Post-diagnosis serum 25-hydroxyvitamin D concentrations in women treated for breast cancer participating in a lifestyle trial in Italy.

OBJECTIVE: To report cross-sectionally serum levels of 25-hydroxyvitamin D [25(OH)D] in women living in Italy within 12 months from breast cancer (BC) diagnosis. METHODS: Baseline data were obtained from 394 women diagnosed with primary BC, enrolled from 2016 to 2019 in a lifestyle trial conducted in Italy. Subjects' characteristics were compared between two 25(OH)D concentrations (hypovitaminosis D<20 and ≥20 ng/mL) with the Chi-squared test or Fisher's exact test for small-expected counts. Using multiple logistic regression-adjusted models, we estimated odds ratios (ORs) of hypovitaminosis D with 95% confidence intervals (CIs) in the total sample and in the unsupplemented subgroup. RESULTS: Hypovitaminosis D was found in 39% of all subjects, 60% in unsupplemented subjects, and 10% in supplemented subjects. Increasing ORs of hypovitaminosis D were found with increasing body mass index, 25-30, >30, and ≥35 versus <25 kg/m2 (ORs: 2.50, 4.64, and 5.81, respectively, in the total cohort and ORs: 2.68, 5.38, and 7.08 in the unsupplemented); living in the most southern Italian region (OR 2.50, 95%CI 1.22-5.13); and with hypertriglyceridemia (OR 2.46; 95%CI 1.16-5.22), chemotherapy history (OR 1.86, 95%CI 1.03-3.38), and inversely with anti-estrogenic therapy (OR 0.43, 95%CI 0.24-0.75) in the total sample. CONCLUSIONS: Hypovitaminosis D in women recently diagnosed with BC and participating in a lifestyle trial in Italy was widespread and highest with obesity, hypertriglyceridemia, and chemotherapy use. Considering that hypovitaminosis D is a risk factor for lower efficacy of bone density treatments and possibly BC mortality, our results suggest the need to promptly address and treat vitamin D deficiency.

Multi-failure psoriasis patients: characterization of the patients and response to biological therapy in a multicenter Italian cohort.

INTRODUCTION: Patients with psoriasis who have failed multiple biologic drugs have been defined as "multi-failure," although there are no clear data on the characteristics, comorbidities, and best treatment strategies for this population. Nowadays, given the next generation and the number of biologics available, patients are considered multi-failure when ≥4 biologics fail to achieve a good response. METHODS: Demographic characteristics and efficacy of anti-interleukin drugs in multi-failure patients were compared to a cohort of general psoriatic patients treated with IL-23 or IL-17 inhibitors. RESULTS: In total 97 multi-failure patients (≥4 lines of biologics) were compared with 1,057 patients in the general cohort. The current drugs in the multi-failure group were risankizumab (34), ixekizumab (23), guselkumab (21), brodalumab (7), tildrakizumab (5), ustekinumab (4), secukinumab (2), and certolizumab pegol (1). A significant difference was found in the multi-failure cohort for age of psoriasis onset (mean 29.7 vs. 35.1, P < 0.001), concurrent psoriatic arthritis (45.4 vs. 26.9%, P < 0.001), diabetes mellitus (30.9 vs. 10.9%, P < 0.001), and cardiovascular comorbidity (54.6 vs. 39.8%, P = 0.005). In multi-failure patients, current biological therapy showed a good initial response (PASI 90 and 100 of 41.24 and 27.84%, respectively, at 16 weeks); the response tended to decline after 40 weeks. Anti-IL-17 agents showed clinical superiority over IL-23 agents in terms of achieving PASI90 at 28 weeks (P < 0.001) and 40 weeks (P = 0.007), after which they reached a plateau. In contrast, IL-23 agents showed a slower but progressive improvement that was maintained for up to 52 weeks. A similar trend was also seen for PASI100 (28 weeks P = 0.032; 40 weeks P = 0.121). CONCLUSIONS: The multi-failure patient is characterized by many comorbidities and longstanding inflammatory disease that frequently precedes the introduction of systemic biologic therapy. Further studies are needed to identify more specific criteria that could be applied as a guideline by clinicians.

Spatial and Environmental Correlates of Prevalence of Treatment for Substance Use Disorders, Retention, and SUD Services Utilization in South Sardinia.

