Adjuvanted influenza vaccine for the Italian elderly in the 2018/19 season: an updated health technology assessment.

BACKGROUND: The elderly, defined here as subjects aged ≥ 65 years, are among at-risk subjects for whom annual influenza vaccination is recommended. For the 2018/19 season, three vaccine types are available for the elderly in Italy: trivalent inactivated vaccine (TIV), adjuvanted TIV (aTIV) and quadrivalent inactivated vaccines (QIV). No health technology assessment (HTA) of seasonal influenza vaccination in the elderly has previously been conducted in Italy. METHODS: An HTA was conducted in 2017 to analyze the burden of influenza illness, the characteristics, efficacy, safety and cost-effectiveness of available vaccines and the related organizational and ethical implications. This was then contextualized to the 2018/19 influenza season. Comprehensive literature reviews/analyses were performed and a static mathematical model developed in order to address the above issues. RESULTS: In Italy, influenza is usually less common in the elderly than in other age-classes, but the burden of disease is the highest; >10% of infected elderly subjects develop complications, and about 90% of all influenza-related deaths occur in this age-class. All available vaccines are effective, safe and acceptable from an ethical standpoint. However, aTIV has proved more immunogenic and effective in the elderly. Furthermore, from the third payer's perspective, aTIV is highly cost-effective and cost-saving in comparison with TIV and QIV, respectively. Nevertheless, vaccination coverage needs to be improved. CONCLUSIONS: According to this HTA, aTIV appeared the vaccine of choice in the elderly. HTA should be reapplied whenever new relevant data become available.

[Vaccination among healthcare workers in Italy: a narrative review]. / La vaccinazione negli operatori sanitari in Italia: una revisione narrativa di letteratura.

Vaccination of healthcare workers (HCWs) is a public health tool of the utmost importance and the Italian National Vaccine Prevention Plan (PNPV) 2017-2019 recommends several vaccinations in this population group. Nevertheless, vaccine hesitancy is influencing HCWs' attitude towards vaccination. Moreover, a large number of measles cases have been reported in Italy among HCWs in 2017 and 2018. In Italy there is no national registry for vaccinations, so data on vaccine coverage among HCWs are not readily accessible. The aim of this literature review is to describe the most recent data about vaccination coverage among HCWs in Italy. We also report studies that evaluated the effectiveness of strategies to increase influenza vaccine uptake. We included all studies conducted in Italy and published between 2008 and 2018, regarding vaccines recommended by the PNPV 2017-2019 (hepatitis B, influenza, pertussis, measles, mumps, rubella, varicella, and tuberculosis). Our findings confirm that low vaccination coverage levels among HCWs exist in several Italian regions and cities, highlighting a relevant gap towards targets set by the PNPV. Studies that evaluated the effectiveness of multicomponent interventions to increase vaccination coverage found only minimal to moderate increases in uptake levels. It is therefore crucial to tackle vaccine hesitancy in HCWs, by identifying effective strategies able to significantly increase vaccine coverage, in order to decrease the risk of nosocomial infections, prevent transmission of preventable diseases to patients, and reduce indirect costs related to HCW absenteeism due to illness.

Multiparametric Evaluation Predicts Different Mid-Term Outcomes in Crohn's Disease.

AIM: To evaluate if a single and/or combined (clinical, endoscopic and radiological) assessment could predict clinical outcomes in Crohn's disease (CD). METHODS: We prospectively evaluated 57 CD cases who underwent both a colonoscopy and a CT-enterography (CTE). Harvey-Bradshaw Index (HBi), SES-CD (and/or Rutgeerts score) and the radiological disease activity were defined to stratify patients according to clinical, endoscopic and radiological disease activity respectively. Hospitalizations, surgery, therapeutic changes and deaths were evaluated up to 36 months (time 1) for 53 patients. RESULTS: CTE and endoscopy agreed in stratifying disease activity in 47% of cases (k = -0.05; p = 0.694), CTE and HBi in 35% (k = 0.09; p = 0.08), endoscopy and HBi in 39% (k = 0.13; p = 0.03). Taken together, CTE, endoscopy and HBi agreed only in 18% of cases (k = 0.01; p = 0.41). Among the 11 cases with mucosal healing, only 3 (27%) showed transmural healing. Patients with endoscopic activity needed significantly more changes of therapy compared to patients with endoscopic remission (p = 0.02). Patients with higher transmural or clinical activity at baseline required significantly more hospitalizations (p < 0.01). Hospitalization rate decreases with an increase in the number of parameters indicating remissions at baseline (p = 0.04). CONCLUSIONS: Clinical, endoscopic and radiological assessments offer complementary information and could predict different mid-term outcomes in CD.

