[New users of mental health services for adults in Tuscany (Italy). Characteristics of cases and pathways of care]. / Nuova utenza dei Servizi di Salute Mentale per adulti della Toscana. Caratteristiche dei casi e percorsi della presa in carico.

The aim of this cross-sectional study was to describe the characteristics and pathways of care for users ("first visits") of adult mental health services in Tuscany. A questionnaire was mailed to healthcare workers of mental health services in Tuscany. Overall 184 psychiatrists and psychologists replied (136 psychiatrists and 48 psychologists) Sixty three percent of new users of mental health services were female, 32.6% were aged 18 to 34 years (32.6%) and 4.4% were foreign-born. Waiting times were lower for seeing a psychiatrist with respect to a psychologist (9.0 days ± 8.5 versus 19.2 days ± 18.7; p < 0.001). Severity of disease was the main reason for accepting persons presenting to the mental health services as patients; this occurred in 87% of cases. Persons accepted as patients were younger (42.2 years ± 14.9 versus 51.0 years ± 20.9; p < 0.05) and had an earlier onset of symptoms with respect to those not accepted as patients (32.1 years ± 15.2 vs 39.7 years ± 19.7; p < 0.05). The average duration of the mental disorder at the time of contact with the mental health service was 10.1 years and only 1/3 contacted the health service within one year of onset of the mental disorder. In conclusion, the duration of the mental disorder of adult patients contacting mental health services is high. This highlights the need for the various community agencies (e.g social services, health agencies, etc.) to facilitate access to care for people with a mental disorder.

Risk factors for disability in older persons over 3-year follow-up.

BACKGROUND: the identification of modifiable risk factors for preventing disability in older individuals is essential for planning preventive strategies. PURPOSE: to identify cross-sectional correlates of disability and risk factors for the development activities of daily living (ADL) and instrumental ADL (IADL) disability in community-dwelling older adults. METHODS: the study population consisted of 897 subjects aged 65-102 years from the InCHIANTI study, a population-based cohort in Tuscany (Italy). Factors potentially associated with high risk of disability were measured at baseline (1998-2000), and disability in ADLs and IADLs were assessed both at baseline and at the 3-year follow-up (2001-03). RESULTS: the baseline prevalence of ADL disability and IADL disability were, respectively, 5.5% (49/897) and 22.2% (199/897). Of 848 participants free of ADL disability at baseline, 72 developed ADL disability and 25 of the 49 who were already disabled had a worsening in ADL disability over a 3-year follow-up. Of 698 participants without IADL disability at baseline, 100 developed IADL disability and 104 of the 199 who already had IADL disability had a worsening disability in IADL over 3 years. In a fully adjusted model, high level of physical activity compared to sedentary state was significantly associated with lower incidence rates of both ADL and IADL disability at the 3-year follow-up visit (odds ratio (OR): 0.30; 95% confidence intervals (CI) 0.12-0.76 for ADL disability and OR: 0.18; 95% CI 0.09-0.36 for IADL disability). After adjusting for multiple confounders, higher energy intake (OR for difference in 100 kcal/day: 1.09; 95% CI 1.02-1.15) and hypertension (OR: 1.91; 95% CI 1.06-3.43) were significant risk factors for incident or worsening ADL disability. CONCLUSIONS: higher level of physical activity and lower energy intake may be protective against the development in ADL and IADL disability in older persons.

Association between satisfaction and stress with aspects of job and practice management among primary care physicians.

BACKGROUND: Reforms introduced in the last decade in Italian general practice, have contributed to the changing role of primary care physicians (PCPs) within the Italian National Health Service, with potential difficulties adapting that may lead to job stress and dissatisfaction. The present study aims to compare job satisfaction and stress levels of PCPs working in primary healthcare teams (PHCTs) with those for practitioners operating in single ambulatory offices, and to assess potential associations with aspects of job and practice management. METHOD: A postal survey was conducted between January and March 2005 among PCPs working in Tuscany. Data were collected by using a structured questionnaire containing questions concerning personal, professional, job and practice characteristics. The Warr-Cook-Wall scale and the Cooper test were used to assess job satisfaction and stress, respectively. RESULTS: From 3043 PCPs, a response rate of 45.2% was achieved. Significant differences were found between PHCT physicians and solo practitioners in several aspects of their job. Physicians working in PHCTs appeared more satisfied in some aspects of their practice such as organisation, whereas they were less satisfied about workload and interaction with other healthcare providers. Multivariate modelling showed relevant aspects of dissatisfaction and stress, particularly the difficulties of collaboration with other healthcare providers, and access to specialised services. CONCLUSION: Reform strategies aimed at improving the quality of care among PCPs needs to take into account the contextual determinants of physician satisfaction and stress, and should highlight programmes that might be pursued to improve the integration of PCPs within the Italian National Health System.