This study explored the economic, social, and spatial correlates of treatment prevalence, retention, and service utilization for substance use disorder (SUD) in South Sardinia. Data from 1,667 patients with an ICD-10 diagnosis of SUD were extracted from the medical records of individuals assisted by three public addiction services in 2019. We used a spatial autoregressive model, a parametric proportional hazard model, and Poisson regression to examine the associations of spatial factors and residents' socioeconomic status with the prevalence of treatment at the census block level, treatment retention, and SUD service utilization at the individual level. The prevalence was higher among residents of areas closer to competent treatment centers, with the worst building conservation status, a lower percentage of high school and university graduates, and a higher percentage of unemployed, divorced, separated, or widowed residents. Men who were older at the time of their first treatment access; primary users of cocaine, cannabis, and alcohol; had higher education level; and who lived far from competent treatment centers and closer to drug trafficking centers interrupted their treatment earlier. Primary heroin users experienced more SUD treatment encounters. Living in economically and socially disadvantaged areas and near treatment facilities was associated with a higher prevalence, whereas living near drug-dealing centers and far from competent treatment centers was associated with a decrease in treatment retention.

Diabetes management in cancer patients. An Italian Association of Medical Oncology, Italian Association of Medical Diabetologists, Italian Society of Diabetology, Italian Society of Endocrinology and Italian Society of Pharmacology multidisciplinary consensus position paper.

Cancer management has significantly evolved in recent years, focusing on a multidisciplinary team approach to provide the best possible patient care and address the various comorbidities, toxicities, and complications that may arise during the patient's treatment journey. The co-occurrence of diabetes and cancer presents a significant challenge for health care professionals worldwide. Management of these conditions requires a holistic approach to improve patients' overall health, treatment outcomes, and quality of life, preventing diabetes complications and cancer treatment side-effects. In this article, a multidisciplinary panel of experts from different Italian scientific societies provide a critical overview of the co-management of cancer and diabetes, with an increasing focus on identifying a novel specialty field, 'diabeto-oncology', and suggest new co-management models of cancer patients with diabetes to improve their care. To better support cancer patients with diabetes and ensure high levels of coordinated care between oncologists and diabetologists, 'diabeto-oncology' could represent a new specialized field that combines specific expertise, skills, and training.

Correlation between airborne pollen data and the risk of tick-borne encephalitis in northern Italy.

Tick-borne encephalitis (TBE) is caused by a flavivirus that infects animals including humans. In Europe, the TBE virus circulates enzootically in natural foci among ticks and rodent hosts. The abundance of ticks depends on the abundance of rodent hosts, which in turn depends on the availability of food resources, such as tree seeds. Trees can exhibit large inter-annual fluctuations in seed production (masting), which influences the abundance of rodents the following year, and the abundance of nymphal ticks two years later. Thus, the biology of this system predicts a 2-year time lag between masting and the incidence of tick-borne diseases such as TBE. As airborne pollen abundance is related to masting, we investigated whether inter-annual variation in pollen load could be directly correlated with inter-annual variation in the incidence of TBE in human populations with a 2-year time lag. We focused our study on the province of Trento (northern Italy), where 206 TBE cases were notified between 1992 and 2020. We tested the relationship between TBE incidence and pollen load collected from 1989 to 2020 for 7 different tree species common in our study area. Through univariate analysis we found that the pollen quantities recorded two years prior for two tree species, hop-hornbeam (Ostrya carpinifolia) and downy oak (Quercus pubescens), were positively correlated with TBE emergence (R2 = 0.2) while a multivariate model with both tree species better explained the variation in annual TBE incidence (R2 = 0.34). To the best of our knowledge, this is the first attempt at quantifying the correlation between pollen quantities and the incidence of TBE in human populations. As pollen loads are collected by widespread aerobiological networks using standardized procedures, our study could be easily replicated to test their potential as early warning system for TBE and other tick-borne diseases.

Midwives' experiences of providing maternity care to women and families during the COVID-19 pandemic in Northern Italy.

