Impact of antibiotic exposure on antibiotic-resistant Acinetobacter baumannii isolation in intensive care unit patients: a systematic review and meta-analysis.

BACKGROUND: Acinetobacter baumannii (AB) poses a significant threat to critically ill patients in intensive care units (ICUs). Although an association between antibiotic exposure and resistant AB is reported in the literature, a synthesis of evidence in ICU patients is still lacking. AIM: To summarize the evidence on the association between prior antibiotic exposure and the occurrence of resistant AB in ICU patients. METHODS: Online databases were searched for cohort and case-control studies providing data on the association of interest. Carbapenem/multidrug-resistant AB isolation was compared with non-isolation; carbapenem/multidrug-resistant AB was compared with carbapenem/antibiotic-susceptible AB; and extensively drug-resistant AB isolation was compared with non-isolation. Each comparison was subjected to a restricted maximum likelihood random-effects meta-analysis per antibiotic class, estimating pooled ORs. Stratified meta-analyses were performed by study design, outcome type and association-measure adjustment. FINDINGS: Overall, 25 high-quality studies were retrieved. Meta-analyses showed that carbapenem/multidrug-resistant AB isolation was associated with previous exposure to aminoglycosides, carbapenems, third-generation cephalosporines, glycylcyclines, and nitroimidazoles. Increased risk of isolation of carbapenem/multidrug-resistant AB isolation vs carbapenem/antibiotic-susceptible AB was shown for prior exposure to aminoglycosides, antipseudomonal penicillins, carbapenems, fluoroquinolones, glycopeptides, and penicillins. Third-generation cephalosporin exposure increased the risk of extensively drug-resistant AB isolation vs non-isolation. CONCLUSION: This systematic review clarifies the role of antibiotic use in antibiotic-resistant AB spread in ICUs, although for some antibiotic classes the evidence is still uncertain due to the small number of adjusted analyses, methodological and reporting issues, and limited number of studies. Future studies need to be carried out with standardized methods and appropriate reporting of multivariable models.

The Sapienza University of Rome network of automated external defibrillators: a prototype webMap developed to speed access to community defibrillators and increase survival from out-of-hospital cardiac arrest.

OBJECTIVE: In Italy, only around 10% of people who experience out-of-hospital cardiac arrest (OHCA) survive. A large portion of OHCA events in public settings are characterized by an initial shockable rhythm, which requires prompt defibrillation. We aimed to create a system to quickly locate nearby public access automated external defibrillators (AEDs) on the campus of Sapienza University of Rome, the largest public university in Europe. MATERIALS AND METHODS: We developed the AED webMap through a 6-step process involving the: 1) collection of information and geographical coordinates for each AED from the university management system; 2) development of a new geolocation database; 3) integration of information contained in the new database with data provided by university departments; 4) geolocation of AEDs in the Google MyMaps environment; 5) graphic representation of all AEDs on digital map templates using specific symbols, with pop-ups containing additional information for each AED; and 6) publication of the webMap on the university website. RESULTS: The AED webMap was published on the university website (https://www.uniroma1.it/it/pagina/defibrillatori-sapienza-in-rete) and facilitates prompt identification of nearby AEDs by providing: 1) detailed AED geolocalization with interactive pop-up information for each AED, including whether the AED is located internally or externally; 2) the option to use different base maps (e.g., digital street map); 3) calculation and display of the route to reach the chosen AED; and 4) the possibility to migrate towards multiple platforms. CONCLUSIONS: The webMap can help bystanders quickly identify, locate, and reach nearby AEDs present on the campus of the largest public university in Europe, a measure that could help speed defibrillation and maximize the life-saving potential of AEDs in the event of OHCA.

Knowledge, attitude, barriers, professional behaviour and possible interventions: a survey on healthcare-associated infections among the healthcare workers of an intensive care unit in a large teaching hospital in Rome.

