Knowledge, opinions and attitudes of Italian mothers towards HPV vaccination and Pap test.

AIM: This study evaluated the knowledge and attitudes of Italian mothers - whose daughters had been vaccinated in 2012 - towards primary (anti-HPV vaccination) and secondary (Pap test screening) cervical cancer prevention, as well as sources of information and mother-daughter communication on health issues. METHODS: The survey - part of a multicenter study carried out in 4 Italian cities (Ferrara, Rome, Cassino and Palermo) - was conducted through self-administered questionnaires. The first univariate analysis evaluated differences between mothers of under-18s and over-18s relative to knowledge and attitudes on HPV vaccination and Pap test. The second univariate analysis evaluated differences between the 2 groups of mothers and possible geographical variations regarding the sources of information on HPV and Pap test. RESULTS: The sample proved knowledgeable about the correlation between HPV and cervical cancer (>85%) but less aware of other HPV-related diseases. HPV vaccination should be administered before first sexual intercourse according to mothers of over-18s, and to 14- to 17-year-olds according to mothers of under-18s. Up to 88% of mothers of under-18s and 80% of mothers of over-18s declared that the vaccine should be given free of charge. More mothers of under-18s consulted a general practitioner (GP) or gynecologist before deciding to vaccinate their daughters. Mothers of under-18s received information on HPV vaccination mainly from GPs and gynecologists, while mothers of over-18s were informed through TV and books/journals. Over 80% of the sample declared satisfaction with the information received from their gynecologist during the Pap test. CONCLUSIONS: The findings provide useful information for the development of effective public health interventions that may help improve acceptance of HPV vaccination among mothers.

Knowledge, attitudes, and smoking behaviours among physicians specializing in public health: a multicentre study.

BACKGROUND: Healthcare professionals have an important role to play both as advisers-influencing smoking cessation-and as role models. However, many of them continue to smoke. The aims of this study were to examine smoking prevalence, knowledge, attitudes, and behaviours among four cohorts physicians specializing in public health, according to the Global Health Profession Students Survey (GHPSS) approach. MATERIALS AND METHODS: A multicentre cross-sectional study was carried out in 24 Italian schools of public health. The survey was conducted between January and April 2012 and it was carried out a census of students in the selected schools for each years of course (from first to fourth year of attendance), therefore among four cohorts of physicians specializing in Public Health (for a total of n. 459 medical doctors). The GHPSS questionnaires were self-administered via a special website which is created ad hoc for the survey. Logistic regression model was used to identify possible associations with tobacco smoking status. Hosmer-Lemeshow test was performed. The level of significance was P ≤ 0.05. RESULTS: A total of 388 answered the questionnaire on the website (85%), of which 81 (20.9%) declared to be smokers, 309 (79.6%) considered health professionals as behavioural models for patients, and 375 (96.6%) affirmed that health professionals have a role in giving advice or information about smoking cessation. Although 388 (89.7%) heard about smoking related issues during undergraduate courses, only 17% received specific smoking cessation training during specialization. CONCLUSIONS: The present study highlights the importance of focusing attention on smoking cessation training, given the high prevalence of smokers among physicians specializing in public health, their key role both as advisers and behavioural models, and the limited tobacco training offered in public health schools.

Cross-sectional seroprevalence of antibodies against 6, 11, 16 and 18 human papilloma virus (HPV) types among teenagers and young women in Italy.

BACKGROUND: Little is known about human papilloma virus (HPV) seroprevalence in the healthy Italian population. The aim of the study was to assess seroprevalence of antibodies against HPV 6, 11, 16 and 18 among girls and young women in Italy. METHODS: Sera were tested with a commercially available ELISA assay detecting specific IgG. RESULTS: Seroprevalence was 54.1% in girls between 11 to 18 years old and 8.2% in over 18s. Overall seropositivity in birth cohorts invited for free immunization reached 72.8% and was significantly higher than in other age subgroups. The highest levels of antibodies were detected in girls of 12 years old that should have just completed the vaccination schedule. CONCLUSION: A standardized seroepidemiological survey on HPV represents a useful tool for identifying groups at risk in which immunization is recommended, monitoring of vaccinated women, assessing whether booster vaccination is required.