PROBLEM: The COVID-19 pandemic has significantly challenged maternity provision internationally. Rapid and radical changes were implemented, with midwives facing anxiety and moral distress if not able to provide optimal and woman-centred care in line with professional values. BACKGROUND: Healthcare professionals' stress and burnout are commonly reported during other global emergencies, which may eventually contribute to reduced quality of care. There is lack of evidence of the challenges faced by midwives in Italy during the COVID-19 pandemic. AIM: To explore midwives' experiences of providing care to women and families during the COVID-19 pandemic. METHODS: Qualitative interpretive phenomenological approach, using semi-structured interviews and thematic analysis. The sample included 15 midwives. Ethical approval was obtained. FINDINGS: Four themes were identified: 1) adjusting to the ever-evolving organisation of care; 2) physical, psychological and relational challenges; 3) support network; 4) deferred sense of awareness. DISCUSSION: Midwives faced professional and personal challenges during the pandemic, displaying feelings of fear, anxiety, uncertainty, discomfort, lack of support and knowledge with potential long-term effects. Adjusting to the continuous, rapid and drastic re-organisation of maternity services was particularly challenging. Factors facilitating a safe, supportive and empowering workplace included support from colleagues and managers, access to appropriate PPE, reliable guidelines, good communication and emotional support. Positive aspects of personal and professional development included communication skills, establishment of trusting relationships, sense of empowerment and teamwork. CONCLUSION: In the context of a pandemic, optimisation of midwives' physical, emotional and psychological wellbeing should be considered. Timely and comprehensive guidelines and appropriate resources should be provided to assist midwives in facilitating family-centred respectful maternity care and preserving childbirth as a bio-psychosocial event.

Use of music therapy in pediatric oncology: an Italian AIEOP multicentric survey study in the era of COVID-19.

Music therapy (MT) is a complementary therapy offered to children, young adults, and their families in pediatric oncology and palliative care. We performed a survey to collect information about MT in pediatric oncology in Italy. The outbreak of COVID-19 unavoidably changed the scenario of MT, suggesting some considerations presented in this survey. 27/32 (84.4%) centers belonging to the Infections and Supportive Therapy Working Group of Association of Pediatric Hematology and Oncology (AEIOP) completed in 2 different time points (T1 and T2) an online survey on MT, before and after COVID-19 pandemia. Different kinds of music approach were used taking care of patients in 21/27 centers, while in 14/21 (66%), a specific project of MT conducted by a music therapist was present. In 6/14 centers, MT activities were delivered for < 3 h/week, in 3 centers for > 3 and < 10 h/week, and in the remaining 5 for > 3 h/week. MT sessions were in different areas, day hospital, or ward (patient rooms, operating rooms, waiting rooms), on an individual basis or by groups. Patients were invited to MT by psychologists, caring physician, or nurse, or on equipé decision. MT was evaluated with tools self-made by music therapist in 11/14 centers. After COVID-19, MT has been withdrawn in 3 centers, sessions in the waiting rooms were reduced, individual sessions were preferred, and enrollment by multidisciplinary teams increased. CONCLUSION: This survey represents the starting platform to compare and discuss different experience of MT in AIEOP centers, to implement MT in pediatric oncology for a more qualified assistance to patients, and to improve quality of care. WHAT IS KNOWN: • Music therapy in pediatric oncology and palliative care can be used for the management and prevention of various somatic and psychological symptoms of patients and often is provided to children together with their families. • In Italy the application of Music therapy in the AIEOP pediatric oncology centers is constantly increasing, but due to the outbreak of Covid-19 Pandemic, Italian pediatric oncology departments were obliged to adopt restrictive measures. WHAT IS NEW: • Although the majority of Centres did not abrogate MT interventions, judgment about limitation should be carefully taken since MT helps children and even more adolescents in their fight against cancer. • The best practice of Music therapy in pediatric oncology requires communication and collaboration among qualified music therapists and multidisciplinary care team, using a model of family-centered care that actively involves parents/ caregivers in assessment, treatment planning, and care delivery.

The COVID-19 pandemic response and its impact on post-corona health emergency and disaster risk management in Italy.

