Study of the excess mortality associated with the SARS-CoV-2 pandemic in the Local Health Authorities and Districts of the Autonomous Region of Sardinia - quinquennium 2017-2021

Background

Based on the indications of the Italian National Recovery and Resilience Plan and the Ministerial Decree n°77/2022, detecting specific populations' social-welfare needs is essential to reorganize the national and regional health service. The present analysis studies the impact of pandemic and pre-pandemic conditions in terms of mortality on Sardinian health service organizational subunits to indirectly investigate the need for specific social and health interventions.

Design

Retrospective observational mortality study on the Sardinian resident population, surveyed by the Italian National Institute of Statistics (Istat) from 2017 to 2021.

Methods

The database was built by crossing demographic data from the Istat divided into 21 five-year age groups (0-4 to 100+). Mortality and excess mortality were calculated with a focus on local health authorities and districts. The analysis were made considering three age groups (0-64, ≥ 65, 0-100+) and comparing the individual years 2020 and 2021 with the pre-pandemic triennium 2017-2019. To better understand the phenomenon of excess mortality, the old age index was calculated for the Local Health Authority and District for each year of the quinquennium considered.

Results

Standardized mortality ratios increased in the biennium of the SARS-CoV-2 pandemic compared to the baseline 2017-2019. A global increaseof the Standardized mortality ratios in all districts (2021) was measured, including those with Standardized mortality ratios already increasing in 2020. Notably, the Standardized mortality ratios (2020 and 2021) were often increased by the 0-64 age group. The regional excess mortality (0-100+) confirmed an increase in mortality compared to the baseline, with a slight decrease from 2020 to 2021.

Conclusions

Sardinia presents peculiar demographic and geographical characteristics. Monitoring mortality rates and excess mortality confirms to be crucial to constantly re-modulating health interventions and planning of the supply of services, including the equitable allocation of resources based on actual health needs. Sardinia should embrace the concept of "age-friendly community" and create communities designed to promote active aging and social participation.

Does the Response to a Stressful Condition in Older Adults with Life Rhythm Dysregulations Provide Evidence of the Existence of the "Dysregulation of Mood, Energy, and Social Rhythms Syndrome"?

OBJECTIVE

The COVID-19 lockdown periods have given rise to the "Dysregulation of Mood, Energy, and Social Rhythms Syndrome" (DYMERS). This syndrome is characterized by a poor regulation of biological, social, and behavioral rhythms, including sleep, nutrition, and social contacts. The purpose of this cohort study was to examine whether older adults with pre-existing DYMERS had a more negative perception of their health-related quality of life (H-QoL) during the COVID-19 pandemic lockdown, regardless of the presence of concurrent mood disorders.

METHOD

The entire study population (N = 93; age > 65 year) was categorized based on whether they exhibited dysregulated rhythms at the outset of the study. A comparison was made between DYMERS-positive individuals and DYMERS-negative individuals, and we assessed their H-QoL at the conclusion of the study. We also compared the H-QoL of individuals in the cohort who did not have a positive depression score to understand the impact of the rhythm dysregulation alone.

RESULTS

The frequency of individuals with a critical health-related quality of life score (SF12 < 25) was higher in the cohort with pre-existing DYMERS during lockdown (33.33% vs. 6.17%). This difference remained significant even when only individuals without depressive symptomatology were considered (27.27% vs. 2.60%).

CONCLUSION

The results of this study indicate that DYMERS can exert a substantial influence on health-related quality of life (H-QoL), even when mood disturbances are not present. Additional research is required to investigate the relationship between DYMERS and other psychiatric conditions as well as its nature as a standalone disorder.

The impact of MDQ positivity on quality of life impairment: Does it support the hypothesis of "Dysregulation of Mood, Energy, and Social Rhythms Syndrome" (DYMERS)?

