17 European countries in 2004-2014. RESULTS: The results show that the mammographic screening trend decreases after an initial increase (coefficient for the linear term = 0.40; p = 0.210; 95% CI = - 0.25, 1.06; coefficient for the quadratic term = - 0.07; p = 0.027; 95% CI = - 0.14, - 0.01), while the cervical screening trend is essentially stable (coefficient for the linear term = 0.39, p = 0.312, 95% CI = - 0.42, 1.20; coefficient for the quadratic term = 0.02, p = 0.689, 95% CI = - 0.07, 0.10). There is a significant difference among the country-specific slopes for breast and cervical cancer screening (SD = 16.7, p < 0.001; SD = 14.4, p < 0.001, respectively). No association is found between participation rate and educational level, income, type of employment, unemployment and preventive expenditure. However, participation in cervical cancer screening is significantly associated with a higher proportion of younger women (≤ 49 years) and a higher Gini index (that is, higher income inequality). CONCLUSIONS: In conclusion three messages: organized cancer screening programmes may reduce the socioeconomic inequalities in younger people's use of preventive services over time; socioeconomic variables are not related to participation rates; these rates do not reach a level of stability in several countries. Therefore, without effective recruitment strategies and tailored organizations, screening participation may not achieve additional gains.

[The Adherence's indicators of cancer patients to oral chemotherapy. A sistematic literature review]. / Gli indicatori di aderenza dei pazienti oncologici alla chemioterapia orale. Evidenze empiriche da una revisione sistematica della letteratura.

INTRODUCTION: Adherence has a key role in treating patients as influences the effectiveness of therapeutic treatment for improving overall survival, life expectancy, quality of life and reducing healthcare costs. There are gaps in identifying indicators to be used to evaluate adherence and ways in which these indicators should be adopted. The aim of this paper is to identify adherence's indicators in literature. METHODS: Systematic review was carried out in, Cinhal-EBSCO, Medline-PUBMED and Scopus including studies of measure patient's adherence in English and published from 2010 to 2016. Inclusion and exclusion criteria were used. The quality of the articles was assessed with the NewCastle Ottawa Scale for observational studies and the Cochrane Collaboration Risk of Bias for experimental studies. RESULTS: Of the 7,368 papers initially retrieved, 15 met the inclusion criteria (11 observational studies, 4 RCTs), for a total of 1,396 patients. The indicators found are: self-report tools, pill counts, drug recharge rate, continuous measures, metabolic dosage. A patient is considered adherent to the treatment if he or she assumes a percentage of drugs ≥ 80% of the prescribed medications. DISCUSSION: A better adherence rating is obtained by using multiple instruments at the same time. The objective indicators derive from the direct measurement methods of adherence, the subjective ones from the indirect.

The switch between cataract surgical settings: Evidence from a time series analysis across 20 EU countries.

OBJECTIVES: To analyze trajectories of cataract surgery rates and to confirm the switch between inpatient cases and day surgery or outpatient cases. DESIGN: Pooled, cross-sectional, time series analysis. METHODS: Data on 20 European countries from 2004 to 2014 retrieved from the OECD. RESULTS: The number of cataract surgery cases per 100,000 population has increased since 2004 (b = 31.1, p < 0.001, 95% CI = 26.7, 35.6). A reversal of the inpatient cases and same-day cases was found: the first ones decreased (b = -14.7, p < 0.001, 95% CI = -17.7, -11.8) while day surgery and outpatient cases increased (b = 37.5, p < 0.001, 95% CI = 31.6, 43.4, and b = 8.3, p = 0.001, 95% CI = 3.6, 13.1, respectively). Since 2004, the ratio of day surgery and outpatient cases to inpatient cases has grown significantly (b = 3.3, p < 0.001, 95% CI = 2.5, 4.0), reaching a share of 31.7 in 2014. However, this slope of 3.3 was not constant and slowed over the years: from 4.5 per year during the first five years to 1.9 in the second five. No association was found between cataract surgery rate and two regressors: elderly people, and health care expenditure per capita. CONCLUSION: EU countries have preserved cataract surgery, and this preservation is probably affected by the switch from inpatient to same-day surgery, thanks to the decrease in the cost and equivalent clinical outcomes. However, the slope of the switch slowed over time. Consequently, health care systems must support this process of change especially through reforms in financial and organizational fields.

Declining Amenable Mortality: Time Trend (2000-2013) and Geographic Area Analysis.

OBJECTIVE: To update amenable mortality in 32 OECD countries at 2013 (or last available year), to describe the time trends during 2000-2013, and to evaluate the association of these trends with various geographic areas. DATA SOURCES: Secondary data from 32 countries during 2000-2013, gathered from the World Health Organization Mortality Database. STUDY DESIGN: Time trend analysis. DATA COLLECTION: Using Nolte and McKee's list, age-standardized amenable mortality rates (SDRs) were calculated as the annual number of deaths over the population aged 0-74 years per 100,000 inhabitants. We performed a mixed-effects polynomial regression analysis on the annual SDRs to determine whether specific geographic areas were associated with different SDR trajectories over time. PRINCIPAL FINDINGS: The OECD average annual decrease was 3.6/100,000 (p < .001), but slowed over time (coefficient for the quadratic term = 0.11, p < .001). Eastern and Atlantic European countries had the steepest decline (-6.1 and -4.7, respectively), while Latin American countries had the lowest slope (-1.7). The OECD average annual decline during the 14-year period was -0.5 (p < .001) for cancers and -2.5 (p < .001) for cardiovascular diseases, with significant differences among countries. CONCLUSION: Declining trend of amenable SDRs was continuing to 2013 but with steepness change compared with previous periods and with a slowdown.