Background: The COVID-19 pandemic has profoundly impacted societies, influencing countries' Health Emergency and Disaster Risk Management (H-EDRM) systems. By taking Italy as a case study, this research aimed to investigate the response to the COVID-19 pandemic, focusing on the changes made to the existing H-EDRM system, with an emphasis on human resources, health service delivery, and logistics and the forward-looking strategies for the next health emergencies and disasters. Methods: We performed a retrospective observational case study using qualitative methodology. Data was collected via semi-structured interviews and analyzed considering the World Health Organization (WHO) H-EDRM framework. Multiple interviewees were selected to obtain a holistic perspective on the Italian response to COVID-19. Stakeholders from five different sectors (policy-making, hospital, primary care, third sector, lay community) from three of the most impacted Italian regions (Piemonte, Lombardia, and Veneto) were interviewed, for a total of 15 respondents. Results: Results on human resources revolved around the following main themes: personnel, training, occupational health, and multidisciplinary work; results on health service delivery encompassed the following main themes: public health, hospital, and primary care systems; results on logistics dealt with the following themes: infrastructures, supplies, transports, and communication channels. Lessons learned stressed on the importance of considering pragmatic disaster preparedness strategies and the need for cultural and structural reforms. Stakeholders mentioned several implications for the post-pandemic H-EDRM system in Italy. Conclusions: Findings highlight that the interconnection of sectors is key in overcoming pandemic-related challenges and for future disaster preparedness. The implications for the Italian H-EDRM system can inform advancements in disaster management in Italy and beyond.

Diagnostic therapeutic care pathway for pediatric food allergies and intolerances in Italy: a joint position paper by the Italian Society for Pediatric Gastroenterology Hepatology and Nutrition (SIGENP) and the Italian Society for Pediatric Allergy and Immunology (SIAIP).

Epidemiologic data suggest an increased prevalence of pediatric food allergies and intolerances (FAIs) during the last decades. This changing scenario has led to an increase in the overall healthcare costs, due to a growing demand for diagnostic and treatment services. There is the need to establish Evidence-based practices for diagnostic and therapeutic intervention that could  be adopted in the context of public health policies for FAIs are needed.This joint position paper has been prepared by a group of experts in pediatric gastroenterology, allergy and nutrition from the Italian Society for Pediatric Gastroenterology Hepatology and Nutrition (SIGENP) and the Italian Society for Pediatric Allergy and Immunology (SIAIP). The paper is focused on the Diagnostic Therapeutic Care Pathway (DTCP) for pediatric FAIs in Italy.

Adverse events related to herbal dietary supplements and over-the-counter medications containing laxatives: a 10-year update from the Italian Phytovigilance and Pharmacovigilance systems.

INTRODUCTION: Products containing anthraquinones (AQ) are associated with an increased risk of serious adverse events (AEs). We performed an update of the available evidence retrieved by the spontaneous reports of AE associated with herbal dietary supplement (DS) and over-the-counter medications (OTC-M) used as laxatives. METHODS: Analysis and evaluation of AE reports retrieved from the Italian Phytovigilance and Pharmacovigilance systems was performed from February 2011 to December 2020. RESULTS: Totally 110 AE reports, 24 related to herbal DS and 86 to OTC-M, were analyzed. Most subjects were females. Herbal products analyzed mostly contained AQ derivatives. Most AEs were gastrointestinal (41.6%), central nervous system (18.2%), and dermatological disorders (12.6%). CONCLUSIONS: The number of AE reports recorded in the last 10 years is still relatively low. However, given the seriousness of some AEs, that does not represent a guarantee of safety. This study may contribute to enhance public awareness on the risks associated with misuse or abuse of laxatives.

Long-term outcomes of pediatric infections: from traditional infectious diseases to long Covid.

There is limited evidence available on the long-term impact of SARS-CoV-2 infection in children. In this article, the authors analyze the recent evidence on pediatric long Covid and lessons learnt from a pediatric post-Covid unit in Rome, Italy. To gain a better understanding of the concerns raised by parents and physicians in relation to the potential long-term consequences of this novel infection, it is important to recognize that long-term effect of a post-infectious disease is not a new phenomenon.

The authors analyze the recent evidence on pediatric long Covid and lessons learnt from a pediatric post-Covid unit in Rome, Italy. Also, we analyze the long-term effects of other infectious diseases.

Foodborne Toxigenic Agents Investigated in Central Italy: An Overview of a Three-Year Experience (2018-2020).

