Tobacco endgame measures and their adaptation in selected European countries: A narrative review synthesis.

Due to the continued detrimental effects of tobacco use, a growing number of countries are embracing the idea of tobacco endgame, meaning ending the tobacco epidemic instead of controlling it. This narrative review aims to synthesize and update the evidence from earlier scientific reviews on effective tobacco endgame measures, as well as to assess their integration to current national strategies among European countries with official tobacco endgame goals. The synthesis of the prior scientific literature found most evidence on product-focused and some evidence for supply-focused policies. Little evidence was detected for user- and institutional-focused measures. An update for the tobacco-free generation measure showed uncertainty in reducing smoking prevalence, especially for adolescents' reactions to age-restrictive laws. All the countries that established a tobacco endgame strategy have included product standards in their measures, predominantly based on European Union regulations on conventional tobacco products, yet standards above this level and considering other products were also common. Cessation measures were given strong emphasis in strategies, yet none of the countries linked these to specific endgame measures. Despite commonly mentioning vulnerable groups, such as youth and pregnant women, adoption of measures to reduce tobacco use among these groups was scarce. Lastly, the decline in tobacco use seems to be modest, implying challenges in meeting the endgame goals. To meet these goals, European countries should reinforce the implementation of known effective tobacco control measures such as tax increases. Furthermore, new innovative strategies and measures to meet the objective of an endgame should be explored.

The confidence in the results of physiotherapy systematic reviews in the musculoskeletal field is not increasing over time: a meta-epidemiological study using AMSTAR 2 tool.

OBJECTIVES: To assess the confidence in the results of systematic reviews on the effectiveness of physiotherapy for musculoskeletal conditions in the past 10 years and to analyze trends and factors associated. METHODS: This is a metaepidemiological study on systematic reviews (SRs) with meta-analysis of randomized controlled trials (RCTs). MEDLINE, Cochrane Database of Systematic Reviews, CINAHL, and PEDro were searched for SRs of RCT on physiotherapy interventions for musculoskeletal disorders from December 2012 to December 2022. Two researchers independently screened the records based on the inclusion criteria; a random sample of 100 studies was selected, and each journal, author, and study variable was extracted. The methodological quality of SRs was independently assessed with the AMSTAR 2 tool. Any disagreement was solved by consensus. RESULTS: The confidence in SRs results was critically low in 90% of the studies, and it did not increase over time. Cochrane reviews are predominantly represented in the higher AMSTAR 2 confidence levels, with a statistically significant difference compared to non-Cochrane reviews. The last author's H-index is the only predictor of higher confidence among the variables analyzed (OR 1.04; 95% CI: 1.01, 1.06). CONCLUSION: The confidence in SRs results is unacceptably low. Given the relevance of musculoskeletal disorders and the impact of evidence synthesis on the clinical decision-making process, there is an urgent need to improve the quality of secondary research by adopting more rigorous methods.

Risk of COVID-19 death for people with a pre-existing cancer diagnosis prior to COVID-19-vaccination: A systematic review and meta-analysis.

While previous reviews found a positive association between pre-existing cancer diagnosis and COVID-19-related death, most early studies did not distinguish long-term cancer survivors from those recently diagnosed/treated, nor adjust for important confounders including age. We aimed to consolidate higher-quality evidence on risk of COVID-19-related death for people with recent/active cancer (compared to people without) in the pre-COVID-19-vaccination period. We searched the WHO COVID-19 Global Research Database (20 December 2021), and Medline and Embase (10 May 2023). We included studies adjusting for age and sex, and providing details of cancer status. Risk-of-bias assessment was based on the Newcastle-Ottawa Scale. Pooled adjusted odds or risk ratios (aORs, aRRs) or hazard ratios (aHRs) and 95% confidence intervals (95% CIs) were calculated using generic inverse-variance random-effects models. Random-effects meta-regressions were used to assess associations between effect estimates and time since cancer diagnosis/treatment. Of 23 773 unique title/abstract records, 39 studies were eligible for inclusion (2 low, 17 moderate, 20 high risk of bias). Risk of COVID-19-related death was higher for people with active or recently diagnosed/treated cancer (general population: aOR = 1.48, 95% CI: 1.36-1.61, I2 = 0; people with COVID-19: aOR = 1.58, 95% CI: 1.41-1.77, I2 = 0.58; inpatients with COVID-19: aOR = 1.66, 95% CI: 1.34-2.06, I2 = 0.98). Risks were more elevated for lung (general population: aOR = 3.4, 95% CI: 2.4-4.7) and hematological cancers (general population: aOR = 2.13, 95% CI: 1.68-2.68, I2 = 0.43), and for metastatic cancers. Meta-regression suggested risk of COVID-19-related death decreased with time since diagnosis/treatment, for example, for any/solid cancers, fitted aOR = 1.55 (95% CI: 1.37-1.75) at 1 year and aOR = 0.98 (95% CI: 0.80-1.20) at 5 years post-cancer diagnosis/treatment. In conclusion, before COVID-19-vaccination, risk of COVID-19-related death was higher for people with recent cancer, with risk depending on cancer type and time since diagnosis/treatment.