Gut Microbiota in Health, Diverticular Disease, Irritable Bowel Syndrome, and Inflammatory Bowel Diseases: Time for Microbial Marker of Gastrointestinal Disorders.

Few data exist on differences in gut microbiota composition among principal gastrointestinal (GI) diseases. We evaluated the differences in gut microbiota composition among uncomplicated diverticular disease (DD), irritable bowel syndrome (IBS) and inflammatory bowel diseases (IBD) patients. DD, IBS, and IBD patients along with healthy controls (CT) were enrolled in our Italian GI outpatient clinic. Stool samples were collected. Microbiota composition was evaluated through a metagenomic gene-targeted approach. GI pathology represented a continuous spectrum of diseases where IBD displayed one extreme, while CT displayed the other. Among Phyla, Biplot PC2/PC3 and dendogram plot showed major differences in samples from IBS and IBD. DD resembled species CT composition, but not for Bacteroides fragilis. In IBS, Dialister spp. and then Faecalibacterium prausnitzii were the most representative species. Ulcerative colitis showed a reduced concentration of Clostridium difficile and an increase of Bacteroides fragilis. In Crohn's disease, Parabacteroides distasonis was the most represented, while Faecalibacterium prausnitzii and Bacteroides fragilis were significantly reduced. Each disorder has its definite overall microbial signature, which produces a clear differentiation from the others. On the other hand, shared alterations constitute the "core dysbiosis" of GI diseases. The assessment of these microbial markers represents a parameter that may complete the diagnostic assessment.

Detecting persons at risk for diabetes mellitus type 2 using FINDRISC: results from a community pharmacy-based study.

Background: This cross-sectional study has been developed within the framework of the Italian project 'We love your heart' ('Ci sta a cuore il tuo cuore') and reports the results of the initial type 2 diabetes mellitus (T2DM) risk assessment carried out in a big network of community pharmacies in Italy and Spain. Methods: In total 4002 pharmacists from 854pharmacies were specifically trained to collect data and perform the evaluation of the probability of developing T2DM among pharmacy customers. The risk of developing T2DM within 10 years was evaluated using the FINDRISC. Results: Overall, 7234 (22.1%) subjects were at low risk to develop the disease, whereas 43.3% were at slightly elevated risk (scores 7-11), 19.3% were at moderate (scores 12-14), 13.9% were at high (scores 15-20), and 1.4% were at very high risk (scores > 20). Spanish participants showed higher levels of risk than Italian (16.7 vs. 14.7%) taking the cut-off FINDRISC ≥ 15. Conclusion: This study shows that considerable percentage of persons is likely to develop diabetes in the next 10 years. Analyses of the risk factors indicate that men were more susceptible to develop this disease, as well as the Spanish participants respect to Italian.

Effectiveness of nutritional interventions addressed to elderly persons: umbrella systematic review with meta-analysis.

Background: The number of Europeans aged over 65 will double between 2010 and 2060, reaching 30% of the European population. Nutrition is emerging as a key element of healthy life since both obesity and malnutrition are established risk factors for morbidity and disability. The aim of this umbrella review (UR) is to summarize the findings of all current systematic reviews (SRs) and meta-analyzes (MAs) on the effectiveness of nutritional intervention designed to promote healthy aging in older individuals. Methods: Eligible articles published in English or Italian between January 2000 and May 2016 were identified in six databases. Only studies that analyzed nutritional interventions in the population of 65 years and over, or papers specifically targeting older adults were deemed eligible. Results: Twenty-eight papers, out of which twenty-five SRs and three MAs, met the inclusion criteria and were included in this umbrella SR. Supplementation with vitamin D and other kind of products was highly effective in preventing falls and fractures. Furthermore, several interventions, ranging from the prescription of supplements to environmental and organizational programs, resulted in an improvement in energy and protein intake, as well as positive weight outcomes. Positive findings were also found for the elderly at risk of malnutrition and for older patients with dementia. Conclusions: The findings of this UR indicate that the use of a wide range of supplements and environmental and organizational intervention improve a number of anthropometric, nutritional and functional indices in the elderly.