Methods: A questionnaire of 36 questions was developed and administered to assess socio-occupational characteristics, knowledge of Healthcare-associated infections, attitudes and barriers encountered in compliance with hygiene standards, self-analysis of professional behaviour, and proposals for new interventions. Variables were evaluated by univariate analysis, and multivariable logistic regression models were constructed to identify predictors of adequate knowledge, positive attitude and appropriate professional behaviour. Background: Healthcare-associated infections are the main complications of hospitalization. A bottom-up approach, where the Healthcare workers involved play a key role, can be adopted to limit the Healthcare-associated infections burden. To this end, a survey was conducted in the main intensive care unit of Umberto I Teaching Hospital of Rome, where an active surveillance system has been in place since April 2016. Results: Overall, 79/89 Healthcare workers completed the questionnaire. Multivariate analysis showed that Healthcare workers, who participated in ward meetings to share active surveillance reports, were more likely to have adequate knowledge (aOR=4.21, 95% CI: 1.36-13.07). Only job type seemed to be a predictor of adequate behaviour, since nurses and physicians were more likely to show adequate behaviour than residents in training (aOR=0.21, 95% CI: 0.06-0.74). Direct observation of compliance with standard hygiene precautions and the identification of 'local champions' to manage Healthcare-associated infections' issues were the most requested interventions. Conclusions: Our study suggests that the training of healthcare professionals is a key factor in preventing and containing the spreading of Healthcare-associated infections. Moreover, by encouraging greater Healthcare workers' involvement, we conclude that a bottom-up approach is likely to improve Healthcare-associated infections' prevention and management.

The impact of the COVID-19 pandemic on healthcare-associated infections in intensive care unit patients: a retrospective cohort study.

BACKGROUND: During the intensive care units' (ICUs) reorganization that was forced by the COVID-19 emergency, attention to traditional infection control measures may have been reduced. Nevertheless, evidence on the effect of the COVID-19 pandemic on healthcare-associated infections (HAIs) is still limited and mixed. In this study, we estimated the pandemic impact on HAI incidence and investigated the HAI type occurring in COVID-19 patients. METHODS: Patients admitted to the main ICU of the Umberto I teaching hospital of Rome from March 1st and April 4th 2020 were compared with patients hospitalized in 2019. We assessed the association of risk factors and time-to-first event through multivariable Fine and Grey's regression models, that consider the competitive risk of death on the development of HAI (Model 1) or device related-HAI (dr-HAI, Model 2) and provide estimates of the sub-distribution hazard ratio (SHR) and its associated confidence interval (CI). A subgroup analysis was performed on the 2020 cohort. RESULTS: Data from 104 patients were retrieved. Overall, 59 HAIs were recorded, 32 of which occurred in the COVID-19 group. Patients admitted in 2020 were found to be positively associated with both HAI and dr-HAI onset (SHR: 2.66, 95% CI 1.31-5.38, and SHR: 10.0, 95% CI 1.84-54.41, respectively). Despite being not confirmed at the multivariable analysis, a greater proportion of dr-HAIs seemed to occur in COVID-19 patients, especially ventilator-associated pneumonia, and catheter-related urinary tract infections. CONCLUSIONS: We observed an increase in the incidence of patients with HAIs, especially dr-HAIs, mainly sustained by COVID-19 patients. A greater susceptibility of these patients to device-related infections was hypothesized, but further studies are needed.

What is the Prevalence of Low Health Literacy in European Union Member States? A Systematic Review and Meta-analysis.