Effects of the implementation of the dynamic silver code in the emergency department.

BACKGROUND: Older persons accessing the Emergency Department (ED) spend more time and are at increased risk of poor outcomes. The Dynamic Silver Code (DSC), based on administrative data, predicts mortality of 75+ subjects visiting the ED. OBJECTIVE: To evaluate the effects of the implementation of the DSC in the ED. METHODS: A pre-post comparison was conducted in the ED of a community hospital in Florence, Italy before and after the DSC was fully implemented. In the post-DSC phase, a clinical decision tree was applied: patients at low-mild risk (DSC class I and II) were assigned to Internal Medicine, those at moderate risk (class III) to Geriatrics, and those at high risk (class IV) required geriatric consultation before assignment. Outcome measures were ED length of stay (LOS) and, in patients admitted to Geriatrics, weight of the Diagnosis Related Groups (DRG), hospital LOS, and mortality. RESULTS: 7,270 patients were enrolled in the pre-DSC and 4,725 in the post-DSC phase. ED LOS decreased from a median of 380 [206, 958] in the pre-DSC to 318 [178, 655] min in the post-DSC period (p<0.001). Class III represented the largest share of admissions to Geriatrics in the post-DSC period (57.7 % vs. 38.3 %; p<0.001). In patients admitted to Geriatrics, hospital LOS decreased by one day (p = 0.006) between the two study periods, with greater DRG weight and comparable mortality. CONCLUSIONS: Application of the DSC seemed to ease patient flow and to reduce LOS of older patients in the ED and increased appropriateness of admissions to Geriatrics.

Tobacco endgame in the WHO European Region: Feasibility in light of current tobacco control status.

INTRODUCTION: To assess the feasibility of developing World Health Organization (WHO) European Region countries' goals and measures in line with tobacco endgame objectives, information on the current tobacco control context and capacity is needed. The aim of this study was to assess the implementation of the Framework Convention on Tobacco Control (WHO FCTC) and MPOWER measures in the region. METHODS: In this cross-sectional study we used data from the WHO FCTC implementation reports and MPOWER from 2020 in 53 WHO European Region countries. Six domains (i.e. capacity, taxation and price policies, other national key regulations, public awareness raising and communication, tobacco use cessation, and monitoring) were formed. Subsequently, available indicators under these domains were scored and the level of implementation was computed for each country. Mann-Whitney tests were carried out to compare the scores between the group of countries with and without official endgame goals. RESULTS: Overall, implementation of the WHO FCTC with the selected indicators at the country level ranged from 28% to 86%, and of MPOWER from 31% to 96%. Full implementation was achieved by 28% of WHO FCTC Parties in the region in taxation and price policies, 12% in public awareness raising and communication, and 42% in monitoring. In capacity, tobacco use cessation and other national key regulations, none of the Parties in the region reached full implementation. Overall median WHO FCTC scores were significantly higher in countries with official endgame goals than in those without (p<0.001). CONCLUSIONS: There is unequal implementation of both WHO FCTC and MPOWER measures among WHO European Region countries. MPOWER and WHO FCTC provide all the measures for the necessary first steps, followed by innovative measures, to accomplish tobacco endgame goals.