[Unhealthy dietary habits among toddlers in Rome (Italy): a cross sectional study]. / Abitudini alimentari non salutari tra i bambini in età prescolare a Roma (Italia): uno studio trasversale.

OBJECTIVE: To explore the nutrition and food habits of toddlers, in order to develop interventions to promote healthy eating starting from the early years of life. METHODS: We conducted a cross-sectional study among 204 children aged from 3 months to 3 years, registered in 10 nursery schools in Rome, Italy. Children's diet-related behaviors and parent's food attitudes were evaluated using a 10-item questionnaire for parents. After administering the questionnaire, pediatricians of the local health authority conducted motivational interviews with parents to encourage them to make their children adopt healthy behaviors at home. Descriptive and analytical statistical methods were used to evaluate dietary habits in children, after stratifying by nursery school grade attended. RESULTS: The data showed that unhealthy dietary habits occur even in nursery schoolaged children. In particular, over 50% of children were reported to watch TV while eating meals at home every day and to drink fruit juices at least 1-2 times per week. Unhealthy dietary habits were found to be more common among older children: there were significant differences in the proportions of older and younger children who consumed fruit juices or snacks more than twice per week (35.7% and 8.9% respectively of older children vs 3.3% and 3.3% respectively of younger children), who watched TV during meals (26.8% of older children versus 16.9% of younger children) and whose parents attribute a moral value to food as a reward more than twice a week (almost 14.3% of older children's parents vs 0.0% of small children's parents). On the contrary, older children were found to eat fruit significantly more frequently compared to younger children (51.8% vs 24.6% of young children ate fruit >2 times a week). Parents of children with at least one unhealthy behavior had low awareness of healthy dietary choices: 86.7% believed that their children's diets were healthy. CONCLUSION: This study showed that unhealthy dietary habits occur among Italian toddlers. These should be prevented by promoting specific interventions. Parents should be made aware of the possible consequences of their own behavior, considering that home food habits influence the development of dietary attitudes in children. Preventive interventions aimed at preschoolers may also be beneficial for parents themselves and for other family members.

Fostering Flu Vaccination in Healthcare Workers: Forum Theatre in a University Hospital.

The World Health Organization recommends flu vaccination as the most effective way to prevent the disease and its severe outcomes and has established the minimum vaccination coverage for people at risk at 75%. Even though healthcare workers (HCWs) represent a strongly recommended target group for flu vaccination campaigns, the average coverage among them is still inadequate. In flu season 2015/2016, our University Hospital tested Forum Theatre (FT) as a new participative strategy to foster HCWs engagement regarding flu vaccination. The aim of this study was to evaluate HCWs' satisfaction with and perceived utility of FT. In 2015, five FT sessions were organized in hospital units which were considered at risk for flu based on the type of admitted patients. After each session, participants were asked to complete an assessment questionnaire. The χ² test or the t-test was used to compare the proportion of participants who were satisfied with the FT and considered it useful (utility score). Data was analyzed according to gender, profession, and age. In all, 16.5% of HCWs who worked in four out of five of the units identified, participated in the FT sessions. Questionnaire results indicated that 74% of spectators were satisfied with their experience and 70% considered this methodology a useful approach for other health issues. Gender, age, and profession did not influence satisfaction or utility scores. Participative strategies such as FT represent an innovative solution to increasing HCWs' awareness of the importance of flu vaccination and could positively impact their adherence to vaccination recommendations. FT can also be a meaningful HCW teaching tool for learning about and changing attitudes toward other clinic and public health issues.

Influenza and pneumococcal vaccination in older adults living in nursing home: a survival analysis on the shelter study.