Background

DSM-5 separates bipolar (BD) from depressive disorders, but some experts consider BD as part of a spectrum of mood disorders. The interpretation of numerous false positives of BD screened by the Mood Disorders Questionnaire (MDQ) is part of this debate. Recent study results suggest that the worsening of health-related quality of life (H-Qol) associated with MDQ positivity does not depend solely on mood disorders. This study aims to clarify whether the impairment may be due to other concomitant disorders, unrelated to mood disorders, leading to a worsening of H-Qol. Additionally, the study aims to explore if MDQ positivity itself observe clinical significance.

Design and methods

The study involved pairs of cases (MDQ+) and controls (MDQ-) matched for sex, age, and absence of DSM-IV psychiatric comorbidity. The impact of MDQ positivity on the quality of life in a sample of MDQ+ comorbid with MDD was measured and compared to impact of MDD in other chronic disorders.

Results

The H-Qol was significantly worse in MDQ+ than in controls (both groups without any psychiatric co-morbidity). The worsening was similar to severe chronic disorders The burden of worsening quality of life due to MDD was mild in another sample of MDQ positives with comorbid MDD.

Conclusion

The study hypothesizes that MDQ positivity may be related to hyperactivation and dysregulation of rhythms typical of stress disorders. In fact, MDQ+ was found strongly related to sleep disturbances. Future studies could verify if a "Dysregulation of Mood, Energy, and Social Rhythms Syndrome" (DYMERS), causes worsening the H-Qol in MDQ+.

Recurrent nasal basal cell carcinoma treated with standard surgery excision: evaluation of volume ratio

BACKGROUND

Basal cell carcinoma (BCC) is the most common malignant skin tumor. Although it rarely evolves into a metastatic disease, BCC can lead to a significant morbidity due to local invasion. The risk of lesion recurrence depends on clinical and histopathological factors as described by the Nation Comprehensive Cancer Network (NCCN). The surgical excision margins have a well-known role: there is a close relationship between high recurrence rate of BCC and the tumor proximity to the surgical margins. Aim of our study was to assess whether there is a significative correlation between recurring BCC and volume ratio (VRb/t), defined as ratio between excisional biopsy volume and tumor volume, and if VRb/t is a useful parameter to assess the risk of recurrence of BCC.

METHODS

Retrospective case-control study in 80 patients with history of recurrent basal cell carcinoma of the nose (cases), and 43 patients with history of basal cell carcinoma of the nose with no evidence of relapse (controls) in the following 8 years.

RESULTS

Surgical excision margins, histological subtype, ulceration, depth of invasion and volume ratio (VRb/t) were evaluated in case and controls. The evaluation of VRb/t evidenced a significant difference between recurrent BCC and non-recurrent BCC. The mean values of VRb/t were 6.17 for cases and 11.94 for controls. The Binomial Logistic Regression has displayed, for values of VRb/t around 7, a probability of 75% to identify BCCs belonging to the recurrent group.

CONCLUSIONS

Our data show a significant correlation between recurrent BCCs and VRb/t. VRb/t can help in the assessment of recurrence risk, used together with others prognostic factor. For values of VRb/t close to 7 it should be recommended a close follow-up to promptly identify a possible recurrence.

Effect of a Low-Moderate Exercise Program on Dysmetabolism in Older Adults: Results of a Randomized Controlled Trial

Physical exercise has been shown to improve dysmetabolism in older adults, reducing cardiovascular risk, while its role in preventing dysmetabolism is less known. Moreover, most of the trials use exercise programs that are difficult to put into daily practice. The purpose of this Randomized Controlled Trial (RCT) was to evaluate the effectiveness of a 3-month moderate exercise program in improving or preventing dysmetabolism in 120 older adults, randomly selected for the exercise program (experimental group) or cultural activities (control group). None of the subjects were following a hypocaloric diet, and all of them reported healthy eating habits. Anthropometric (Body Mass Index (BMI) and Waist Circumference (WC)) and metabolic variables (fasting plasma glucose (FPG), High-Density Lipoprotein Cholesterol (HDL-C), and triglycerides (TG)) were assessed at baseline (T0) and at the end of the trial (T1). Dysmetabolism was defined by the presence of an increased WC plus at least two metabolic alterations. At T0, the two groups did not differ by sex, age, education, BMI, WC, FPG, HDL-C levels, and prevalence of dysmetabolism. The mean BMI value indicated overweight, and WC values were higher than the cut-off. At T1, a slight reduction in the number of people with dysmetabolism was found only in the experimental group. However, none of the individuals without dysmetabolism at T0 in the experimental group developed it at T1, while 11.4% developed it in the control group (p = 0.032). This study highlights that a moderate exercise program, accessible in daily practice, can prevent dysmetabolism in older adults, even while being overweight, while if dysmetabolism is already present, more prolonged combined nutritional and exercise interventions will be needed.