BACKGROUND: Many studies have shown that low health literacy (HL) is associated with several adverse outcomes. In this study, we systematically reviewed the prevalence of low HL in Europe. METHODS: PubMed, Embase, and Scopus were searched. Cross-sectional studies conducted in the European Union (EU), published from 2000, investigating the prevalence of low HL in adults using a reliable tool, were included. Quality was assessed with the Newcastle-Ottawa Scale. Inverse-variance random effects methods were used to produce pooled prevalence estimates. A meta-regression analysis was performed to assess the association between low HL and the characteristics of the studies. RESULTS: The pooled prevalence of low HL ranged from of 27% (95% CI: 18-38%) to 48% (95% CI: 41-55%), depending on the literacy assessment method applied. Southern, Western, and Eastern EU countries had lower HL compared to northern Europe (ß: 0.87, 95% CI: 0.40-1.35; ß: 0.59, 95% CI: 0.25-0.93; and ß: 0.72, 95% CI: 0.06-1.37, respectively). The assessment method significantly influenced the pooled estimate: compared to word recognition items, using self-reported comprehensions items (ß: 0.61, 95% CI: 0.15-1.08), reading or numeracy comprehensions items (ß: 0.77, 95% CI: 0.24-1.31), or a mixed method (ß: 0.66, 95% CI: 0.01-1.33) found higher rates of low HL. Refugees had the lowest HL (ß: 1.59, 95% CI: 0.26-2.92). Finally, lower quality studies reported higher rates of low HL (ß: 0.56, 95% CI: 0.06-1.07). DISCUSSION: We found that low HL is a public health challenge throughout Europe, where one in every three to almost one in every two Europeans may not be able to understand essential health-related material. Additional research is needed to investigate the underlying causes and to develop remedies. PROSPERO REGISTRATION: CRD42019133377.

Multimodal surveillance of healthcare associated infections in an intensive care unit of a large teaching hospital

BACKGROUND: Healthcare-associated infections (HAIs), or nosocomial infections, represent a significant burden in terms of mortality, morbidity, length of stay and costs for patients hospitalized in intensive care units (ICUs). Surveillance systems are recommended by national and international institutions to gather data on HAIs in order to develop and evaluate interventions that reduce the risk of HAIs. STUDY DESIGN: Here we describe the methodology and the results of the surveillance system implemented in the ICU of the Policlinico Umberto I, a large teaching hospital in Rome, from April 2016 to October 2018. METHODS: The multimodal infection surveillance system integrates four different approaches: i) active surveillance of inpatients; ii) environmental microbiological surveillance; iii) surveillance of isolated microorganisms; and iv) behavioral surveillance of healthcare personnel. Data were collected on catheter-related bloodstream infections, ventilation-associated pneumonia, catheter-associated urinary tract infections and primary bloodstream infections that developed in patients after 48 h in the ICU. For environmental surveillance 14 points were selected for sampling (i.e. bed edges, medication carts, PC keyboards, sink faucets). The system of active surveillance of HAIs also included surveillance of microorganisms, consisting of the molecular genotyping of bacterial isolates by pulsed-field gel electrophoresis (PFGE). From 1 November 2016, monitoring of compliance with guidelines for hand hygiene (HH) and proper glove or gown use by healthcare personnel was included in the surveillance system. After the first six months (baseline phase), a multimodal intervention to improve adherence to guidelines by healthcare personnel was conducted with the ICU staff. RESULTS: Overall, 773 patients were included in the active surveillance. The overall incidence rate of device-related HAIs was 14.1 (95% CI: 12.2-16.3) per 1000 patient-days. The monthly device-related HAI incident rate showed a decreasing trend over time, with peaks of incidence becoming progressively lower. The most common bacterial isolates were Klebsiella pneumoniae (20.7%), Acinetobacter baumannii (17.2%), Pseudomonas aeruginosa (13.4%) and Staphylococcus aureus (5.4%). Acinetobacter baumannii and Klebsiella pneumoniae showed the highest proportion of isolates with a multidrug-resistant profile. A total of 819 environmental samples were collected, from which 305 bacterial isolates were retrieved. The most frequent bacterial isolates were Acinetobacter baumannii (27.2%), Staphylococcus aureus (12.1%), Enterococcus faecalis (11.1%), Klebsiella pneumoniae (5.2%) and Pseudomonas aeruginosa (4.7%). All Acinetobacter baumannii, Pseudomonas aeruginosa and Klebsiella pneumoniae environmental isolates were at least multidrug-resistant. Genotyping showed a limited number of major PFGE patterns for both clinical and environmental isolates of Klebsiella pneumoniae and Acinetobacter baumannii. Behavioral compliance rates significantly improved from baseline to post-intervention phase. CONCLUSIONS: By integrating information gathered from active surveillance, environmental microbiological surveillance, surveillance of bacterial isolates and behavioral surveillance of healthcare personnel, the multimodal infection surveillance system returned a precise and detailed view of the infectious risk and microbial ecology of the ICU.