Background: Influenza and pneumococcal vaccines have been proved to be effective and safe in preventing and controlling infection among elderly, reducing morbidity and mortality. However, some evidences raised health concerns related to these vaccinations. This study aims to identify prevalence and outcomes related to influenza and pneumococcal vaccinations in a large European population of frail old people living in nursing homes (NHs). Methods: We conducted a survival analysis of NH residents participating to the Services and Health for Elderly in Long-TERm project, a prospective cohort study collecting information on residents admitted to 57 NH in eight countries (Czech Republic, England, Finland, France, Germany, Italy, The Netherlands and Israel). Clinical and demographical data were collected using the international resident assessement instrument for long-term care facilities. Incident mortality was recorded during 1-year follow-up. A shared-frailty Cox regression model was used to assess the impact of vaccination status on mortality. Results: Mean age of 3510 participants was 84.6 years (SD = 7.7). In total, 81.7 and 27.0% received influenza and pneumococcal vaccination, respectively. Overall, 727 (20.7%) residents died during the follow-up period. After adjusting for potential confounders, which included age, sex, number of diseases, depression, cognitive and functional status, influenza (HR = 0.80; 95% CI 0.66-0.97) and the combination of influenza and pneumococcal vaccination (HR = 0.72; 95% CI 0.57-0.91), but not pneumococcal vaccination alone (HR = 0.52; 95% CI 0.25-1.06), were associated with a statistically significant reduction in mortality in respect of no vaccinations. Conclusion: In a population of older adult living in NH influenza and the combination of influenza and pneumococcal vaccination were associated with a reduction in all-cause mortality respect to no vaccination.

Prevalence of alcohol abuse among workers in Italy. / La prevalenza dell'abuso di alcol tra I lavoratori in Italia.

BACKGROUND: Unhealthy alcohol consumption among workers increases the risk of job-related injuries and reduces productivity. Therefore, preventing workplace alcohol abuse is a public health priority. OBJECTIVES: This study is based upon data collected by PASSI and aims to outline the prevalence and socio-demographic characteristics of alcohol consumption among workers in Italy. METHODS: PASSI is a nationwide surveillance system that examines health-related behaviours and the degree of knowledge and adherence to the preventive interventions offered by the Italian National Health Service. Between 2010 and 2013, 101,002 telephone interviews were collected from a sample of residents aged 18-69, randomly selected from local health unit lists. RESULTS: 45.3% of those interviewed declared to be abstemious, while 16.5% reported an unhealthy alcohol drinking, with a higher prevalence among workers than non-workers (18.0% vs 14.2%, p minor of 0.001). Binge drinking was the most common kind of risky drinking (8.7%), followed by alcohol consumption before meals (7.3%) and heavy consumption (4.0%). Among workers, unhealthy alcohol consumption was significantly related (p minor of 0.001) to discontinuous work (OR 1.34), male gender (OR 2.34), younger age (18-34 vs 50-69 years old, OR 2.38) and serious economic problems (OR 1.26). It was also associated with Italian citizenship (OR 1.33) and residency in the northern (OR 2.17) and central (OR 1.29) regions. CONCLUSIONS: PASSI provides reliable and updated data to develop and assess interventions in workplace health promotion.

Workplace health promotion programs for older workers in Italy.

BACKGROUND: Italy is the European country with the highest number of citizens over the age of sixty. In recent years, the unsustainability of the social security system has forced the Italian government to raise the retirement age and reduce the chances of early exit, thus sharply increasing the age of the workforce. Consequently, a significant proportion of older workers are currently obliged to do jobs that were designed for young people. Systematic health promotion intervention for older workers is therefore essential. OBJECTIVES: The European Pro Health 65+ project aims at selecting and validating best practices for successful/active aging. In this context we set out to review workplace health promotion projects carried out in Italy. METHODS: To ascertain examples of workplace health promotion for older workers (WHPOW), we carried out a review of the scientific and grey literature together with a survey of companies. RESULTS: We detected 102 WHPOW research studies conducted in conjunction with supranational organizations, public institutions, companies, social partners, NGOs and educational institutions. The main objectives of the WHPOW were to improve the work environment, the qualifications of older workers and attitudes towards the elderly, and, in many cases, also to improve work organization. CONCLUSIONS: The best way to promote effective WHPOW interventions is by disseminating awareness of best practices and correct methods of analysis. Our study suggests ways of enhancing WHPOW at both a national and European level.

[The new National Immunization Program 2017-2019 and the Essential Care Levels: what is going to change?] / Il Nuovo Piano Nazionale Prevenzione Vaccinale 2017-2019 e i LEA: cosa cambia?