Physical exertion (lifting) and retinal detachment among people with myopia.

BACKGROUND: People with myopia (near sightedness) are at increased risk for retinal detachment. We explored other factors that may be associated with retinal detachment within this high-risk group. METHODS: We conducted a case-control study comprising 61 cases with retinal detachment and myopia and 99 hospital controls who also had myopia. Cases were recruited from a general hospital, and controls from ophthalmologic clinics. Participants compiled a questionnaire including details of past and current occupational lifting tasks to explore Valsalva maneuver as a possible risk factor. We devised a cumulative lifting index to distinguish light and heavy lifting. RESULTS: After adjusting for potential confounders, we found strong associations of retinal detachment with eye surgery, eye or head trauma, severe myopia (all known risk factors), and heavy lifting (vs. no lifting, odds ratio = 4.4 [95% confidence interval = 1.5-13]) and high body mass index (>or=25.5 kg/m, 6.8 [1.6-29]). CONCLUSIONS: Heavy occupational lifting and being overweight may be important risk factors for retinal detachment among people with myopia. The role of these risk factors in the etiology of retinal detachment deserves to be explored in more general populations.

Liver enzymes and risk of diabetes and cardiovascular disease: results of the Firenze Bagno a Ripoli (FIBAR) study.

The aim of the study was to assess gamma-glutamyl transpeptidase (gamma-GT), alanine aminotransferase, and aspartate aminotransferase (AST) in the prediction of diabetes and cardiovascular disease (CVD) in subjects free from hepatic diseases other than nonalcoholic fatty liver disease. The present analysis was performed on the cohort of subjects enrolled in the Firenze Bagno a Ripoli (FIBAR) study, a screening program for diabetes performed between 1 March 2001 and 31 December 2003 in the city of Florence on 3124 subjects who underwent an oral glucose tolerance test. Incident cases of diabetes in nondiabetic subjects (n = 2662) were obtained through databases of drug prescriptions, hospital admissions, and lists of subjects eligible for reimbursement. Incident CVD in subjects free of diabetes and CVD at enrollment (n = 2617) was identified through hospital admissions and through the register of causes of death. Mean follow-up was 39.6 +/- 12.0 months and 39.8 +/- 11.4 months for diabetes and CVD, respectively. Yearly incidence of diabetes and CVD was 0.4% and 0.2%, respectively. After adjustment for age and sex, gamma-GT >40 U/L was associated with increased incidence of diabetes and CVD (hazard ratio [95% confidence interval]: 2.54 [1.26-5.11], P < .05 and 2.21 [0.98-5.43], P < .10, respectively). Risk of diabetes, but not of CVD, was increased in patients with gamma-GT in the 25- to 40-U/L range. After adjustment for confounders, AST >40 U/L predicted CVD (hazard ratio, 6.5 [95% confidence interval, 1.5-28.1]), but not diabetes. Elevated gamma-GT or AST is an independent predictor of CVD. An increase of gamma-GT levels above the reference range, or also in the upper reference range, is an independent predictor of incident diabetes.

Low total plasma carotenoids are independent predictors of mortality among older persons: the InCHIANTI study.