Smoking intensity changes during the COVID-19 pandemic waves in a cohort of smokers in Italy.

INTRODUCTION: COVID-19 lockdown in Italy resulted in increased smoking consumption, mainly associated with mental distress. This study aims to update previous findings investigating changes in smoking intensity during the whole COVID-19 pandemic. METHODS: This analysis was carried out within the "LOST IN ITALY" ("LOckdown and lifeSTyle IN ITALY") and "LOST IN TOSCANA" studies on 880 smokers with information collected during main pandemic peaks. Changes in cigarettes/day were investigated in association with survey-periods, socio-demographic and psychological characteristics through a linear mixed-model. RESULTS: Net of psychological distress and socio-demographic variables, in comparison to pre-pandemic period cigarettes/day increased by 1.16 during lockdown, and remained over half higher subsequently. In the overall period, an increase of >1 cigarette/day was also associated to lower education, older age, male gender and psychotropics drugs use. CONCLUSIONS: After 2 years of pandemic, cigarettes/day have not yet returned to the pre-pandemic levels, mainly due to socio-demographic factors, but also to nicotine addiction, that tends to stabilize consumption.

Second-hand smoke exposure and cervical cancer: a systematic review and meta-analysis.

PURPOSE: The association between second-hand smoke (SHS) exposure and cervical cancer (CC) risk is still unclear. The aim of this study is to provide an accurate and updated estimate of this association. METHODS: Through an original methodology to identify original publications, we conducted a systematic review and meta-analysis of all epidemiological studies published up to October 2022 evaluating the association between SHS exposure and CC risk among female non-smokers. Meta-analytic estimates were obtained using random-effects models and dose-response relationships were derived using log-linear functions. RESULTS: Out of 25 eligible studies, 21 were included in the meta-analysis, providing a pooled relative risk (RR) of cervical intraepithelial neoplasia (CIN) of grade 2 or higher of 1.52 (95% confidence interval, CI 1.30-1.78, 21 studies) for overall SHS exposure versus non-exposure. When restricting the analysis to invasive CC, the pooled RR was 1.42 (95% CI 1.17-1.71, 13 studies), whereas the pooled RR for CIN was 1.50 (95% CI 1.22-1.84, 6 studies). Analyzing RR by setting or source of SHS exposure resulted in significant associations with CC risk for SHS exposure at home (RR for CIN2+ 1.49, 95% CI 1.21-1.84, 14 studies), in non-specified settings (RR for CIN2+ 1.64, 95% CI 1.20-2.23, 8 studies) and from partner (RR for CIN2+ 1.55, 95% CI 1.25-1.94, 10 studies). The risk of CIN2+ significantly increased linearly with the intensity and pack-years of SHS exposure. CONCLUSION: This comprehensive review and meta-analysis confirmed the association of SHS exposure with CC, further suggesting the need to raise concern about SHS exposure in the population.

Cannabis use in repeated representative cross-sectional studies on Italian adults after the COVID-19 pandemic.

Lockdown measures in response to the COVID-19 pandemic in 2020 yielded dramatic changes in drug consumption. A cross-sectional study was conducted on a representative sample of 6003 Italian adults (18-74 years) in April-May 2020 - reporting information before lockdown and at the time of interview - and two years later (i.e., in February-March 2022). Italian adults using cannabis decreased from 7.0% in pre-pandemic to 5.9% during lockdown (percent change -15.7%) and to 6.7% in 2022 (-4.3%). The reduction was particularly evident among adults aged 55-74 years, whereas cannabis use strongly increased among those aged 18-34 years. In the last period considered (2022), cannabis use was significantly more frequent in men (adjusted odds ratio, OR = 1.43), adults aged 18-34 years (p-trend <0.001), individuals with a low or high level of education (OR = 1.42 and 1.46, respectively), those from Central or Southern Italy/islands (OR = 1.50 and 1.38, respectively), and those with an economic status above the average (OR = 3.07). In 2022, cannabis use was also more frequently reported in current smokers (OR = 3.52), current e-cigarette and heated tobacco product users (OR = 6.09 and 2.94, respectively), individuals with a risky alcohol consumption (OR = 4.60), gamblers (OR = 3.76), those with anxiety and depression (OR = 2.50 and 2.80, respectively), those using psychotropic drugs (OR = 8.96), those with a low quality of life (OR = 1.91), and those sleeping less (OR = 1.42). After the COVID-19 pandemic, cannabis use was more frequent in individuals with other addictive behaviours, and with anxiety and depressive symptoms.