Italy is witnessing relevant challenges in the field of prevention and control of vaccine-preventable diseases. The worrying and growing phenomenon of "vaccine-hesitancy" has contributed to the reduction of vaccination coverage, undermining goals reached thanks to vaccines introduction. The new Italian National Immunization Plan (NIP) 2017-2019 and the update of the list of Essential Care Levels (LEA), approved in the current year, extend the vaccination offer based on the latest scientific evidence with the introduction of new vaccines and the enlargement of target population. The decree-law containing urgent measures in immunization field issued in June 2017 represents a tool to achieve the goals reported in global and national immunization plans. Among others it has increased mandatory vaccinations from 4 to 10 and has made them compulsory for pre-school admission. Following the global and European vaccination goals, the priorities identified by the Italian NIP are to: maintain the polio-free status; pursue the elimination of measles and congenital rubella; ensure an active and free of charge vaccination offer, the access to services and the availability of vaccines; target hard to reach populations with low vaccination coverage; develop an institutional communication plan on vaccinations. Regarding the vaccination offer, the main novelties introduced by the NIP 2017-2019 include the introduction of: vaccines against N. meningitidis B, rotavirus and varicella in newborns; tetravalent meningococcal vaccine (ACWY135) and a booster dose of anti-polio in adolescents; pneumococcal vaccines (PCV13 + PPV23) and anti-Zoster in subjects aged sixty-five. Furthermore, the NIP 2017-2019 establishes to extend HPV vaccination to male adolescents. The cost of new vaccinations, funded by the National Health System, is about 100 million euros in 2017 but, thanks to the new vaccination schedule, it is estimated that approximately 200 million euros will be saved because of the annual reduction of direct costs of vaccine-preventable diseases. Furthermore, the NIP tries to act against the growing public skepticism in vaccines, proposing solutions to counteract the fall in vaccination coverage by promoting a culture of vaccination and the empowerment of both health workers and general population. In this perspective, the NIP proposes to promote institutional communication campaigns, based on transparency, conveying information about vaccines risks and benefits and the ethical and social value of vaccinations. It is further proposed to strengthen the training of healthcare professionals, jointly with disciplinary actions against physicians who do not recommend vaccinations. Particular attention is also placed on the implementation of vaccines registries for the homogenization of data recording that allows to evaluate and to monitor vaccine policies. The update of LEA, which include a list of services provided by SSN, has adopted the innovations of the NIP and overcomes the criticism of regional inequalities in vaccination offer guaranteeing the same offer all over the Italian country. In conclusion, the NIP 2017-2019 and the new LEA are fully integrated into the current epidemiological and cultural scenario. They envisage a supply of evidence-based vaccinations, ensuring a free, equal and uniform vaccination offer on a national scale and striving for the promotion of a culture of vaccination.

[Audit as a tool to improve the efficiency of the immunization services: the experience of a Local Health Authority in Rome]. / L'audit come strumento per il miglioramento dell'efficienza dei centri vaccinali: l'esperienza di una ASL Romana.

INTRODUCTION: The Italian Ministry of Health has launched an alert about the reduction in vaccine coverage (VC), which decreased below 95% since 2014 for many paediatric vaccines, oppositely from the National Prevention Plan 2014-18 and the National Immunization Plan 2017-2019. Even though the growing vaccine hesitancy attracts the attention of the media in the last few years, the organization of an easily accessible and efficient supply network remains a crucial imperative for ensuring satisfactory and uniform vaccine coverage. Taking into consideration some critical issues identified within the vaccination centres of the Local Health Authority (ASL) RM/A, the local health management decided to improve the VC in deep collaboration with all the health professionals. The amelioration process includes the following actions: verifying the current situation, analysing the main concerns, evaluating the possible solution, and activating those already deemed feasible. This paper aims to describe in details the methodology used in the audit and to present the results and actions undertaken following this amelioration process. METHODS: In the ASL RM/A, which counts 550.000 inhabitants, all the 5 vaccination centres started from 2014 to carry out at least one 30-hour audit each year in order to improve VC. The audits are structured according to the four steps defined by the Ministry of Health to address systematically the critical points identified, by implementing the improvement actions proposed by the audit team to the health management. The audits, accredited under the ECM for the medical and nursing personnel, started in February 2014 and the last edition of the program was completed in December 2016. RESULTS: During 20 meetings the audit "Centri Vaccinali" involved 11 professionals from 5 vaccine centres, who acknowledged being highly satisfied with the audit, which has been recognized as a valuable tool for improving their work. Following the activities performed in the VC improvement programme, throughout the 3-years period an in-depth review of the most relevant procedures implemented daily by the involved experts was conducted. Moreover, the share of goals and deadlines among the various professionals has leaded to a positive and fruitful collaboration of all experts working in the vaccination centres. This was achieved without creating an additional burden deriving from the improvement process activities. The analysis conducted after two years from the start of the programme has shown not just a significant improvement in vaccine coverage, but also an important increase in the number of vaccine sessions and in the total number of administered vaccines. CONCLUSIONS: Throughout the described process of improvement, the collaboration among health care professionals was significantly improved and immunization strategies were identified and shared among the centres. The audit demonstrated to be an effective methodology for facilitating the accessibility and usage of vaccination centres by the citizen/user as well as by the healthcare providers. It showed a quick and significant improvement that, by promoting accountability and transparency, will ensure greater efficacy and safety of vaccine services.