GHPSS multicenter Italian survey: smoking prevalence, knowledge and attitudes, and tobacco cessation training among third-year medical students.

AIMS AND BACKGROUND: Healthcare professionals have an important role to play both as advisers - influencing smoking cessation - and as role models. The aims of this study were to examine smoking prevalence, knowledge and attitudes among Italian university students attending medical schools using the Global Health Professions Student Survey (GHPSS) approach. METHODS AND STUDY DESIGN: A multicenter cross-sectional study was conducted among University students of 9 Italian medical schools (age ranging between 19 and 29 years). The GHPSS questionnaire was self-administered. A logistic regression model was used to identify possible factors associated with tobacco smoking status. Data were analyzed with the software SPSS 19.0 for Windows. RESULTS: Seven hundred thirty medical students (response rate 100%) were enrolled. The prevalence of current smokers was 20.4% (males 22.4%, females 19.1%). Of the total sample, 87.7% believed that health professionals should receive specific training in techniques to quit smoking, and 65% believed that health professionals had a role in giving advice or information about smoking cessation. However, 89.4% answered that they had not received specific training on smoking cessation techniques. Multivariate analysis showed that students belonging to universities in southern Italy were more likely to be smokers (OR = 2.00; 95% CI: 1.03-3.97). CONCLUSIONS: This Italian multicenter survey found that one fifth of future medical doctors are smokers. There is a need to adopt a standard undergraduate curriculum containing comprehensive tobacco prevention and cessation training to improve their effectiveness as role models.

Multidimensional evaluation of performance with experimental application of balanced scorecard: a two year experience.

BACKGROUND: In today's dynamic health-care system, organizations such as hospitals are required to improve their performance for multiple stakeholders and deliver an integrated care that means to work effectively, be innovative and organize efficiently. Achieved goals and levels of quality can be successfully measured by a multidimensional approach like Balanced Scorecard (BSC). The aim of the study was to verify the opportunity to introduce BSC framework to measure performance in St. Anna University Hospital of Ferrara, applying it to the Clinical Laboratory Operative Unit in order to compare over time performance results and achievements of assigned targets. METHODS: In the first experience with BSC we distinguished four perspectives, according to Kaplan and Norton, identified Key Performance Areas and Key Performance Indicators, set standards and weights for each objective, collected data for all indicators, recognized cause-and-effect relationships in a strategic map. One year later we proceeded with the next data collection and analysed the preservation of framework aptitude to measure Operative Unit performance. In addition, we verified the ability to underline links between strategic actions belonging to different perspectives in producing outcomes changes. RESULTS: The BSC was found to be effective for underlining existing problems and identifying opportunities for improvements. The BSC also revealed the specific perspective contribution to overall performance enhancement. After time results comparison was possible depending on the selection of feasible and appropriate key performance indicators, which was occasionally limited by data collection problems. CONCLUSIONS: The first use of BSC to compare performance at Operative Unit level, in course of time, suggested this framework can be successfully adopted for results measuring and revealing effective health factors, allowing health-care quality improvements.

[A study to compare formal duties of medical directors of Italian public hospitals with actual activities performer]. / Studio comparativo di compiti e funzioni del Dirigente Medico di Presidio Ospedaliero.

It is difficult to identify, from a regulatory point of view, the actual competencies of medical directors of public hospitals in Italy. A questionnaire survey was therefore conducted to identify which are the activities actually performed by this professional. One hundred twenty local health authorities participated in the survey. Findings reveal that many activities conducted by the hospital medical director, such a mediation with the local health authorities, are not formally recognized and that the medical director actually conducts more complex activities than those formally pertaining to his role.