Time-Trends in Air Pollution Impact on Health in Italy, 1990-2019: An Analysis From the Global Burden of Disease Study 2019.

Objectives: We explored temporal variations in disease burden of ambient particulate matter 2.5 µm or less in diameter (PM2.5) and ozone in Italy using estimates from the Global Burden of Disease Study 2019. Methods: We compared temporal changes and percent variations (95% Uncertainty Intervals [95% UI]) in rates of disability adjusted life years (DALYs), years of life lost, years lived with disability and mortality from 1990 to 2019, and variations in pollutant-attributable burden with those in the overall burden of each PM2.5- and ozone-related disease. Results: In 2019, 467,000 DALYs (95% UI: 371,000, 570,000) were attributable to PM2.5 and 39,600 (95% UI: 18,300, 61,500) to ozone. The crude DALY rate attributable to PM2.5 decreased by 47.9% (95% UI: 10.3, 65.4) from 1990 to 2019. For ozone, it declined by 37.0% (95% UI: 28.9, 44.5) during 1990-2010, but it increased by 44.8% (95% UI: 35.5, 56.3) during 2010-2019. Age-standardized rates declined more than crude ones. Conclusion: In Italy, the burden of ambient PM2.5 (but not of ozone) significantly decreased, even in concurrence with population ageing. Results suggest a positive impact of air quality regulations, fostering further regulatory efforts.

The role of smoking in COVID-19 progression: a comprehensive meta-analysis.

The association between current smoking and coronavirus disease 2019 (COVID-19) progression remains uncertain. We aim to provide up-to-date evidence of the role of cigarette smoking in COVID-19 hospitalisation, severity and mortality. On 23 February 2022 we conducted an umbrella review and a traditional systematic review via PubMed/Medline and Web of Science. We used random-effects meta-analyses to derive pooled odds ratios of COVID-19 outcomes for smokers in cohorts of severe acute respiratory syndrome coronavirus 2 infected individuals or COVID-19 patients. We followed the Meta-analysis of Observational Studies in Epidemiology reporting guidelines. PROSPERO: CRD42020207003. 320 publications were included. The pooled odds ratio for current versus never or nonsmokers was 1.08 (95% CI 0.98-1.19; 37 studies) for hospitalisation, 1.34 (95% CI 1.22-1.48; 124 studies) for severity and 1.32 (95% CI 1.20-1.45; 119 studies) for mortality. Estimates for former versus never-smokers were 1.16 (95% CI 1.03-1.31; 22 studies), 1.41 (95% CI: 1.25-1.59; 44 studies) and 1.46 (95% CI 1.31-1.62; 44 studies), respectively. Estimates for ever- versus never-smokers were 1.16 (95% CI 1.05-1.27; 33 studies), 1.44 (95% CI 1.31-1.58; 110 studies) and 1.39 (95% CI 1.29-1.50; 109 studies), respectively. We found a 30-50% excess risk of COVID-19 progression for current and former smokers compared with never-smokers. Preventing serious COVID-19 outcomes, including death, seems the newest compelling argument against smoking.

The Association of Tobacco Smoking, Second-hand Smoke, and Novel Tobacco Products With COVID-19 Severity and Mortality in Italy: Results From the COSMO-IT Study.