[An effective clinical leadrship to strenghten the immunization policies in Italy]. / Una leadership medica efficace a tutela della prevenzione vaccinale in Italia.

Effective governance for health is a prerequisite for implementing a transformation in healthcare. Any change, in order to be fully implemented, requires a strong and transparent leadership. The recent drop in vaccine cover has led our National Health Service to implement a number of changes in health prevention and immunization strategies that make vaccination an optimal paradigm of how healthcare leadership should not remain the focus of few scientists and public health specialists, but it should be more and more widespread at all levels. In fact, as in other areas of health, the implementation of a national evidence-based planning through efficient organization and management is not sufficient to ensure good results, but it is necessary that the whole system - institutions, policy makers, healthcare professionals, media and citizens themselves - is actively involved in driving change, promoting ethical, economic and social value of vaccinations.

[A health promotion campaign to improve flu vaccination adherence among medical residents in an Italian Teaching Hospital]. / Una campagna di promozione della salute per migliorare l'adesione alla vaccinazione antinfluenzale nei medici in formazione specialistica in un ospedale universitario italiano.

INTRODUCTION: In Italy annual flu vaccination for health care workers is recommended but coverage is usually unsatisfying. The compliance is even worse among medical residents (MRs) both in literature, both in our experience: in the flu season 2014/ 15 only 0.6% of MRs enrolled at the Università Cattolica del Sacro Cuore (UCSC) were vaccinated. For this reason, during the influenza season 2015/16, the Institute of Public Health of the UCSC, in collaboration with the Health Management of the "Agostino Gemelli" Teaching Hospital (FPG) and with the directive board of the Medical Specialization Schools (SSM) present at the University has tested several strategies to improve awareness and adherence to flu vaccination campaign by its staff. This study aims to analyze the impact of the strategies used during the 2015/16 campaign on flu vaccination coverage among MRs of an important Italian Teaching Hospital. METHODS: The study was conducted among MRs enrolled at the UCSC - FPG in 2015/16. The data was collected by the Occupational Medicine which, during the influenza seasons, immunize MRs against influenza free of charge. For each variable - vaccination, area of specialization (surgical, medical, clinical services), typology of SSM - was measured the absolute and percentage frequency. In order to compare the flu vaccination coverage between seasons 2014/15 and 2015/16 and between areas of specialization in 2015/16 chi-square test was used (statistical significance level of 0.05). The data were analyzed using STATA Software. RESULTS: Were included in the analysis 42 SSM with a total of 1041 MRs. During the vaccination campaign 2015/16, flu vaccine was administered to 99 MRs (9.5%), 8.9% more than in the previous season (p<0.001). There is also a significant difference in vaccine coverage between surgical, medical and clinical services areas in 2015/16 (p <0.001). The highest vaccination coverage was recorded among MRs of Hematology and Urology (54.5%). However, no one MRs had undergone flu vaccination in about 40% of SSM. CONCLUSIONS: Seasonal flu vaccination among HCWs is important to protect patients as well as them self and their family members. Considering that MRs represent the next generation of HCWs, they should be sensitized about the importance of preventing the spread of influenza in hospital population, becoming an active part of the necessary cultural change. This study highlights a first and promising, although insufficient, increase in flu vaccination coverage among MRs enrolled at the UCSC - FPG after introducing simple strategies to promote vaccination itself and, more generally, positive and proactive behaviors. The study summarizes the results in the short term, but it is well known that cultural changes require time and constancy. Therefore, it will be useful to monitor the improvement over time and extend the assessment to all health care professionals.