Foodborne diseases (FBDs) represent a worldwide public health issue, given their spreadability and the difficulty of tracing the sources of contamination. This report summarises the incidence of foodborne pathogens and toxins found in food, environmental and clinical samples collected in relation to diagnosed or suspected FBD cases and submitted between 2018 and 2020 to the Food Microbiology Unit of the Istituto Zooprofilattico Sperimentale del Lazio e della Toscana (IZSLT). Data collected from 70 FBD investigations were analysed: 24.3% of them started with an FBD diagnosis, whereas a further 41.4% involved clinical diagnoses based on general symptomatology. In total, 5.6% of the 340 food samples analysed were positive for the presence of a bacterial pathogen, its toxins or both. Among the positive samples, more than half involved meat-derived products. Our data reveal the probable impact of the COVID-19 pandemic on the number of FBD investigations conducted. In spite of the serious impact of FBDs on human health and the economy, the investigation of many foodborne outbreaks fails to identify the source of infection. This indicates a need for the competent authorities to continue to develop and implement a more fully integrated health network.

Juvenile idiopathic arthritis-associated uveitis in the era of biological therapy: how the disease changed in more than 20 years of observation in a tertiary referral center in Rome (Italy).

OBJECTIVES: To describe the ophthalmological characteristics in a Juvenile idiopathic arthritis (JIA) cohort and to evaluate how therapeutic advances have changed the course of the uveitis. METHODS: Analysis of a retrospective cohort study of consecutive JIA pediatric patients including JIA-associated uveitis (JIA-U) and comparison with a previous study in the same uveitis center assessed before the wide-spread of biological therapy. RESULTS: The total of 49 JIA patients were analyzed, of whom 18 JIA-U, compared with a JIA-U past cohort of 66 patients. Systemic corticosteroids were used significantly less in the current JIA-U group (p = 0.008) than in the past one. JIA-U present cohort was on therapy more frequently with conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) than the past group (p = 0.039), mostly treated with methotrexate (93.3%). Furthermore, a larger use of biologic disease-modifying anti-rheumatic drugs (bDMARDs) was described in the current JIA-U group (p = 0.005) also associated with csDMARDs (p = 0.003). Adalimumab was used more (72.7%) in the present JIA-U cohort compared to a larger treatment with infliximab (61.5%) in the past (p = 0.005). Higher number of uveitis recurrences was observed in the previous cohort compared to the current one (p = 0.005). Fewer complications were described in this study than in the previous: posterior synechiae (p = 0.007), cataract (p < 0.001), band keratopathy (p < 0.001), and elevated intraocular pressure (IOP) (p = 0.047). CONCLUSION: Current therapies reduced the uveitis recurrences and ocular complications including cataract due also to the lower use of corticosteroids. The new close collaboration with the pediatric rheumatologic center in the same University has contributed to the care improvement and decrease of uveitis complications.

Resilient managed competition during pandemics: lessons from the Italian experience during COVID-19.

In the last decades, several European health systems have abandoned their vertically integrated health care in favour of some form of managed competition (MC), either in a centralised or decentralised format. However, during a pandemic, MC may put health systems under additional strain as they are designed to follow some form of 'organisational self-interest', and hence face reduced incentives for both provider coordination (e.g. temporary hospital close down, change in the case-mix), and information sharing. We illustrate our argument using evidence for the Covid-19 pandemic outbreak in Italy during March and April 2020, which calls for the development of 'coordination mechanisms' at times of a health emergency.

Biological disease-modifying antirheumatic drugs may mitigate the risk of psoriatic arthritis in patients with chronic plaque psoriasis.

OBJECTIVE: To estimate the incidence of psoriatic arthritis (PsA) in patients with psoriasis who had received a continuous treatment with biological disease-modifying antirheumatic drugs (bDMARDs) compared with phototherapy. METHODS: A retrospective non-randomised study involving patients with moderate-to-severe plaque psoriasis, who were prescribed at least 5 years of bDMARDs or at least three narrow-band ultraviolet light B (nb-UVB) phototherapy courses, and did not have a diagnosis of PsA at enrolment. Development of PsA in each patient was assessed by a rheumatologist according to the Classification for Psoriatic Arthritis criteria. The annual and cumulative incidence rate of PsA was estimated by using an event per person-years analysis. Cox proportional hazards models were undertaken to assess the hazard risk (HR) of PsA after adjustment for confounders. RESULTS: A total of 464 psoriatic patients (bDMARDs, n=234 and nb-UVB, n=230) were followed between January 2012 and September 2020 (corresponding to 1584 and 1478 person year of follow-up for the two groups, respectively). The annual incidence rate of PsA was 1.20 cases (95% CI 0.77 to 1.89) versus 2.17 cases (95% CI 1.53 to 3.06) per 100 patients/year in the bDMARDs versus phototherapy group, respectively (HR 0.29, 0.12-0.70; p=0.006). The variables independently associated with higher risk of PsA were older age (adjusted HR 1.04, 1.02-1.07), nail psoriasis (adjusted HR 3.15, 1.63-6.06) and psoriasis duration >10 years (adjusted HR 2.02, 1.09-3.76); notably, bDMARDs treatment was associated with a lower risk of incident PsA (adjusted HR 0.27, 0.11-0.66). CONCLUSIONS: bDMARDs treatment may delay or reduce the risk of incident PsA in patients with moderate-to-severe chronic plaque psoriasis.