BACKGROUND: Plasma carotenoids are considered a valid biological marker for fruit and vegetable dietary intake. Recent studies show that low carotenoid levels are associated with a high risk of inflammation, cancer, and cardiovascular disease. AIM OF THE STUDY: To determine whether low plasma carotenoids are associated with increased mortality among older adults. METHODS: Longitudinal study among 1,043 adults, 65 years and older, in the InCHIANTI study, a population-based cohort of adults living in the community in the Tuscany region, Italy. RESULTS: Mean total carotenoid concentration was 1.80 micromol/l. During eight years of follow-up, 310 (29.7%) of participants died. Eight-year survival was lower in the lowest compared with the highest tertile of total serum carotenoids (P < 0.0001 by Mantel-Haenszel chi-square). In a multivariate Cox proportional hazards model adjusted for age, education, smoking, body mass index, energy intake, and chronic diseases, adults in the highest tertile of plasma carotenoids at enrollment had lower mortality compared to those in the lowest tertile (Hazards Ratio obtained by considering carotenoids level as an ordinal variable 0.81, 95%; CI 0.65-0.99; P for trend = 0.046). CONCLUSIONS: Low plasma carotenoids are an independent risk factor for mortality among older adults living in the community.

Incidence rates of in-hospital carpal tunnel syndrome in the general population and possible associations with marital status.

BACKGROUND: Carpal tunnel syndrome (CTS) is a socially relevant condition associated with biomechanical risk factors. We evaluated age-sex-specific incidence rates of in-hospital cases of CTS in central/northern Italy and explored relations with marital status. METHODS: Seven regions were considered (overall population, 14.9 million) over 3-6-year periods between 1997 and 2002 (when out-of-hospital CTS surgery was extremely rare). Incidence rates of in-hospital cases of CTS were estimated based on 1) codified demographic, diagnostic and intervention data in obligatory discharge records from all Italian public/private hospitals, archived (according to residence) on regional databases; 2) demographic general population data for each region. We compared (using the chiscore test) age-sex-specific rates between married, unmarried, divorced and widowed subsets of the general population. We calculated standardized incidence ratios (SIRs) for married/unmarried men and women. RESULTS: Age-standardized incidence rates (per 100,000 person-years) of in-hospital cases of CTS were 166 in women and 44 in men (106 overall). Married subjects of both sexes showed higher age-specific rates with respect to unmarried men/women. SIRs were calculated comparing married vs unmarried rates of both sexes: 1.59 (95% confidence interval [95% CI], 1.57-1.60) in women, and 1.42 (95% CI, 1.40-1.45) in men. As compared with married women/men, widows/widowers both showed 2-3-fold higher incidence peaks during the fourth decade of life (beyond 50 years of age, widowed subjects showed similar trends to unmarried counterparts). CONCLUSION: This large population-based study illustrates distinct age-related trends in men and women, and also raises the question whether marital status could be associated with CTS in the general population.

[Health effects of heat waves]. / Effetti sulla salute delle ondate di calore.

Climate change, characterized by increased mean temperatures and more frequent occurrence of extreme temperatures, may lead to adverse health effects through different and complex mechanisms due to substantial changes in the physical and social environment. The most easily measurable health effects of climate change in high-risk groups are the direct effects of excessively high temperatures. A literature review was performed to identify studies regarding heat waves, risk factors and prevention programmes. A large number of studies performed in Europe during the August 2003 heat wave, and previously in both Europe and North America, showed excess mortality during periods of extreme heat. The role of pollution as a confounding factor remains dubious. Groups at risk include the elderly, the urban population, individuals with impaired health and those with low income. Aging of the population (especially in industrialised nations) and increased urbanization (especially in developing countries) may further increase ill health effects of high temperatures.

Health observation compared to health reporting: findings from a pilot study in Florence.

PURPOSE: Both health interview surveys (HISs) and health examination surveys (HESs) are used to describe the health status of populations. In Italy, to determine the feasibility of conducting a national-level HES, a pilot HES was conducted in the city of Florence among participants of a previous national-level HIS. The aim of the present analysis was to compare the results of the two surveys. METHODS: The study population consisted of the 343 Florence residents 35 to 74 years of age who participated in both surveys (sample drawn with probabilistic criteria). We compared the self-reported HIS data to the HES health measurements for diabetes, hypertension, osteoporosis, smoking, height, weight, and body mass index. For categorical variables, contingency tables were used, calculating symmetric and asymmetric indices. For the continuous variables, Student's t test for matched samples was used. RESULTS: The prevalence of the most important pathologic conditions and risk factors determined with HES measurements was significantly higher than that based on self-reported HIS data. CONCLUSIONS: The results stress that individuals have poor knowledge of their own health; therefore health measurements need to be taken.