"The final countdown": Is intraoperative, intermittent neuromonitoring really useful in preventing permanent nerve palsy? Evidence from a meta-analysis.

BACKGROUND: The aim of our research was to explore the specific role of intermittent intraoperative neuromonitoring (IONM) versus visualization alone in preventing permanent nerve palsy in thyroid surgery. METHODS: A systematic review was conducted by searching electronic databases using specific keywords and completed by hand search. The article selection process was carried out by 2 independent investigators using well-defined inclusion and exclusion criteria. Articles evaluating the role of IONM versus visualization alone in preventing recurrent laryngeal nerve palsy were evaluated for inclusion. The relative risk with a confidence interval of 95% was estimated for nonrandomized studies, and risk difference was estimated for randomized control studies. Subgroup meta-analyses were carried out stratifying the studies on the basis of the design and the definition of permanent injury. The heterogeneity among the studies was evaluated with Higgins' Index. RESULTS: A total of 14 articles were included; of these, 10 were nonrandomized studies and 4 were randomized control studies. With regard to the meta-analyses, including nonrandomized studies that defined as permanent an injury persisting for 6 months or 12 months after thyroid surgery, the overall relative risks were, respectively, 0.79 (confidence interval 95%, 0.60-1.05) and 0.75 (confidence interval 95%, 0.43-1.30). As for the meta-analysis including randomized control studies, the risk difference was 0.00 (confidence interval 95%, -0.01 to 0.00). No heterogeneity was found in any of the analyses conducted (Higgins' Index = 0%). CONCLUSION: Our results show that the use of IONM does not prevent permanent nerve palsy; no significant benefit of IONM over visualization alone in reducing the rate of recurrent laryngeal nerve injuries could be proven. In conclusion, IONM should not be considered the standard care in preventing recurrent laryngeal nerve palsy.

Complications in thyroid surgery. Harmonic Scalpel, Harmonic Focus versus Conventional Hemostasis: A meta-analysis.

BACKGROUND: To evaluate the incidence of postoperative complications, hemostatic effects and safety of Total Thyroidectomy (TT) performed using the Harmonic Scalpel (HS), the Harmonic Focus (HF) or Conventional Hemostasis (CH). METHODS: The meta-analysis was performed according to PRISMA guidelines. A literature search was conducted from 2003 to 2014 and stringent criteria were required for inclusion. Thirteen studies concerning an overall population of 1458 compared HS versus CH, whilst 8 studies with 1667 patients compared HF versus CH. RESULTS: There was a significant reduction of operative time (Mean Difference [MD] = -25.49 min.; 95% CI -32.43 to -18.55), intraoperative blood loss (MD = -30.49 mL; 95% CI -53.01 to -7.97), postoperative drainage volume (MD = -12.90 mL; 95% CI -22.83 to -2.98) and postoperative pain (MD = -0.87; 95% CI -1.27 to -0.46) in patients underwent TT with HS. Regarding HF group, a significant reduction of operative time (MD = -25.99 min., 95% CI -34.56 to -17.41), length of hospital stay (MD = -0.57; 95% CI -0.97 to -0.17), transient hypocalcemia (OR = 0.56; 95% CI 0.39 to 0.81) and postoperative pain (MD = -1.33 days; 95% CI -2.49 to -0.17) resulted. CONCLUSIONS: HS TT can be a safe, useful and fast alternative to conventional TT. The newer HF can reduce the rate of hypocalcemia. Future RCTs of larger patient cohorts with more detailed data of postoperative complications, cost-effectiveness and cosmetic results, randomization procedures, intention-to-treat analyses and blinding of outcome assessors are needed to draw more meaningful conclusions.

The impact of level of education on adherence to breast and cervical cancer screening: Evidence from a systematic review and meta-analysis.

OBJECTIVE: To assess the inequalities in adherence to breast and cervical cancer screening according to educational level. METHODS: A systematic review was carried out between 2000 and 2013 by querying an electronic database using specific keywords. Studies published in English reporting an estimation of the association between level of education and adherence to breast and/or cervical cancer screening were included in the study. Two different meta-analyses were carried out for adherence to breast and cervical cancer screening, respectively: women with the highest level of education and women with the lowest level of education were compared. The level of heterogeneity was investigated and subgroup analyses were carried out. RESULTS: Of 1231 identified articles, 10 cross-sectional studies were included in the analysis. The meta-analyses showed that women with the highest level of education were more likely to have both screenings with an overall OR=1.61 (95% CI 1.36-1.91; I(2)=71%) for mammography and OR=1.96 (95% CI 1.79-2.16; I(2)=0%) for Pap test, respectively. Stratified meta-analysis for breast cancer screening included only studies that reported guidelines with target age of population ≥50 years and showed a reduction in the level of heterogeneity and an increase of 36% in the adherence (95% CI 1.19-1.55; I(2)=0%). CONCLUSIONS: This study confirms and reinforces evidence of inequalities in breast and cervical cancer screening adherence according to educational level.