A telehealth intervention for ensuring continuity of care of pediatric obesity during the CoVid-19 lockdown in Italy.

BACKGROUND AND AIMS: Restriction measures adopted during the Coronavirus Disease-19 pandemic favored unhealthy behaviors. Tele-health offered the opportunity to pursue alternative ways of chronic diseases management. This retrospective study sought to determine the effects of a telehealth counselling intervention during the lockdown to children and adolescents with obesity previously engaged in a family-based secondary care program in an outpatient clinic of South Italy. METHODS AND RESULTS: 117 out of 156 patients participated to the tele-health intervention. Participants underwent videocalls with each component of the multidisciplinary team to receive support in adopting adequate dietary habits and to practice exercise at home. They were included in a closed social group to watch age-adapted tutorials on healthy habits. 75 patients returned to the Center after the end of the lockdown, while only 7 patients who did not participate to the videocalls, took part to the follow-up. Body Mass Index and body composition were assessed in all these patients. BMI z score did not increase in both groups. However, a significant increase of fat mass was observed in the non-participating group (0.046), while the intervention group showed an increase of fat free mass (p < 0.000). CONCLUSION: Notwithstanding the limited sample size, the telehealth intervention allowed the maintenance of baseline weight status in participants, with an increase of fat-free mass. As the CoViD-19 pandemic moves forward, the increasing adoption of the new technologies may help the continuity of care, even in pediatric obesity treatment.

Looking for a strategy in treating peritoneal gastric cancer carcinomatosis: an Italian multicenter Gastric Cancer Research group's analysis.

BACKGROUND: The present study provides a snapshot of Italian patients with peritoneal metastasis from gastric cancer treated by surgery in Italian centers belonging to the Italian Research Group on Gastric Cancer. Prognostic factors affecting survival in such cohort of patients were evaluated with the final aim to identify patients who may benefit from radical intent surgery. METHODS: It is a multicentric retrospective study based on a prospectively collected database including demographics, clinical, surgical, pathological, and follow-up data of patients with gastric cancer and synchronous macroscopic peritoneal metastases. Patients were surgically treated from January 2005 to January 2017. We focused on patients with macroscopic peritoneal carcinomatosis (PC) treated with upfront surgery in order to provide homogeneous evidences. RESULTS: Our results show that patients with peritoneal carcinomatosis cannot be considered all lost. Strictly selected cases (R0/R1 and P1 patients) could benefit from an aggressive surgical approach performing an extended lymphadenectomy and HIPEC treatment. CONCLUSION: The main result of the study is that GC patients with limited peritoneal involvement can have a survival benefit from a surgery with "radical oncological intent", that means extended lymphadenectomy and R0 resection. The retrospective nature of this study is an important bias, and for this reason, we have started a prospective multicentric study including Italian stage IV patients that hopefully will give us more answers.

An Integrated Control Plan in Primary Schools: Results of a Field Investigation on Nutritional and Hygienic Features in the Apulia Region (Southern Italy).