The impact of different rehabilitation strategies after major events in the elderly: the case of stroke and hip fracture in the Tuscany region.

BACKGROUND: On a regional level, our aims were to describe rehabilitation patterns for elderly patients with stroke and hip fracture and to investigate mortality risk during the 6-month post acute period. METHODS: Data sources included administrative data relative to patients aged 65+ resident in Tuscany admitted in hospital for stroke or hip fracture between 2001 and 2003, traced up to 3 years before and 6 months following index admission. The study design involves computerized linkage of administrative data, and an exploratory analysis of the association between rehabilitation patterns and 6-month mortality, adjusting for clinical, demographic, and acute-related care characteristics using multivariate Cox regression. RESULTS: Rehabilitation patterns vary greatly across Tuscany with considerable cost implications. Six month mortality risk for stroke patients is significantly lower among residents of Local Health Authorities where patients are more frequently rehabilitated, specifically in extra-hospital settings. CONCLUSION: Our study, targeting two crucial conditions for elderly patients, found a high variability of rehabilitation patterns across a region, albeit coherent between the two pathologies, associated with remarkable differences in average expenditure. Differences in hazard rates for 6-month mortality after stroke at population level were also found. These results need to be confirmed and further investigated through a more robust information framework.

General practitioners' knowledge and practice of complementary/alternative medicine and its relationship with life-styles: a population-based survey in Italy.

BACKGROUND: The growing popularity of CAM among the public is coupled with an ongoing debate on its effectiveness, safety, and its implications on the reimbursement system. This issue is critically important for GPs, who have a "gatekeeping" role with respect to health care expenditure. GPs must be aware of medications' uses, limitations and possible adverse effects. Our objective was to explore GPs' knowledge of CAM and patterns of recommendation and practice, as well as the relationship between such patterns and GPs' life-styles. METHODS: A cross-sectional study was conducted in Tuscany, a region of central Italy. One hundred percent female GPs (498) and a 60% random sample of male GPs (1310) practising in the region were contacted through a self-administered postal questionnaire followed by a postal reminder and telephone interview. RESULTS: Overall response rate was 82.1%. Most respondents (58%) recommended CAM but a far smaller fraction (13%) practised it; yet 36% of CAM practitioners had no certificated training. Being female, younger age, practising in larger communities, having had some training in CAM as well as following a vegetarian or macrobiotic diet and doing physical activity were independent predictors of CAM recommendation and practice. However, 42% of GPs did not recommend CAM to patients mostly because of the insufficient evidence of its effectiveness. CONCLUSION: CAM knowledge among GPs is not as widespread as the public demand seems to require, and the scarce evidence of CAM effectiveness hinders its professional use among a considerable number of GPs. Sound research on CAM effectiveness is needed to guide physicians' behaviour, to safeguard patients' safety, and to assist policy-makers in planning regulations for CAM usage.

[Femur fractures among elderly in Lazio and Tuscany regions from 1999 to 2003]. / Le fratture di femore tra gli anziani del Lazio e della Toscana: analisi del fenomeno nel periodo 1999-2003.

OBJECTIVES: to compare the assistance delivered to elderly persons (age 65 +) hospitalized in 1999-2003 after femur fracture between two Italian regions (Lazio and Tuscany). Indicators derived from current databases have been used. MAIN OUTCOMES: 1) age-standardized proportion of patients treated surgically; 2) age-standardized proportion of patients with surgery within 2 days from admission among all the patients with surgery; 3) age-standardized proportion of deaths within 30 days from admission. METHODS: incident cases and patients undergoing surgery were retrieved from abstract discharge records, while deaths were traced through record linkage with mortality registers. RESULTS: in the period covered by the study, 32019 incident cases occurred in Lazio region and 30406 in Tuscany. The analysis shows better results for Tuscany for each indicator. In 2003, the age-standardized proportions of patients treated surgically were 83.0% in Lazio and 86.2% in Tuscany. The age-standardized proportion of patients undergoing surgery within 2 days from admission were respectively 14.7%, and 29.8%. The age-standardized proportions of deaths occurring within 30 days from admission were 5.0% and 2.8%. Lazio shows higher proportions of deaths both for patients with and without surgery. CONCLUSIONS: the use of the same procedure based on purely administrative data (available at national level) provides confidence on the reliability of the comparison between the two regions. Similar low-budget studies may easily be extended to other geographical areas.