Prevalence survey of healthcare-associated infections in a large teaching hospital.

BACKGROUND: Healthcare-associated infection (HAI) is the most frequent adverse event in healthcare settings. It is associated with increased mortality and antimicrobial resistance, leading to prolonged hospital stays and consistent financial loss for healthcare systems. The objective of this study was to estimate the burden of HAIs and antimicrobial use in the Teaching Hospital Policlinico Umberto I (THPUI) of Rome and to identify the most critical areas for intervention. METHODS: Data were collected according to the most recent ECDC point prevalence survey protocol in November 2018. Descriptive statistics for all variables were calculated. Univariate analysis was used to assess possible associations between variables and HAIs. Variables with a significance level of p<0.25 were included in a multiple logistic regression model. RESULTS: A total of 799 patients were included in the analysis; of these, 13.3% presented with at least one HAI. Bloodstream infection was the most common, accounting for 30.9% of total infections. Overall, 125 microorganisms were isolated, with Enterobacteriaceae being the most frequent (32%). At the time of the survey, 49.1% patients were receiving antimicrobial therapy. The multivariate analysis showed a significant association between HAI and use of medical devices (OR=34.30; 95% CI:3.69-318.66), length of stay (OR=1.01; 95% CI:1.00-1.02) and exposure to prophylactic antimicrobial therapy (OR=0.23; 95% CI:0.11-0.47). CONCLUSIONS: The ECDC methodology proved to be applicable to THPUI, where HAI prevalence was higher than the European standard (6.7%). This highlights the need to implement targeted measures to prevent and control HAIs, including continuous monitoring to evaluate the effectiveness of such interventions.

Cohort study of electronic cigarette use: safety and effectiveness after 4 years of follow-up.

OBJECTIVE: More than a decade after e-cigarette (e-cig) market launch, limited information are available on their safety after 24 months of use. In 2013, we started the first observational study assessing e-cig long-term effectiveness and safety, directly comparing tobacco smokers and e-cig users. Here we report the results after four years of follow-up. PATIENTS AND METHODS: Adults (30-75 years) were included if: smokers of ≥1 tobacco cigarette/day (tobacco smokers); users of any type of e-cig inhaling ≥50 puffs weekly (e-cig users); users of both tobacco and e-cig (dual users). Data were collected by phone and/or internet, and carbon monoxide levels tested in 50% of those declaring tobacco abstinence. Main outcomes were: possibly smoking-related diseases (PSRD; validated through hospital discharge data or visit in 62.6% of the sample); 4-year tobacco abstinence; number of tobacco cigarettes/day. RESULTS: Data were available for 228 e-cig users (all ex-smokers), 471 tobacco smokers, 216 dual users. A PSRD was observed in 73 subjects (8.0%). No differences emerged across groups in PSRD rates, with negligible variations in self-reported health. Of e-cig users, 63.6% remained tobacco abstinent; dual users and tobacco smokers showed non-significantly different rates of tobacco (33.8% vs. 26.8%) and all-product (20.2% vs. 19.4%) cessation, and a similar decrease in cigarettes/day. Almost 40% of the sample switched at least once (tobacco smokers: 17.2%; dual users: 81.9%). CONCLUSIONS: After four years, a scarce, non-significant harm reduction was observed among e-cig or dual users. Given the long-lasting health effects of tobacco smoking, the benefits of e-cig use may start being detectable at the next follow-up (six years). The complete switch to e-cig may help tobacco quitters remain abstinent, but e-cig use in addition to tobacco did not increase the likelihood of smoking cessation or reduction.

Disinvestment in healthcare: an overview of HTA agencies and organizations activities at European level.