BACKGROUND: Despite the robust evidence of an excess risk of coronavirus disease 2019 (COVID-19) severity and mortality in ever smokers, the debate on the role of current and ex-smokers on COVID-19 progression remains open. Limited or no data are available on the link between electronic cigarette (e-cigarette), heated tobacco product (HTP) and second-hand smoke (SHS) exposure and COVID-19 progression. To fill this knowledge gap, we undertook the COvid19 and SMOking in ITaly (COSMO-IT) study. METHODS: A multi-centre longitudinal study was conducted in 2020-2021 in 24 Italian hospitals on a total of 1,820 laboratory-confirmed COVID-19 patients. We estimated multivariable odds ratios (OR) and 95% confidence intervals (CI) to quantify the association between smoking-related behaviours (ie, smoking status, e-cigarette and HTP use, and SHS exposure) and COVID-19 severity (composite outcome: intubation, intensive care unit admission and death) and mortality. RESULTS: Compared to never smokers, current smokers had an increased risk of COVID-19 mortality (OR 2.17; 95% CI, 1.06-4.41). E-cigarette use was non-significantly associated to an increased risk of COVID-19 severity (OR 1.60; 95% CI, 0.96-2.67). An increased risk of mortality was observed for exposure to SHS among non-smokers (OR 1.67; 95% CI, 1.04-2.68), the risk being particularly evident for exposures of ≥6 hours/day (OR 1.99; 95% CI, 1.15-3.44). CONCLUSION: This multicentric study from Italy shows a dismal COVID-19 progression in current smokers and, for the first time, in SHS exposed non-smokers. These data represent an additional reason to strengthen and enforce effective tobacco control measures and to support smokers in quitting.

Electronic cigarette use as an aid to quit smoking: Evidence from PASSI survey, 2014-2021.

This paper updates a previous cross-sectional study on the effectiveness of electronic cigarettes (e-cigarettes) as an aid to quit smoking. In the 2014-2021 PASSI survey, the ongoing Italian behavioural risk factor surveillance system, on a total of 239,812 subjects representative of the Italian adult population respondents who smoked and made at least one quit attempt in the previous 12 months (i.e., 19,234 subjects) were categorized into four groups according to the method used in their most recent quit attempt: no aid, e-cigarettes, standard pharmacological support (medications) and/or smoking cessation services (SCSs), other unspecified methods. The primary outcome was self-reported abstinence for a period ≥6 months. Thirteen percent of participants used e-cigarettes to quit, 83% no aid, 2% medications/SCSs, 3% other unspecified methods. Smoking abstinence was reported among 10% of those using no aid; 11% among e-cigarette users; 16% among those using medications/SCSs; and 13% among those using other unspecified methods. No significant difference in abstinence was observed for those reporting no aid compared with e-cigarette users (adjusted Prevalence Ratio [aPR] = 0.93; 95% confidence interval [CI] = 0.79-1.10). Those using medications/SCSs were significantly more likely to report abstinence than e-cigarette users (aPR = 1.35; 95% CI = 1.01-1.81). E-cigarettes as consumer products are not associated with higher quitting rates than those recorded using no aid, therefore there is no health benefit for allowing them to be marketed to smokers.

Healthcare use and healthcare costs for patients with advanced cancer; the international ACTION cluster-randomised trial on advance care planning.

BACKGROUND: Advance care planning supports patients to reflect on and discuss preferences for future treatment and care. Studies of the impact of advance care planning on healthcare use and healthcare costs are scarce. AIM: To determine the impact on healthcare use and costs of an advance care planning intervention across six European countries. DESIGN: Cluster-randomised trial, registered as ISRCTN63110516, of advance care planning conversations supported by certified facilitators. SETTING/PARTICIPANTS: Patients with advanced lung or colorectal cancer from 23 hospitals in Belgium, Denmark, Italy, the Netherlands, Slovenia and the UK. Data on healthcare use were collected from hospital medical files during 12 months after inclusion. RESULTS: Patients with a good performance status were underrepresented in the intervention group (p< 0.001). Intervention and control patients spent on average 9 versus 8 days in hospital (p = 0.07) and the average number of X-rays was 1.9 in both groups. Fewer intervention than control patients received systemic cancer treatment; 79% versus 89%, respectively (p< 0.001). Total average costs of hospital care during 12 months follow-up were €32,700 for intervention versus €40,700 for control patients (p = 0.04 with bootstrap analyses). Multivariable multilevel models showed that lower average costs of care in the intervention group related to differences between study groups in country, religion and WHO-status. No effect of the intervention on differences in costs between study groups was observed (p = 0.3). CONCLUSIONS: Lower care costs as observed in the intervention group were mainly related to patients' characteristics. A definite impact of the intervention itself could not be established.

Dose-risk relationships between cigarette smoking and cervical cancer: a systematic review and meta-analysis.