Multidimensional evaluation of performance: experimental application of the balanced scorecard in Ferrara university hospital.

BACKGROUND AND AIMS: One of the best-known performance planning and evaluation techniques utilising both monetary and non-monetary data is the Balanced Scorecard (BSC). This is a means of rationalising the global activity of a business in the attempt to create value, and to translate the company vision into a set of tactical objectives and measurable strategies. The aim of this study was to implement and evaluate the use of BSC in two departments of the St. Anna University Hospital, Ferrara: the Analysis Laboratory and Digestive Endoscopy operating units (OU). MATERIALS AND METHODS: With the collaboration of the health workers involved, a precise methodological programme was pursued: Definition of the strategic map from 4 perspectives, according to Kaplan and Norton, Definition of the Key Performance Areas (KPA), or macro-objectives, Identification of the cause-effect relationships between KPAs, Identification of the sub-objectives of each KPA, Definition of the Key Performance Indicators (KPI), Definition of the weight/importance of each objective in the global evaluation. RESULTS: The information gathered permitted the definition of macro- and sub-objectives for each perspective, as well as determining the relevant indicators, standards, weights, frequency of detection and means of acquisition. Strategic maps showing the cause/effect relationships in each OU were created, as were 'evaluation panels', which describe the global performance of each department. For each perspective, the fundamental data were summarised in one table. Evaluation of each perspective yielded a positive result for the majority of the objectives, and the global result (including all 4 perspectives) was found to be satisfactory. DISCUSSION-CONCLUSION: The Balanced Scorecard was implemented in the abovementioned OUs of St. Anna University Hospital, Ferrara, after the health workers themselves realised the need for change.In our research the employees were pleased to be evaluated, not only for the financial outcomes, but also for the satisfaction of improving internal procedure, relationships with the community and their own growth/learning. BSC is an ideal point of contact between the financial and clinical dimensions of management. However, difficulties in its application were faced, among these, at least in the initial phase, the lack of information systems able to drive it, and the complexity of the research for specific indicators needed to be overcome. The time factor (on average, at least two years are required) and the availability of technological resources were also limiting factors.The rapid diffusion of BSC among the principal international profit and non-profit organisations is testament to its great potential. This project could be seen as a preparatory phase in the strategical analysis of a subsequent business plan.

Mutagenic activity of overnight urine from healthy non-smoking subjects.

Urinary mutagenicity was evaluated in relation to environmental mutagen exposure (i.e., diet, indoor/outdoor activities, residential area etc.) on the day prior to sample collection, and also considering factors that contribute to the variability of Salmonella mutagenicity assay results. Overnight urine samples from 283 healthy non-smoking residents of northeast Italy (46% males, 20-62 years) were analyzed for mutagenicity on sensitive Salmonella typhimurium strain YG1024 with S9 mix employing the preincubation version of the plate incorporation assay (i.e., the Salmonella reverse mutation test). Urinary mutagenicity varied between 0.02 and 9.84 rev/ equiv. ml, and 7% of samples were positive (i.e., sample elicited a two-fold increase in revertants). There was an evident increase in mutagenicity in subjects with increased intake of mutagen-rich meals (n = 80) (P < 0.01 and positive urine 13% vs. 5%, P = 0.025). Indoor-exposed subjects (n = 65) also showed a higher percentage of positive urine (14% vs. 5%, P = 0.015). In particular, those subjects exposed to cooking fumes the previous evening (n = 28) revealed higher urinary mutagenicity (P = 0.035, positive urine 25% vs. 5%, P < 0.001) than non-indoor exposed. The sources of variability of the mutagenicity assay, mainly the histidine content of the urine concentrate (z = 4.06, P < 0.0001), and to a lesser extent bacterial inoculum size (z = 2.33, P = 0.019), also significantly influenced urinary mutagenicity values. In a linear multiple regression analysis, their effects were still significant (i.e., histidine content P = 0.026 and inoculum size P = 0.021), but the effects of diet, indoor exposure, and other environmental exposures (i.e., traffic and heating system exhausts, residential area) were not. It is concluded that the previous day's exposure to mutagen-rich meals and cooking fumes may influence the presence of mutagenic activity in the overnight urine of non-smoking subjects. This mutagenic activity, which remains in contact with bladder mucosa for several hours, could be considered risk factors for colorectal adenoma and possibly other cancers (i.e., bladder) in non-smokers. Accurate control of histidine content and bacterial inoculum size is strongly recommended when investigating the mutagenic activity of urine from non-smokers.