[Injury-related Emergency Department visits in Tuscany (Italy)]. / Accessi ai Pronto Soccorso toscani per cause traumatiche.

The frequency of injuries underscores the need for planning and implementing efficient injury surveillance systems. Emergency Departments represent the preferred source of data on injuries but information regarding emergency department visits is not always available. We examined the feasibility of utilizing emergency department data to monitor the occurrence of injuries in Tuscany. Each of the 52 public hospital emergency departments operating in the 12 local health units of Tuscany were asked to provide yearly data on the numbers and types of injury-related visits since the year 2003. They were also asked whether attendance records were computerised. This data was used to estimate the number of injury-related visits by cause of injury, at the regional level. The results of this study were combined with those of a previous study to estimate the number of hospital admissions for motor vehicle accidents in Tuscany in 2004. The latter was then compared to corresponding data from the hospital discharge abstract database. In 2002, the number of emergency departments with computerised attendance records was only 27 while in 2005 it was 43 and a greater number of emergency departments were able to codify each type of injury-related visit. A slight decrease was observed in the total number of visits for all causes, between 2002 and 2004 (respectively 1.314.874 and 1.256.509). In 2002, motor vehicle accidents were the most frequent cause of injury-related ED visit (8%), followed by home injuries (7.2%) and workplace accidents (6%). In 2004, home injuries were the most frequent type of injury (7.5%) followed by motor vehicle accidents (6.9%) and workplace injuries (5%). We estimated 6836 hospital admissions for the year 2004, while only 4800 admissions were registered in the discharge abstract database in the same year. Computerisation of attendance records and improvement in codification of data are a good starting point in utilizing emergency department data for epidemiological surveillance of injuries.

Effect of comorbidity on coronary reperfusion strategy and long-term mortality after acute myocardial infarction.

BACKGROUND: Chronic comorbidity is a prognostic determinant in ST-segment elevation myocardial infarction (STEMI). This study was aimed at determining to what extent this effect is independent or derives from adoption of different therapeutic strategies. METHODS: Seven hundred forty patients with STEMI hospitalized within 12 hours of symptom onset were enrolled in a population-based registry, in a health district comprising 1 teaching hospital with and 5 district hospitals without percutaneous coronary intervention (PCI) facilities. Three categories of increasing chronic comorbidity score (CS-1, n = 259; CS-2, n = 235; CS-3, n = 246) were identified from age-adjusted associations of comorbidities with 1-year survival. RESULTS: Higher CS was associated with lower direct admission or transferal rates to hospital with PCI. Coronary reperfusion therapy (PCI in 91.5% of 470 cases) was adopted less frequently (P < .001) in CS-3 (41.9%) than CS-2 (69.4%) or CS-1 (78.8%). Compared with conservative therapy (n = 270), reperfusion therapy reduced 1-year mortality in the whole series not significantly (P = .816) in CS-1 but significantly in CS-2 (P = .012) and CS-3 (P = .001). This trend persisted after adjusting for age, Killip class, and acute myocardial infarction location (hazard ratio [HR] = 0.63 [95% CI 0.14-2.80], HR = 0.62 [95% CI 0.31-1.25], and HR = 0.47 [95% CI 0.26-0.86] in CS-1, CS-2, and CS-3, respectively). By hypothesizing an extension of coronary reperfusion therapy utilization rate in CS-2 and CS-3 to that in CS-1, from 21 (crude analysis) to 20 (adjusted analysis) deaths were classified as potentially avoidable. CONCLUSION: Increased mortality in patients with chronic comorbidity and STEMI derives, at least in part, from underutilization of coronary reperfusion therapy, and might be reduced with a more aggressive therapeutic approach.

Age and comorbidity in acute myocardial infarction: a report from the AMI-Florence Italian registry.