OBJECTIVE: Cervical cancer (CC) is the fourth most frequent cancer worldwide. Cigarette smoking has been shown to influence CC risk in conjunction with human papillomavirus (HPV) infection. The aim of this study is to provide the most accurate and updated estimate of this association and its dose-response relationship. METHODS: Using an innovative approach for the identification of original publications, we conducted a systematic review and meta-analysis of studies published up to January 2021. Random effects models were used to provide pooled relative risks (RRs) of CC for smoking status. Dose-response relationships were evaluated using one-stage random effects models with linear or restricted cubic splines models. RESULTS: We included 109 studies providing a pooled RR of invasive CC and preinvasive lesions, respectively, of 1.70 [95% confidence interval (CI), 1.53-1.88] and 2.11 (95% CI, 1.85-2.39) for current versus never smokers, and, respectively, 1.13 (95% CI, 1.02-1.24) and 1.29 (95% CI, 1.15-1.46) for former versus never smokers. Considering HPV does not alter the positive association or its magnitude. Risks of CC sharply increased with few cigarettes (for 10 cigarettes/day, RR = 1.72; 95% CI, 1.34-2.20 for invasive CC and RR = 2.13; 95% CI, 1.86-2.44 for precancerous lesions). The risk of CC increased with pack-years and smoking duration and decreased linearly with time since quitting, reaching that of never smokers about 15 years after quitting. CONCLUSION: This comprehensive review and meta-analysis confirmed the association of smoking with CC, independently from HPV infection. Such association rose sharply with smoking intensity and decreased after smoking cessation.

Italians are still loyal to conventional cigarettes, despite novel tobacco products.

INTRODUCTION: Over the last few decades in Italy, we observed a substantial reduction in conventional tobacco cigarette consumption, the introduction of electronic cigarettes (e-cigarette) in 2010, and the launch of heated tobacco products (HTP) in 2015. METHODS: We investigated novel products, i.e. e-cigarettes and HTP, use in Italy in 2018-2021 using data from the cross-sectional annual PASSI (Progressi delle Aziende Sanitarie per la Salute in Italia) survey conducted in representative samples of adults aged 18-69 (overall n = 101,458). We compared characteristics of conventional cigarette smokers with those of novel product users. RESULTS: A stall in e-cigarette use at around 2.4% and a three-fold increase in HTP use from 0.5% in 2018 to 2.5% in 2021 were recorded, with around 60% of e-cigarette users and 70% of HTP users who kept on smoking conventional cigarettes. Around 86% of smokers did not use novel products at all. Novel products use among former smokers was more likely in younger e-cigarette with no nicotine users, whereas older users of both novel products were less able to completely shift to an exclusive use. CONCLUSIONS: After 10 years from the introduction of e-cigarettes and 5 years from that of HTP, the majority of smokers in Italy were still loyal to conventional tobacco cigarettes, and more than half of novel product users kept on smoking conventional cigarettes.

Impact of electronic cigarette and heated tobacco product on conventional smoking: an Italian prospective cohort study conducted during the COVID-19 pandemic.

OBJECTIVE: Debate continues about whether electronic cigarettes (e-cigarettes) and heated tobacco products (HTP) reduce or increase the probability of smoking, with many studies compromised by stated or unstated conflicts of interest. We undertook a longitudinal study in Italy. METHODS: 3185 Italian participants aged 18-74 years provided baseline (April-May) and follow-up (November-December) responses in 2020, reporting smoking status and use of e-cigarettes and HTP. We tracked transitions over that period and reported risk ratios (RR) and corresponding 95% CIs for changes in smoking in relation to baseline use of e-cigarettes and HTPs. RESULTS: Never cigarette smokers who used e-cigarettes at baseline were much more likely to start smoking (compared with never users, RR 8.78; 95% CI: 5.65 to 13.65) and current HTP users (RR 5.80; 95% CI: 3.65 to 9.20). Among ex-smokers, relapse (17.2%) at follow-up was more likely among e-cigarette (RR 4.25; 95% CI: 2.40 to 7.52) and HTP users (RR 3.32; 95% CI: 2.05 to 5.37). Among current smokers at baseline, those who had continued smoking at follow-up were 85.4% overall. These were more frequently current novel product users (compared with non-users, RR 1.10; 95% CI: 1.02 to 1.19 for e-cigarette users; RR 1.17; 95% CI: 1.10 to 1.23 for HTP users). CONCLUSIONS: Both e-cigarette and HTP use predict starting smoking and relapse, and appear to reduce smoking cessation. Due to the limited sample size within specific strata, the association with quitting smoking should be confirmed by larger prospective studies. These findings do not support the use of e-cigarettes and HTPs in tobacco control as a consumer product, at least in Italy.