The perception of professionals and users of the quality of care and respect for human rights in four outpatient care facilities of an Italian hospital during the Covid-19 pandemic

Background:

During the Covid-19 pandemic, delays in providing medical services, dissatisfaction, criticism toward health workers (HW) and the risk of burnout of HW in Italy have been documented. No studies have contrasted the point of view of HW and users on the quality of care and respect for human rights in health facilities.

Objective:

To compare the perception of users of their satisfaction with the care provided with the perception of HW of their satisfaction with work as well as the perception of the respect of HW “s and users” human rights.

Methods:

The “Well-Being at work and respect for human rights questionnaire” (WWRR) was administered on a sample of users (142) and HW (154) in four outpatient health care facilities of a hospital in Sardinia, Italy.

Results:

Users showed higher scores than HW on their satisfaction with the care received (p < 0.0001), the perception of respect for their human rights (p < 0.0001), and availability of resources for care (p < 0.0001). The HW scores were higher than 50% of the maximum in all items, but a relatively low score was reported on the HW’s satisfaction of the resources and the respect for their rights.

Conclusion:

The satisfaction for care and respect for human rights in the outpatient health services was higher than expected. The relatively low score by the HWs in relation to the satisfaction with the resources and perception of respect for their human rights could be a wake-up call. The study does not involve emergency rooms, wards, or Covid units.

Differences in lethality and diffusion of Covid-19 in countries using different kinds of vaccines

To verify if lethality and diffusivity of Covid-19 correlated with percentage of people vaccinated in different countries and whether results on these indicators were comparable under different types of vaccines. A linear regression analysis was conducted between vaccines/inhabitant, new cases/inhabitants and ratio deaths/cases. A comparison between the three indicators was carried out in countries subdivided by kind of vaccine. The proportion of vaccinations/inhabitants correlates negatively with proportion of deaths × 100 cases (R = −3.90, p < 0.0001), but didn’t on incidence of new cases. Countries with prevalence of mRNA vaccines were similar to others on incidence of new cases; but a lower lethality of Sars-Cov2 was found than in countries with prevalence of viral vehicle vaccines (F = 6.064, p = 0.0174) but didn’t against countries with prevalence of inactivated vaccines. The higher is the proportion of vaccine/inhabitant in a given country, the less is the fraction of infected people who die.

Covid-19 vaccines work but other factors play a relevant role: a data analysis on spread and mortality in 24 countries

BACKGROUND

The aim was to outline a methodology to monitor the impact of vaccinations in different countries comparing at two different times within countries and between countries the frequency of new cases and Covid-19 related deaths and the percentage of vaccinations conducted.

DESIGN AND METHODS

The 25 countries with the largest increase in SARS-CoV-2 cases on 8 August 2021 were evaluated. In each nation was calculated the proportion of Covid-19 deaths divided per new cases x 100 and the proportion of new cases per 1.000 inhabitants on 10 January 2021 (before vaccinations' distribution) and 8 August 2021 (when large percentage of the population had been vaccinated in many countries).

RESULTS

The study shows that in the countries with the highest number of cases as of 8 August 2021, the proportion of vaccinations carried out in the population correlates negatively with both the proportion between Covid-19 dead people x100 infected people and with the rate of new cases. However, the proportion of vaccinations does not correlate with the differences in the two same indicators considered in the weeks observed, thus additional factors seem to play an important role.