BACKGROUND: In an era of a growing economic pressure for all health systems, the interest for "disinvestment" in healthcare increased. In this context, evidence based approaches such as Health Technology Assessment (HTA) are needed both to invest and to disinvest in health technologies. In order to investigate the extent of application of HTA in this field, methodological projects/frameworks, case studies, dissemination initiatives on disinvestment released by HTA agencies and organizations located in Europe were searched. METHODS: In July 2015, the websites of HTA agencies and organizations belonging to the European network for HTA (EUnetHTA) and the International Network of Agencies for HTA (INAHTA) were accessed and searched through the use of the term "disinvestment". Retrieved deliverables were considered eligible if they reported methodological projects/frameworks, case studies and dissemination initiatives focused on disinvestment in healthcare. RESULTS: 62 HTA agencies/organizations were accessed and eight methodological projects/frameworks, one case study and one dissemination initiative were found starting from 2007. With respect to methodological projects/frameworks, two were delivered in Austria, one in Italy, two in Spain and three in U.K. As for the case study and the dissemination initiative, both came from U.K. The majority of deliverables were aimed at making an overview of existing disinvestment approaches and at identifying challenges in their introduction. CONCLUSIONS: Today, in a healthcare context characterized by resource scarcity and increasing service demand, "disinvestment" from low-value services and reinvestment in high-value ones is a key strategy that may be supported by HTA. The lack of evaluation of technologies in use, in particular at the end of their lifecycle, may be due to the scant availability of frameworks and guidelines for identification and assessment of obsolete technologies that was shown by our work. Although several projects were carried out in different countries, most remain constrained to the field of research. Disinvestment is a relatively new concept in HTA that could pose challenges also from a methodological point of view. To tackle these challenges, it is necessary to construct experiences at international level with the aim to develop new methodological approaches to produce and grow evidence on disinvestment policies and practices.

The Cost-effectiveness of Genetic Screening for Familial Hypercholesterolemia: a Systematic Review.

BACKGROUND: Familial hypercholesterolemia (FH) is a genetic disorder that leads to elevated plasma LDL-cholesterol levels and premature coronary heart disease (CHD). An understanding of the mutations responsible for FH and the effectiveness of statins in lowering the risk of CHD in FH patients has increased interest in genetic screening strategies to improve FH diagnosis. In this study, we aimed to evaluate the cost-effectiveness of such strategies. METHODS: We performed a systematic review of full economic evaluations that assessed the cost-effectiveness of FH genetic screening strategies. We used relevant search terms to investigate Medline, Scopus, Web of Science, the Database of Abstracts of Reviews of Effects, the Health Technology Assessment Database, and the National Health Service Economic Evaluation Database. Data extraction and assessment of the quality of the studies were performed independently by two reviewers. The key features of the included studies are summarized in a narrative synthesis. RESULTS: We included seven economic evaluations that assessed the cost-effectiveness of genetic screening for FH, published mainly in Europe between 2002 and 2015. Most studies had a no-screening strategy as a comparator, focused on relatives of index cases with genetic or clinical diagnosis of FH (cascade screening), considered a lifetime horizon and adopted a health care payer viewpoint. Cascade screening, based on genetic testing of relatives of an index case with confirmed clinical or genetic diagnosis of FH, was shown to be cost-effective in most settings. CONCLUSIONS: Our review confirms the cost-effectiveness of cascade genetic screening for the diagnosis of FH. Further research may be needed to assess the cost-effectiveness of cascade screening following the introduction of newly recommended therapeutic regimes and next-generation sequencing.

The end of measles and congenital rubella: an achievable dream?