Work-related injuries in young workers: an Italian multicentric epidemiological survey.

Emergency departments records from 33 hospitals were reviewed to disclose work-related injuries occurred in teen-subjects living in 14 Italian cities. During January-June 2000, 317 work-related injuries were reported. Male subjects, 17 year old, working in the industrial field, resulted the most affected, probably due to the fact that among young workers this sex and age class is the most represented one. Cluster analysis identified two groups of work-related injuries: one includes mainly transportation injuries causing lower extremities or multiple body sites traumas. The other is more strictly related to specific working tasks and includes mostly traumas and cut wounds in hand/wrist and head, together with eye lesions. A more intensive supervision on the use of protective equipment, a more appropriate training in hazard recognition and safe work practices, including operation of vehicles in the work site, must be implemented to reduce work-related injuries.

[Attitudes and behaviors toward cardiological procedures: results from a multicenter study in Italy]. / Atteggiamenti e comportamenti nei confronti degli interventi cardiologici: risultati di uno studio multicentrico in Italia.

BACKGROUND: In Italy, cardiovascular diseases represent an important cause of disability in the elderly. Therefore, it is necessary to provide effective and appropriate diagnostic and therapeutic procedures to all the interested subjects. The aim of our study was to estimate attitudes and behaviors of health personnel and representatives of citizen associations toward the following procedures: thrombolysis, coronary artery bypass, pacemaker implantation, and aortic valve replacement. METHODS: Within an Italian multicenter study on the relation between age and treatment of cardiovascular diseases, a questionnaire was administered to a stratified sample of medical doctors (cardiologists, heart surgeons, geriatrics, internists), general practitioners in order to show any existing discrimination in care access as regards age, sex and race of patients. RESULTS: The sample included 283 subjects (73.8% men, median age 47 years). In 53% age was a discriminating factor in the distribution of the therapeutic procedures, with higher statistically significant percentages reported by geriatrics and internists (62.5 and 58.6%, respectively) and lower ones by cardiologists and heart surgeons (48.2 and 41.5%, respectively) (chi2 = 29.592, p < 0.0001). The influence of the shortest expectancy of life in the elderly is the reason for discrimination in 19.6% of the participants. Race and gender do not represent a discriminating factor for 81 and 92.1% of responders, respectively. CONCLUSIONS: The results of our study highlight the presence of different attitudes among health personnel about the distribution of cardiological procedures as regards patients' age, in particular when > 75 years old. An easier access should be given to these patients and this may represent the objective of research aimed at developing better treatments for elderly people.

Influence of the genetic polymorphism in the 5'-noncoding region of the CYP1A2 gene on CYP1A2 phenotype and urinary mutagenicity in smokers.