Predictors of healthy ageing: public health policy targets.

BACKGROUND: The public health policy agenda oriented towards healthy ageing becomes the highest priority for the European countries. The article discusses the healthy ageing concept and its possible determinants with an aim to identify behavioral patterns related to healthy ageing in selected European countries. METHODS: The healthy ageing is assessed based on a composite indicator of self-assessed health, functional capabilities and life meaningfulness. The logistic regression models are used to assess the impact of the healthy lifestyle index, psycho-social index and socio-economic status on the probability of healthy ageing (i.e. being healthy at older age). The lifestyle and psychosocial indexes are created as a sum of behaviors that might be important for healthy ageing. Models are analyzed for three age groups of older people: 60-67, 68-79 and 80+ as well as for three groups of countries representing Western, Southern and Central-Eastern Europe. RESULTS: The lifestyle index covering vigorous and moderate physical activity, consumption of vegetables and fruits, regular consumption of meals and adequate consumption of liquids is positively related to healthy ageing, increasing the likelihood of being healthy at older age with each of the items specified in the index. The score of the index is found to be significantly higher (on average by 1 point for men and 1.1 for women) for individuals ageing healthily. The psychosocial index covering employment, outdoor social participation, indoor activities and life satisfaction is also found to be significantly related to health increasing the likelihood of healthy ageing with each point of the index score. There is an educational gradient in healthy ageing in the population below the age of 68 and in Southern and Central-Eastern European countries. In Western European countries, income is positively related to healthy ageing for females. CONCLUSIONS: Stimulation physical activity and adequate nutrition are crucial domains for a well-defined public health policy oriented towards healthy ageing. The psychosocial elements related to social participation, engagement, networking and life satisfaction are also found to be health beneficial.

Institutional analysis of health promotion for older people in Europe - concept and research tool.

BACKGROUND: European societies are ageing rapidly and thus health promotion for older people (HP4OP) is becoming an increasingly relevant issue. Crucial here is not only the clinical aspect of health promotion but also its organisational and institutional dimension. The latter has been relatively neglected in research on HP4OP. This issue is addressed in this study, constituting a part of the EU project ProHealth65+, engaging ten member countries. This paper is based on two intertwining research goals: (1) exploring which institutions/organisations are performing HP4OP activities in selected European countries (including sectors involved, performed roles of these institutions, organisation of those activities); (2) developing an institutional approach to HP4OP. Thus, the paper provides a description of the analytical tools for further research in this area. METHODS: The mentioned aims were addressed through the mutual use of two complementary methods: (a) a literature review of scientific and grey literature; and (b) questionnaire survey with selected expert respondents from 10 European countries. The expert respondents, selected by the project's collaborating partners, were asked to fill in a custom designed questionnaire concerning HP4OP institutional aspects. RESULTS: The literature review provided an overview of the organisational arrangements in different HP4OP initiatives. It also enabled the development of functional institutional definitions of health promotion, health promotion activities and interventions, as well as an institutional definition adequate to the health promotion context. The distinctions between sectors were also clarified. The elaborated questionnaires provided in-depth information on countries specifically indicating the key sectors involved in HP4OP in those selected countries. These are: health care, regional/local authorities, NGO's/voluntary institutions. The questionnaire and literature review both resulted in the indication of a significant level of cross-sectorial cooperation in HP4OP. CONCLUSIONS: The inclusion of the institutional analysis within the study of HP4OP provides a valuable opportunity to analyse, in a systematic way, good practices in this respect, also in terms of institutional arrangements. A failure to address this aspect in policymaking might potentially cause organisational failure even in evidence-based programmes. This paper frames the perception of this problem.

Workplace health promotion for older workers: a systematic literature review.