A total of 930 cases of ST-segment elevation myocardial infarction were prospectively recorded in the Florence health district. Factors influencing survival or those associated with use of revascularization (percutaneous coronary intervention, 91%) were identified through multivariate analyses (Cox and logistic regression, respectively). The independent protective effect of coronary reperfusion therapy (CRT) was evident at 36 months (39% reduction in the risk of death). After adjusting for all multivariate predictors, CRT use was 63% less likely at age 85 years and older than at under 65 years (p<0.001). Since beyond advancing age, comorbidity appeared to be associated with a reduced chance of CRT, three chronic comorbidity score categories were calculated using information on past medical history. Increased 1-year mortality in patients with higher comorbidity score categories derives, at least in part, from underutilization of CRT. Results confirm that although they might potentially benefit from CRT during ST-segment elevation myocardial infarction, older and frail patients are excluded from CRT, even when eligible.

[Incidence of acute myocardial infarction in Tuscany, 1997-2002: data from the Acute Myocardial Infarction Registry of Tuscany (Tosc-AMI)]. / Incidenza dell'infarto miocardico acuto in Toscana, 1997-2002: i dati del Registro regionale toscano dell'infarto miocardico acuto (Tosc-AMI).

OBJECTIVE: The Acute Myocardial Infarction Regional Registry of Tuscany was aimed to assess incidence and prognosis of acute myocardial infarction (AMI) in Tuscany, and the spread of interventional cardiology (coronarography and coronary angioplasty) in AMI treatment. DESIGN: Record-linkage between current hospitalisation and mortality databases, aimed to identify total events (hospitalised AMI cases + out-of-hospital coronary deaths), also including recurrent events (rule of 28 days or more after any previous event in the same patient). SETTING: Population based registry (residents in Tuscany). MAIN OUTCOME MEASURES: Age-standardised attack rates, 28-day case-fatality and proportion of patients who underwent coronarography or coronary angioplasty. RESULTS: In Tuscany, between 1997 and 2002, AMI attack rates were stable in both genders. Rates of out-of-hospital coronary death (progressively decreasing) and of hospitalised AMI cases (increasing after the year 2000) showed opposite trends. Case-fatality decreased both for total events (largely explained by the reduction of out-of-hospital deaths) and for hospitalised cases. In the same period, the spread of coronarography and coronary angioplasty progressively increased. AMI attack rates and interventional cardiology procedures utilization were significantly different across Tuscany areas, whereas 28-day case-fatality of hospitalised cases did not significantly differ within the region. CONCLUSIONS: Notwithstanding the importance of cardiovascular disease, scanty population-based incidence, case-fatality and treatment data were available in Italy. Monitoring systems based on current hospitalisation and mortality databases could represent an economical and timely tools, providing data useful in a public health perspective and for health planning. The validation of diagnostic codes with standardised criteria could ensure the comparability with other Italian areas.

[Mortality in the area around Massa-Carrara 10 years after ANIC-Agricoltura and Farmoplant chemical plants were shut down]. / Mortalità nell'area di Massa-Carrara nel decennio successivo alla chiusura degli impianti ANIC-Agricoltura e Farmoplant.

OBJECTIVE: To describe mortality of residents in the area of Massa-Carrara for the period 1995-2000 and to compare it with mortality for the years 1990-1994. DESIGN: Geographical descriptive study. SETTING: In the area of Massa-Carrara cause and gender specific standardized mortality ratios (SMR), adjusted for age and municipal deprivation index (reference: Tuscany Region), have been computed for the years 1995-2000 and compared with mortality in the period 1990-1994 calculating ratios between standardized rates by age classes with a direct method (CMF). For those causes showing a statistically significant increase a spatial analysis on a group of municipalities around Massa and Carrara has been carried out. MAIN OUTCOME: Mortality for all causes, and for 30 specific causes. RESULTS: The study results confirm, for the years 1995-2000, the previous observation (1990-1994) of statistically significant excesses for mortality from all causes (SMR 109), all cancers (SMR 112), respiratory diseases (SMR 126), cirrhosis (SMR 226), liver (SMR 161) and lung cancer (SMR 115) in males. A statistically significant excess for larynx (SMR 158) and pleural cancer (SMR 178) is observed in the years 1995-2000, which was not present in 1990-1994. A mortality excess for cirrhosis is confirmed in females (SMR 158) and a new one emerges for liver cancer (SMR 144). The comparison between mortality data for the periods 1995-2000 and 1990-1994 has shown a statistically significant decrease in mortality for all causes and for several specific causes, a significant increase in liver (CMF males 1.35; CMF females 1.78) and blood cancer mortality is also detected (CMF females 1.44). CONCLUSIONS: This study confirms the negative health impact of environmental, occupational exposures in populations living in areas where high-risk factories are located. Adverse health effects are stronger in socially and economically deprived areas, and persist over many years after closing polluting industrial plants. The results of this study point out to the need of health promoting actions aiming at modifying lifestyle risk factors, ameliorating socio-economic conditions, and maintaining a constant control on environment, also through a specific environmental epidemiological surveillance to monitor the impact of reclamation procedures completed or in progress.