Reliability, Validity, and Responsiveness of the Craniocervical Flexion Test in People Who Are Asymptomatic and Patients With Nonspecific Neck Pain: A Systematic Review and Meta-Analysis.

OBJECTIVE: Among the tests designed to evaluate neck neuromuscular function, the craniocervical flexion test (CCFT) assesses the function of the deep cervical flexor muscles (DCFs). The purpose of this study was to conduct a review and meta-analysis of published articles about all measurement properties of the different CCFT versions (CCFT Activation Score [CCFT-AS], CCFT Performance Index [CCFT-PI], CCFT Cumulative Performance Index [CCFT-CPI], and CCFT alternative procedures for measuring activation level (CCFT1) or endurance (CCFT2) in people who were asymptomatic and people with nonspecific neck pain. METHODS: PubMed Central, MEDLINE, CINAHL, Scopus, Web of Science, and Google Scholar were searched from inception to June 30, 2020. Studies were selected if they reported data on reliability, validity, and/or responsiveness of the CCFT in adults who were asymptomatic or who had nonspecific neck pain. Two reviewers independently selected the studies, conducted quality assessment, and extracted the results. All meta-analyses used a random-effects model. RESULTS: Twenty-one studies met the inclusion criteria. The rating of interrater reliability (assessed for CCFT-AS and CCFT-CPI) was positive only for using the test at a group level. The same rating was ascribed to the intrarater reliability of CCFT-AS, CCFT1, and CCFT2, whereas CCFT-PI and CCFT-CPI showed positive intrarater reliability for assessment of individuals as well. CCFT validity was rated as positive for expressly assessing DCF action when measuring DCF activation through electromyography-not through ultrasonography-or craniocervical flexion motion as well as for differentiating patients who were asymptomatic and patients who had nonspecific neck pain (only the AS version). CCFT validity was rated as negative for investigating the CCFT performance correlation with the severity of nonspecific neck pain. CCFT responsiveness was rated as negative. CONCLUSIONS: The CCFT is a potentially useful tool for detecting impairment in DCF control and identifying patients who have nonspecific neck pain and who would benefit from a targeted intervention. However, the limited reliability affects its suitability for that purpose. Further research on the reliability of different CCFT versions in which the raters are thoroughly trained is strongly recommended. IMPACT: The CCFT might help to detect impairment in DCF control and identify patients who have nonspecific neck pain and who would benefit from a targeted intervention. However, the poor reliability of most versions of the test greatly limits its application in clinical practice. Only CCFT-PI and CCFT-CPI seem reliable enough to help in clinical decision-making at the individual level.

Use of electronic cigarettes and heated tobacco products during the Covid-19 pandemic.

Only a few studies investigated changes in electronic cigarette (e-cigarette) and heated tobacco product (HTP) use during pandemic restrictions. We conducted a web-based cross-sectional study of a representative sample of 6,003 Italian adults during the strictest phase of the Covid-19 lockdown (April-May 2020). Participants were asked to report changes in e-cigarette and HTP use compared to before the pandemic. E-cigarette users increased from 8.1% to 9.1% and HTP users from 4.0% to 4.5%. Among e-cigarette non-users before lockdown, 1.8% started using e-cigarettes during lockdown. New users were more frequently younger (p for trend 0.001), men (odds ratio, OR 1.56; 95% confidence interval, CI: 1.03-2.34), cannabis users (OR 2.35; 95% CI: 1.33-4.13), gamblers (OR 3.34; 95% CI: 2.18-5.11) and individuals with anxiety symptoms (OR 1.58; 95% CI: 1.00-2.52). 1.0% of HTP non-users started using it during lockdown. New users were less frequently current than never cigarette smokers (OR 0.19; 95% CI: 0.06-0.61) and more frequently gamblers (OR 2.23; 95% CI: 1.22-4.07). E-cigarettes and HTPs played little role as smoking cessation tools for hardcore smokers but rather provided opportunities for young never smokers to engage in socially acceptable activities, perhaps reflecting the obstacles they faced in obtaining other addictive substances during confinement.