BACKGROUND: Despite substantial progress towards measles and rubella control, outbreaks continue to threaten elimination goals worldwide. STUDY DESIGN: This paper aims to document progress towards the global eradication of measles and rubella. In particular, it investigates the major challenges faced by Italy in reaching the elimination goals. METHODS: A review of the most important literature was carried out. Furthermore, a systematic review of the scientific literature on measles and rubella in the Italian setting was performed for the period 2000-2016. RESULTS: In the National Plan 2010-2015, Italy renewed its commitment to eliminate measles and rubella by 2015. However, Italy recently experienced a high measles burden (2,205 cases in 2013, 1,694 in 2014). Between June 2015 and May 2016, 515 cases were reported, accounting for 28% all cases in Europe. Immunization coverage decreased in recent years, with no Region reaching the 95% target. The systematic review included a total of 175 papers, with an upward trend in the number of published articles, which demonstrates an increasing interest in the field of measles and rubella. The review highlights the need to improve the commitment of the Italian Regions to the elimination goals; to promote Supplementary Immunization Activities (SIAs); to improve the communication skills of health care workers; to improve the health literacy of citizens; and to enhance integrated measles and rubella surveillance. CONCLUSION: Elimination of measles and rubella in Italy will require a substantial improvement in both commitment of the 21 Regions and activity of the whole country towards the WHO goals.

Current state of genomic policies in healthcare among EU member states: results of a survey of chief medical officers.

Background: A need for a governance of genomics in healthcare among European Union (EU) countries arose during an international meeting of experts on public health genomics (PHG). We have conducted a survey on existing national genomic policies in healthcare among Chief Medical Officers (CMOs) of the 28 EU member states, plus Norway. Methods: A questionnaire was sent to CMOs after a meeting on the policy implications of PHG held during the Italian presidency of the Council of EU in 2014. The survey was closed in November 2015. Results: CMOs response rate was 65.5% (19/29). Twelve (63.2%) reported that their countries had a policy for genomics in healthcare in place, and 15 (78.9%) reported that public funding existed. Public research facilities for the development of such policies were documented in 13 (68.4%) countries, and 15 (83.3%) had working groups devoted to policy development. National agencies carrying out Health Technology Assessment of genomic-based technologies were present in nine countries (50%). Sixteen (88.9%) countries reported having agencies dealing with ethical issues related to genomic technologies. About 55% of countries disclosed the lack of information campaigns aimed at citizens, and 44.4% reported they had a legal framework for direct-to-consumer genetic tests. Conclusion: Belgium, France, Italy, Spain and UK documented the presence of a policy on genomics in healthcare. While many caveats are necessary because of the methodology, results suggest a need for a co-ordinated effort to foster development and harmonization of dedicated policies across EU to responsibly integrate genomics policies into existing health systems.

[Risk of nasopharyngeal cancer, Leukemia and other tumors in a cohort of employees and students potentially exposed to (FA) formaldehyde in University laboratories].

FA was recently classified as carcinogen of second class (category 1B). A retrospective cohort study was conducted for the evaluation of the association between exposure to FA and cancer in professionally potentially exposed in a University setting. The cohort was composed of 140 exposed to FA and 364 not exposed in the period 1999-2015. The results showed no cancers of naso-pharynx and leukemias or lymphomas both among exposed and not exposed. Moreover, the exposure to FA is not significantly associated to an increase of other types of tumors.

The need to improve implementation and use of lifestyle surveillance systems for planning prevention activities: an analysis of the Italian Regions.

OBJECTIVES: To describe the level of use of lifestyle surveillance systems in Italy and to identify predictors of their use by the Italian Regions for planning and monitoring purposes. STUDY DESIGN: Data were extracted from the 19 Regional Prevention Plans (RPPs) and the health promotion and prevention projects included in them developed by the Italian Regions within the National Prevention Plan 2010-2013. METHODS: The 19 RPPs and the 702 projects were appraised using a tool specifically developed for the purpose. Multiple logistic regression was performed to identify predictors of use of surveillance systems in the 359 projects that could use them. RESULTS: The analysis of regional epidemiological contexts does not always rely upon surveillance system data and there were too few projects aimed at the maintenance and the development of these systems. Moreover, fewer than half of projects that could have used surveillance systems for planning and evaluation procedures actually did so, despite the potential value of these data. There was a statistically significant association between Regional Health Care Expenditure (RHCE) and the use of surveillance system data for planning and/or evaluation of the projects (OR 7.81, 95% CI 2.86-21.29). CONCLUSIONS: Use of surveillance systems for regional prevention planning in Italy is not optimal due to late implementation, presence of different data collecting systems and RGDP inequalities. There is a pressing need for full implementation of surveillance systems to allow better definition of the priorities and objectives of public health interventions.