BACKGROUND: Aging of the workforce is a growing problem. As workers age, their physical, physiological and psychosocial capabilities change. Keeping older workers healthy and productive is a key goal of European labor policy and health promotion is a key to achieve this result. Previous studies about workplace health promotion (WHP) programs are usually focused on the entire workforce or to a specific topic. Within the framework of the EU-CHAFEA ProHealth65+ project, this paper aims to systematically review the literature on WHP interventions specifically targeted to older workers (OWs). METHODS: This systematic review was conducted by making a comprehensive search of MEDLINE, ISI Web of Science, SCOPUS, The Cochrane Library, CINAHL and PsychINFO databases. Search terms included ageing (and synonyms), worker (and synonyms), intervention (and synonyms), and health (and synonyms). The search was limited to papers in English or Italian published between January, 1(st) 2000 and May, 31(st) 2015. Relevant references in the selected articles were also analyzed. RESULTS: Of the 299 articles initially identified as relating to the topic, 18 articles met the inclusion criteria. The type, methods and outcome of interventions in the WHP programs retrieved were heterogenous, as was the definition of the age at which a worker is considered to be 'older'. Most of the available studies had been conducted on small samples for a limited period of time. CONCLUSION: Our review shows that, although this issue is of great importance, studies addressing WHP actions for OWs are few and generally of poor quality. Current evidence fails to show that WHP programs improve the work ability, productivity or job retention of older workers. In addition, there is limited evidence that WHP programs are effective in improving lifestyles and concur to maintain the health and well-being of older workers. There is a need for future WHP programs to be well-designed so that the effectiveness and cost-benefit of workplace interventions can be properly investigated.

Anticholinergic drugs and negative outcomes in the older population: from biological plausibility to clinical evidence.

The use of medication with anticholinergic properties is widespread among older subjects. Many drugs of common use such as antispasmodics, bronchodilators, antiarrhythmics, antihistamines, anti-hypertensive drugs, antiparkinson agents, skeletal muscle relaxants, and psychotropic drugs have been demonstrated to have an anticholinergic activity. The most frequent adverse effects are dry mouth, nausea, vomiting, constipation, abdominal pain, urinary retention, blurred vision, tachycardia and neurologic impairment such as confusion, agitation and coma. A growing evidence from experimental studies and clinical observations suggests that drugs with anticholinergic properties can cause physical and mental impairment in the elderly population. However, the morbidity and management issues associated with unwanted anticholinergic activity are underestimated and frequently overlooked. Moreover, their possible relation with specific negative outcome in the elderly population is still not firmly established. The aim of the present review was to evaluate the relationship between the use of drugs with anticholinergic activity and negative outcomes in older persons. We searched PubMed and Cochrane combining the search terms "anticholinergic", "delirium", "cognitive impairment", "falls", "mortality" and "discontinuation". Medicines with anticholinergic properties may increase the risks of functional and cognitive decline, morbidity, institutionalization and mortality in older people. However, such evidences are still not conclusive probably due to possible confounding factors. In particular, more studies are needed to investigate the effects of discontinuation of drug with anticholinergic properties. Overall, minimizing anticholinergic burden should always be encouraged in clinical practice to improve short-term memory, confusion and delirium, quality of life and daily functioning.

Does clinical governance influence the appropriateness of hospital stay?

BACKGROUND: Clinical Governance provides a framework for assessing and improving clinical quality through a single coherent program. Organizational appropriateness is aimed at achieving the best health outcomes and the most appropriate use of resources. The goal of the present study is to verify the likely relationship between Clinical Governance and appropriateness of hospital stay. METHODS: A cross-sectional study was conducted in 2012 in an Italian Teaching Hospital. The OPTIGOV(©) (Optimizing Health Care Governance) methodology was used to quantify the level of implementation of Clinical Governance globally and in its main dimensions. Organizational appropriateness was measured retrospectively using the Italian version of the Appropriateness Evaluation Protocol to analyze a random sample of medical records for each clinical unit. Pearson-correlation and multiple linear regression were used to test the relationship between the percentage of inappropriate days of hospital stay and the Clinical Governance implementation levels. RESULTS: 47 Units were assessed. The percentage of inappropriate days of hospital stay showed an inverse correlation with almost all the main Clinical Governance dimensions. Adjusted multiple regression analysis resulted in a significant association between the percentage of inappropriate days and the overall Clinical Governance score (ß = -0.28; p < 0.001; R-squared = 0.8). EBM and Clinical Audit represented the Clinical Governance dimensions which had the strongest association with organizational appropriateness. CONCLUSIONS: This study suggests that the evaluation of both Clinical Governance and organizational appropriateness through standardized and repeatable tools, such as OPTIGOV(©) and AEP, is a key strategy for healthcare quality. The relationship between the two underlines the central role of Clinical Governance, and especially of EBM and Clinical Audit, in determining a rational improvement of appropriateness levels.