[Prevalence of dementia in Tuscany: results from four population-based epidemiological studies]. / La prevalenza della demenza in Toscana: i risultati di quattro studi epidemiologici di popolazione.

OBJECTIVE: to provide information on epidemiology of dementia in Tuscany needed to plan for dedicated health and social services. DESIGN: analysis of pooled baseline data from 4 population-based longitudinal studies. SETTING: 4 municipalities in Tuscany. PARTICIPANTS: 4,056 elderly subjects enrolled in 4 longitudinal studies. MAIN OUTCOME MEASURES: age- and sex-specific dementia prevalence rates and estimated number of demented people, by degree of cognitive impairment and BADL disability in the elderly population of Tuscany. RESULTS: out of the evaluated subjects, 293 are demented. Prevalence of dementia increases from about 1 % in the 65-69 age group to about 28 % in the 90+ age group both among women and men. About 43% of the demented study subjects suffer from severe mental deterioration (MMSE < 14) and56% are disabled in at least one Basic Activity of Daily Living (BADL). We estimate that about 19 thousand demented elderly men and 40 thousand demented elderly women are currently living in Tuscany of whom 26 thousand severely mentally impaired and 34 thousand disabled in at least one BADL. The resulting overall dementia prevalence standardised on the Italian 65+ population is 5,3% for men and 7,7% for women. CONCLUSIONS: these estimates could be used as a basis for the evaluation and the planning of social and health care services dedicated to demented people.

In situ breast cancer: incidence trend and organised screening programmes in Italy.

The effect of mammography screening programmes on the incidence of in situ breast cancer (CIS) is described by analysis of the CIS incidence trend in the 1990s and comparison of pre-screening and screening periods in six areas of Italy. All 1069 CIS arising in women aged 40-79 years between 1988 and 1999 were analysed through age-standardised rates and Poisson regression models. The results show that, for the whole series, ductal carcinoma in situ (DCIS) represented 89% and lobular carcinoma in situ (LCIS) 11% of CIS detected. For all six areas, the introduction of screening increased the incidence of DCIS (screening/pre-screening ratio, range 1.12-1.77). Overall, DCIS represented 11% (226/2022) of all screening-detected cancers. A significant increasing trend in DCIS incidence during the 1990s and a modification in pattern of age-specific incidence rates after the beginning of screening programmes were observed. This increase can largely be explained by screening programmes. The incidence observed during the screening period was a persistent 39% higher than during the pre-screening period, after adjustment for the "percentage of cases diagnosed by screening". The increase also involves women at an age not targeted by screening programmes. In conclusion, as the increasing trend in DCIS is not completely explained by the effect of the screening programmes, this supports the use of mammography as a "spontaneous" preventive practice during ongoing organised screening programmes, particularly among age groups not usually invited for screening. Therefore, the effect of mammography on stage-specific incidence of CIS may be more marked than expected on the basis of the effect of screening programmes.

[A teaching experience of Evidence Based Prevention]. / Un'esperienza d'insegnamento della prevenzione basata sulle prove di efficacia.

One year after a 3-day training course on EBP (Evidence Based Prevention), the 130 participants were sent a follow-up questionnaire intended to estimate the persistence of knowledge and the extent of the use of evaluation techniques in EBP. Although respondents to the questionnaire (73%) and participants to the course were not representative of workers in the health field area, results clearly indicate that major drawbacks the use of EBP are the organization of daily work in prevention activities and the limited knowledge of English (i.e. the language in which most scientific literature related to EBP is available). More education on EBP is advisable, including the application of distant learning techniques into the frame of Continuous Medical Education for all Italian professionals involved in Prevention.