Twelve-month treatment with Liraglutide ameliorates Visceral Adiposity Index and common cardiovascular risk factors in type 2 diabetes outpatients.

AIM: In addition to the effects on glycemic control and body weight, GLP-1 receptor agonists may favorably affect other major cardiovascular disease (CVD) risk factors, although currently available data are still sparse. In this retrospective study, we evaluated the effects of 12-month treatment with liraglutide on major CVD risk factors in 115 type 2 diabetes outpatients (60 men and 55 women), on stable hypoglycemic, anti-hypertensive and/or lipid-lowering therapy. METHODS: Clinical and anthropometric data, metabolic and lipid profile, as well as the Visceral Adiposity Index (VAI), an obesity-related CVD risk factor, were measured in all participants at baseline and after 12-month treatment. RESULTS: Treatment with liraglutide was associated with a significant reduction from baseline values of fasting blood glucose (-42.1 mg/dl, P < 0.05), HbA1c (-1.5 %, -17 mmol/mol, P < 0.05), body weight (-7.1 kg, P < 0.05), waist circumference (-6.8 cm, P < 0.001), total-cholesterol (-27.4 mg/dl, P < 0.05), LDL-cholesterol (-25.4 mg/dl, P < 0.05), triglycerides (-56.1 mg/dl, P < 0.05), and non-HDL-C (-36.6 mg/dl, P < 0.05) and an increase of HDL-cholesterol concentrations (+9.3 mg/dl, P < 0.001), a significant reduction in both systolic and diastolic blood pressure (-14.7 mmHg, P < 0.001 and -9.0 mmHg, P < 0.05, respectively) and a decrease of VAI values (-1.6, P < 0.001). All these differences were independent of changes in BMI and comparable in men and women. CONCLUSIONS: In conclusion, 12-month treatment with liraglutide in add-on to on-going hypoglycemic therapy significantly ameliorates all major CVD risk factors and reduces cardiometabolic risk, as estimated by VAI values.

Influence of high-normal serum TSH levels on major cardiovascular risk factors and Visceral Adiposity Index in euthyroid type 2 diabetic subjects.

Although several observations indicate that serum TSH levels in the high normal range are related to cardiovascular (CVD) risk factors in the general population, similar data are limited in diabetic subjects. The aim of this study was to investigate the potential associations between TSH serum levels within the normal range and major metabolic and non-metabolic CVD risk factors in a cohort of euthyroid type 2 diabetic subjects. Thyroid hormones, TSH levels, anthropometric parameters, lipid profile, glucose control, and blood pressure were measured in 490 euthyroid type 2 diabetic subjects, consecutively attending two outpatient diabetic units in Southern Italy. In all subjects, we also calculated the Visceral Adiposity Index (VAI), an obesity-related index associated with CVD risk. Diabetic women showed higher mean serum TSH levels and lower FT4 concentration than diabetic men, while FT3 levels were comparable in the two genders. Stratifying the study population according to quartiles of TSH levels, subjects in the highest TSH quartile were more likely to be female and younger, with higher values of BMI and waist circumference (P = 0.05 both), higher triglycerides (P = 0.002) and non-HDL cholesterol concentrations (P = 0.01), higher VAI values (P = 0.02), and lower FT4 levels (P = 0.05), when compared to those in the lowest quartile. At multivariate analysis, a younger age, female gender, triglycerides levels, and waist circumference were independently associated with higher TSH levels. In conclusion, in type 2 diabetic subjects with no evidence of thyroid disease, higher TSH concentrations within the normal range were more frequent in women and in younger subjects, and they were associated with visceral obesity and higher triglycerides concentrations, two well-known CVD risk factors.

Predictive genetic testing for complex diseases: a public health perspective.