COVID-19, Vulnerability, and Long-Term Mortality in Hospitalized and Nonhospitalized Older Persons.

OBJECTIVE: Studies suggesting that vulnerability increased short-term mortality in older patients with COVID-19 enrolled hospitalized patients and lacked COVID-negative comparators. Aim of this study was to examine the relationship between frailty and 1-year mortality in older patients with and without COVID-19, hospitalized and nonhospitalized. DESIGN: Cohort study. SETTING AND PARTICIPANTS: Patients over 75 years old accessing the emergency departments (ED) were identified from the ED archives in Florence, Italy. METHODS: Vulnerability status was estimated with the Dynamic Silver Code (DSC). COVID-19 hospital discharges (HC+) were compared with non-COVID-19 discharges (HC-). Linkage with a national COVID-19 registry identified nonhospitalized ED visitors with (NHC+) or without COVID-19 (NHC-). RESULTS: In 1 year, 48.4% and 33.9% of 1745 HC+ and 15,846 HC- participants died (P < .001). Mortality increased from 27.5% to 64.0% in HC+ and from 19.9% to 51.1% in HC- across DSC classes I to IV, with HC+ vs HC- hazard ratios between 1.6 and 2.2. Out of 1039 NHC+ and 18,722 NHC- participants, 18% and 8.7% died (P < .001). Mortality increased from 14.2% to 46.7% in NHC+ and from 2.9% to 26% in NHC- across DSC; NHC+ vs NHC- hazard ratios decreased from 5.3 in class I to 2.0 in class IV. CONCLUSIONS AND IMPLICATIONS: In hospitalized older patients, mortality increases with vulnerability similarly in the presence and in the absence of COVID-19. In nonhospitalized patients, vulnerability-associated excess mortality is milder in individuals with than in those without COVID-19. The disease reduces survival even when background risk is low. Thus, apparently uncomplicated patients deserve closer clinical monitoring than commonly applied.

Estimating Prognosis and Frailty in Persons Aged ≥75 Years in the Emergency Department: Further Validation of Dynamic Silver Code.

OBJECTIVES: To assess concurrent validity of the Dynamic Silver Code (DSC), a tool based on administrative data that predicts prognosis in older adults accessing the emergency department (ED), in terms of association with markers of poor functional and cognitive status. DESIGN: Cross-sectional. SETTING AND PARTICIPANTS: Data were obtained in the AIDEA study, which enrolled a cohort of ≥75-year-old patients, accessing the ED of 2 hospitals in Florence, Italy. METHODS: The DSC score and classes (I to IV, corresponding to an increasing risk of death) were obtained from administrative data. Information on health and functional status prior to ED access were collected from face-to-face, direct, or proxy interviews. The 4AT test was administered to screen for possible delirium. Bivariate comparisons of the prevalence of each functional and cognitive marker across 4 DSC classes were performed. Multinomial logistic regression was used to assess the multivariable risk of being in II, III, or IV DSC class vs I. RESULTS: Among 3358 participants (mean age 83 years, men 44%), 32.9%, 30.3%, 19.5%, and 17.2% were in DSC class I, II, III, and IV. Preadmission abnormal functional and cognitive conditions, and delirium in the ED, were increasingly more common from DSC class I through IV (P < .001). In particular, the prevalence of total inability to walk increased from 2.9% (class I) to 23.4% (class IV). In multivariable analyses, this was the strongest predictor of being in progressively worse DSC classes, whereas feeling of exhaustion, reporting of serious falls, weight loss, and severe memory loss or diagnosis of dementia gave some contribution. CONCLUSIONS AND IMPLICATIONS: The ability of the DSC to predict survival in older persons appears to rely on its prevailing association with markers of functional impairment. These results may support clinical use of the tool.