The functional significance of genetic polymorphisms on tobacco smoke-induced CYP1A2 activity was examined. The influence of three polymorphisms of the cytochrome P450 1A2 gene (CYP1A2) (-3860 G-->A (allele *1C), -2467 T-->delT (allele *1D), -163C-->A (allele *1F)), located in the 5'-noncoding promoter region of the gene, on CYP1A2 activity (measured as caffeine metabolic ratio, CMR), was studied in Caucasian current smokers (n=95). Tobacco smoke intake was calculated from the number of cigarettes/day. Also, studied was the influence of these CYP1A2 genotypes on smoking-associated urinary mutagenicity, detected in Salmonella typhimurium strain YG1024 with S9 mix, considering the urinary excretion of nicotine plus its metabolites as an internal indicator of tobacco smoke exposure. Smokers with at least one of the variant alleles CYP1A2 -3860A and -2467 delT showed a significantly increased CYP1A2 CMR (-3860 G/A versus G/G, p<0.05; -2467 delT/delT versus T/delT and T/T, p<0.01). Multiple regression analysis showed that the increase in CYP1A2 CMR (ln values) was again significantly related to the presence of CYP1A2 variants -2467delT and also to variant -163A (p<0.05), but moderately to -3860A (p=0.084). No influence of the number of cigarettes smoked per day by each subject was found. Heavy smokers (n=48, with urinary nicotine plus its metabolites>or=0.69 mg/mmol creatinine) with variant allele -2467delT or -163A had significantly increased urinary mutagenicity (p<0.01 and <0.05). CYP1A2 genetic polymorphisms are shown to influence the CYP1A2 phenotype in smokers, -2467 T-->delT having the main effect. This information is of interest for future studies assessing the possible role of tobacco smoke-inducible CYP1A2 genotypes as individual susceptibility factors in exposure to carcinogens.

Age- and sex-related utilisation of cardiac procedures and interventions: a multicentric study in Italy.

BACKGROUND: Cardiovascular diseases represent the leading cause of death in Italy and one of the most frequent cause of disability in the elderly. The aim of the study was to investigate the influence of age and sex of patient on the utilisation of cardiac procedure and interventions in Italy. METHODS: Retrospective analysis of 2805 patients' medical case notes in cardiology, internal medicine and elderly clinics in six Italian Regions during the period 1996-1997, considering coronary catheterisation (CC), percutaneous transluminal coronary angioplasty (PCTA), coronary artery bypass grafting (CABG), thrombolysis (THR) and permanent pacemaker (PPM) implantation. RESULTS: Older patients (more than 75 years old) were less likely to undergo CC (OR=0.062). Trends for age and sex did not achieve significance for CAGB (OR=0.815 for older patient). Age is a strong predictor of receiving PTCA, with the oldest group of patients being discriminated (OR=0.093 for people older than 75 years), and the same trend was observed for THR (OR=0.264 for patients older than 75 years). For PPM, older patient has a higher likelihood of receiving this type of intervention (OR=3.45 for 65-74 years, and OR=7.77 for patients older than 75 years). As far as gender of patients is concerned, statistically significant differences for all cardiac procedures or interventions considered were not found. CONCLUSIONS: Clinical management of older patients with cardiac disease in Italy may be different from that of younger patients. One possible explanation would be that these patients are being discriminated against mainly because of their age.

Sociomedical indicators in the cholera epidemic in Ferrara of 1855.

The historical report on the cholera epidemic of 1855, conserved in Ferrara City's archives allowed us to verify the probable relation between the environment and epidemic in a broad sense, using log-linear analysis and multiple logistic regression. Two thousand and thirty-three cases were analyzed and the quantitative/qualitative variables available from the report were analyzed in relationship with mortality and morbidity rates, considered as response variables. From the analysis of the quantitative variables, it emerges that the variables having a significant influence on the morbidity/mortality rates are the number of individuals and the average number of inhabitants per house. From the analysis of the qualitative variables, it emerges that all the descriptive variables of the state of the streets and houses express a strong association with mortality and morbidity. With the present analysis, data available--a detailed 'street by street' morbidity and mortality recording from cholera in 1855 in Ferrara--were analyzed with modern means and the overall picture that emerge is that in the better kept houses in the better parts of the town had less cholera morbidity and especially mortality.

Tobacco-smoke exposure indicators and urinary mutagenicity.