From a public health perspective, systematic, evidence-based technology assessments and economic evaluations are needed to guide the incorporation of genomics into clinical and public health practice. However, scientific evidence on the effectiveness of predictive genetic tests is difficult to obtain. This review first highlights the similarities and differences between traditional screening tests and predictive genetic testing for complex diseases and goes on to describe frameworks for the evaluation of genetic testing that have been developed in recent years providing some evidence that currently genetic tests are not used in an appropriate way. Nevertheless, evidence-based recommendations are already available for some genomic applications that can reduce morbidity and mortality and many more are expected to emerge over the next decade. The time is now ripe for the introduction of a range of genetic tests into healthcare practice, but this will require the development of specific health policies, proper public health evaluations, organizational changes within the healthcare systems, capacity building among the healthcare workforce and the education of the public.

Influenza vaccination recommended for all adults aged between 50 and 64 years: conceptual basis and methodological limitations.

In the first half of this year the experts of the Italian Society of Hygiene (SItI), along with those of other National Scientific Societies, agreed with the recommendations made by the USA CDC in 2009, and developed a proposal for a vaccination schedule (Vaccine Schedule for Life), in which influenza vaccination is recommended for all adults aged between 50 and 64 years. In the National Plan for Vaccinal Prevention 2012-2014, which was published just before the issue of the SItI Calendar but concluded earlier (end of 2011), influenza vaccination is recommended "only" for all persons > or = 65 years or included in one of the many at-risk categories. The issue is controversial and has generated considerable debate at national and international level. This short note discusses the logical processes and the scientific evidence in support or against the decision to extend the influenza vaccination. The Authors conclude that the epidemiological approach used by SItI experts is appropriate. In any case, further studies on the topic are strongly needed, and their results should be taken into account in the drafting of future vaccination schedules.

[Implementation of the stewardship model in public health: proposal of an assessment tool for the Italian national prevention plan]. / Implementazione della stewardship in sanità pubblica: proposta di una metodologia valutativa applicabile al piano nazionale della prevenzione.

The stewardship model has been adopted as a system of governance in several countries. In Italy, the Ministry of Health has proposed the use of the stewardship model for implementing the activities of the National Prevention Plan 2010-2012. The authors present the conceptual foundations and methodology used in the development of an assessment tool (audit tool) for evaluating the level of implementation of the stewardship model with regards to the activities of the national prevention plan in all Italian regions.

Influenza vaccine effectiveness for the elderly: a cohort study involving general practitioners from Abruzzo, Italy.

INTRODUCTION: In all Italian regions influenza vaccine is routinely administered to the elderly population. However, vaccination impact has been rarely evaluated because of the high costs of conventional cohort investigations. A promising low-cost alternative approach uses administrative discharge data to derive vaccine effectiveness indicators (hospitalizations and/or deaths) and involves General Practitioners (GPs) to document the exposure. We conducted a cohort analysis using such approach to assess influenza vaccine effectiveness and to investigate the feasibility and validity of that methodology for routine vaccine evaluation. METHODS: During October 2006, all GPs from two Local Health Units (LHUs) were requested to indicate immunization status of all their patients in a specific form containing patient's demographic records. Immunization status information were also collected from Prevention Departments. Main outcomes were hospitalizations for influenza and/or pneumonia. Analyses were based upon random-effect logistic regression. RESULTS: Of a total of 414 GPs assisting 103,162 elderly, 116 GPs (28%) provided data on 32,457 individuals (31.5%). The sample was representative and had an overall 66.2% vaccina-tion rate. During the first semester 2007, the hospitalization rate was low in the sample, with only 7 elderly patients admitted for influenza and 135 for pneumonia. At either bivariate or multivariate analysis, vaccination did not significantly reduce the risk of in-hospital death, influenza or pneumonia admission. DISCUSSION: The study had minimal costs, recruited a large and representative sample size, and had no evidence of a substantial selection bias. Administrative and GP's data may be successively pooled to provide routine assessment of vaccination effectiveness.