Data concerning overweight and obesity in children and adolescent populations are alarming and represent one of the most serious public health problems of our time. Moreover, it is demonstrated that the school environment may play an important role in health promotion with regard to nutritional aspects. This article reports the results of a study conducted in the Apulia region (Southern Italy), aimed at providing an integrated surveillance of the behaviors related to nutrition habits in students and the hygienic and nutritional conditions of the school's canteens attended by enrolled students. To this purpose, a sample of 501 students attending primary school (third class-children approximately eight years old) replied to a validated questionnaire, and official controls (OC), of both food and nutritional safety, were performed in 22 primary schools. A team of healthcare professionals carried out the study, and the implementation of all the prescribed improvement actions were subsequently verified through follow-up OC. The results of our study show a critical situation in the student sample, with 41.3% of children having a weight excess (overweight or obesity). With regard to the children's behaviors, only 59.8% of children ate at least one fruit or had a fruit juice for breakfast, and 10.8% did not have breakfast at all. Overall, 40.1% of the total children played outdoors the afternoon before the survey and 45% reported going to school on foot or by bicycle. During the afternoon, 83.5% of the sample watched television or used video games/tablets/mobile phones, while 42.3% played sports. The schools had an internal canteen with on-site preparation of meals in 36.4%, the remaining 63.6% received meals from external food establishments. With regard to OC, for the hygienic-sanitary section, eleven prescriptions were issued, in the great part related to the structure and organization of the canteen. For the nutritional section, nine corrective actions were prescribed, mainly related to official documents and management. The follow-up OC showed that all prescriptions were subsequently addressed. Eating at school was less frequent among obese and overweight students compared with those with normal weight. Although this evidence needs to be further confirmed, it highlights the potential role that the school canteens may play in health promotion and prevention of nutritional disorders. On the other hand, in order to fulfill its health promotion task, the school canteens have to comply with official regulations and guidelines; therefore, OC during the management of the food service at school are needed.

Process evaluation of integrated West Nile virus surveillance in northern Italy: an example of a One Health approach in public health policy.

West Nile virus (WNV) is endemic in the Po valley area in northern Italy. Regional health authorities have implemented integrated WNV surveillance following a One Health approach, based on collaboration between human, animal and environmental health institutions. We evaluated this integrated WNV surveillance system in Emilia-Romagna, Lombardy and Piedmont regions by means of a process evaluation. We examined the system's implementation fidelity, dose delivered and received, reach, and we identified strengths and weaknesses in the system. Qualitative and semi-quantitative data were obtained from three regional focus groups. Data were discussed in a follow up focus group, where participants suggested recommendations for improving the surveillance system. Inter-institutional and interdisciplinary integration and the creation of a 'community of practice' were identified as key elements for effective surveillance. We identified differences in the degree of interdisciplinary integration in the three regions, likely due to different epidemiological situations and years of experience in surveillance implementation. Greater collaboration and sharing of information, public engagement and economic assessments of the integrated surveillance approach would facilitate its social recognition and guarantee its sustainability through dedicated funding. We demonstrate that a transdisciplinary research approach based on process evaluation has value for designing and fine-tuning integrated health surveillance systems.

COVID-19 incidence and mortality in non-dialysis chronic kidney disease patients.

Many studies reported a higher risk of COVID-19 disease among patients on dialysis or with kidney transplantation, and the poor outcome of COVID-19 in these patients. Patients in conservative management for chronic kidney disease (CKD) have received attention only recently, therefore less is known about how COVID-19 affects this population. The aim of this study was to provide evidence on COVID-19 incidence and mortality in CKD patients followed up in an integrated healthcare program and in the population living in the same catchment area. The study population included CKD patients recruited in the Emilia-Romagna Prevention of Progressive Renal Insufficiency (PIRP) project, followed up in the 4 nephrology units (Ravenna, Forlì, Cesena and Rimini) of the Romagna Local Health Authority (Italy) and alive at 1.01.2020. We estimated the incidence of COVID-19, its related mortality and the excess mortality within this PIRP cohort as of 31.07.2020. COVID-19 incidence in CKD patients was 4.09% (193/4,716 patients), while in the general population it was 0.46% (5,195/1,125,574). The crude mortality rate among CKD patients with COVID-19 was 44.6% (86/193), compared to 4.7% (215/4,523) in CKD patients without COVID-19. The excess mortality of March-April 2020 was +69.8% than the average mortality of March-April 2015-19 in the PIRP cohort. In a cohort mostly including regularly followed up CKD patients, the incidence of COVID-19 among CKD patients was strongly related to the spread of the infection in the community, while its lethality is associated with the underlying kidney condition and comorbidities. COVID-19 related mortality was about ten times higher than that of CKD patients without COVID. For this reason, it is urgent to offer a direct protection to CKD patients by prioritizing their vaccination.