In this study, the correlation of indicators of external (i.e. mean daily intake of condensate, nicotine, tobacco and tobacco proteins, and daily number of cigarettes smoked) and of internal tobacco-smoke exposure (i.e. urinary 1-pyrenol, nicotine and its metabolites and trans,trans-muconic acid) with urinary mutagenicity, detected on YG1024 Salmonella typhimurium strain with S9, were examined in 118 smokers. An increase in urinary mutagenicity was clearly significantly correlated with each external and internal indicators of exposure to tobacco smoke (correlation coefficient (r) ranging between 0.22 and 0.54, P<0.01), with a greater extent in the case of indicators of internal dose. In multiple regression analysis, among the indicators of external exposure, daily tobacco intake was the only variable significantly associated with urinary mutagenicity (t=2.47, P=0.015, with partial contribution to r(2)=5.15%). Instead, when all indicators of exposure (external and internal) were considered in the analysis, the influence of urinary 1-pyrenol on urinary mutagenicity was predominant, followed by those of urinary trans,trans-muconic acid and nicotine plus metabolites (t=4.63, 2.73 and 2.08, P<0.001, P=0.002 and 0.04, with partial contribution to r(2)=17.0, 6.66 and 3.96%, respectively), with no influence at all of external tobacco-smoke exposure indicators. In conclusion, our results show that indicators of internal dose are better correlated with formation of mutagens in urine of smokers. Among these, the best indicator was urinary 1-pyrenol and this result designates the combustion processes of tobacco as the determining step for the formation of urinary mutagens. However, as these biomarkers cannot be analysed the amount of daily tobacco intake represent the best valuable index of external (presumptive) exposure to tobacco-smoke genotoxins.

Exposure levels and cytochrome P450 1A2 activity, but not N-acetyltransferase, glutathione S-transferase (GST) M1 and T1, influence urinary mutagen excretion in smokers.

We investigated the polymorphic enzymes cytochrome P450 1A2 (CYP1A2), N-acetyltransferase (NAT2), glutathione S-transferase (GST) M1 (GSTM1), and T1 (GSTT1) in relation to cigarette smoking-associated urinary mutagenicity detected on YG1024 Salmonella typhimurium strain with S9 mix in 97 smokers. In each subject, cigarette smoke intake was checked by analysis of urinary nicotine plus its metabolites. NAT2 and CYP1A2 phenotypes were determined by the molar ratio of urinary caffeine metabolites detected by high-performance liquid chromatography, and GSTT1 and GSTM1 genotypes were determined by PCR. An increase in urinary mutagenicity was significantly related to levels of exposure to cigarette smoke and CYP1A2 N-hydroxylation activity (linear multiple regression analysis t = 4.51 and P < 0.001 and t = 3.09 and P = 0.003; F = 6.31, P < 0.001). Urinary mutagenicity was significantly higher in CYP1A2 extensive metabolizer smokers (n = 49) than in CYP1A2 poor metabolizer ones (n = 48; 2176 +/- 1525 versus 1384 +/- 1206 revertants/mmol creatinine, Mann-Whitney U-test, z = 2.65, P < 0.001). The highest mutagenic activity was seen in subjects CYP1A2 extensive metabolizer/NAT2 slow acetylators (n = 29) with respect to the other phenotype combinations (n = 68; 2392 +/- 1660 versus 1525 +/- 1238 revertants/mmol creatinine, Mann-Whitney U-test, z = 2.37, P = 0.017). NAT2 acetylation activity was slightly but inversely related to urinary mutagenicity, and the association was not significant. No effect of GSTM1 and GSTT1 genotypes in lowering (detoxifying) urinary mutagens was found. The significant enhancement of urinary mutagenicity associated with increased CYP1A2 activity, as already seen for diet-caused urinary mutagenicity, allows for many analogies between the process of mutagen formation derived from cooked meat and that from cigarette smoke condensate. In conclusion, the intensity of tobacco smoke exposure, modulated by CYP1A2 activity, is the major determinant of mutagenic urine among smokers, whereas GSTM1 and GSTT1 genotypes have no influence on this biomarker. This study suggests that CYP1A2 should definitely be determined in future studies involving urinary mutagenicity in cases in which smoking is a factor.