CONCLUSIONS

This work indicates that mass vaccination is associated with a lower spread of the pandemic and, to greater extent, with a lowering of mortality in infected people.

Previous functional social and behavioral rhythms affect resilience to COVID-19-related stress among old adults

BACKGROUND

Functioning of Social Behavioral Rhythms (SBRs) may affect resilience toward stressful events across different age groups. However, the impact of SBRs on the coronavirus disease of 2019 (COVID-19) in elder people is yet to ascertain, representing the aim of the present report.

DESIGN AND METHODS

Follow-up of a peer-reviewed randomized controlled trial on exercise on old adults (³65 years), concurrent to the onset of the pandemic-related lockdown. Post-RCT evaluations occurred after further 12 and 36 weeks since the beginning of the lockdown phase. People with Major Depressive Episode (MDE) at week-48 (follow-up endpoint) were deemed as cases, people without such condition were considered controls. MDE was ascertained using the Patient Health Questionnaire-9 (PHQ-9); SBRs functioning at week 12 onward, through the Brief Symptom Rating Scale (BSRS).

RESULTS

Seventy-nine individuals (53.2%, females) entered the RCT-follow-up phase. The frequency of MDE did not significantly change before versus during lockdown (OR 2.60, CI95%=0.87-9.13). People with BSRS>1 standard deviation of the whole sample score at week-12 had an inflated risk of DE during lockdown (OR=5.6, 95%CI: 1.5-21.4) compared to those with lower BSRS scores. Such odd hold after excluding individuals with MDD at week-12. The post-hoc analysis could be potentially affected by selection bias.

CONCLUSIONS

Overall, older adults were resilient during the first phase of the pandemic when functioning of pre-lockdown was still preserved, in contrast to the subsequent evaluations when the impairment of daily rhythms was associated with impaired reliance.

Exercise in Older Adults to Prevent Depressive Symptoms at the Time of Covid-19: Results of a Randomized Controlled Trial with Follow-Up

Background

This study aimed to verify, through a randomized controlled trial, whether a medium-intensity mixing/aerobic/anaerobic exercise (accessible to older adults even with mild chronic diseases) can effectively counteract depressive episodes. A characteristic of the trial was that the follow-up coincided (unscheduled) with the lockdown due to Covid-19.

Methods

Participants (N=120) were randomized into an intervention group, performing physical exercise, and a control group. Participants, aged 65 years and older, belonged to both genders, living at home, and cleared a medical examination, were evaluated with a screening tool to detect depressive episodes, the PHQ9, at pre-treatment, end of the trial (12-week), and follow-up (48-week).

Results

A decrease in the frequency of depressive episodes after the trial (T1) was found in both groups; however, a statistically significant difference was observed only in the control group (p=0.0039). From T1 to follow-up (conducted during the lockdown), the frequency of depressive episodes increased in the control group, reaching a frequency equal to the time of study entry (p=0.788). In the experimental group, the frequency of depressive episodes did not change at the end of the trial but reached a statistically significant difference compared to the start of the study (p = 0.004) and was higher than the control group (p=0.028).

Conclusion

Moderate-intensity physical exercise can be conducted safely, benefitting older adults even suffering from mild chronic disorders. Physical exercise seems to guarantee a long-term preventive effect towards depressive symptoms, especially in serious stressful situations such as the lockdown due to the Covid-19 pandemic.

Clinical Trial Registration Number NCT03858114

Moderate Exercise Improves Cognitive Function in Healthy Elderly People: Results of a Randomized Controlled Trial

Background

Physical activity in the elderly is recommended by international guidelines to protect against cognitive decline and functional impairment.

Objective

This Randomized Controlled Trial (RCT) was set up to verify whether medium-intensity physical activity in elderly people living in the community is effective in improving cognitive performance.

Design

RCT with parallel and balanced large groups.

Setting

Academic university hospital and Olympic gyms.

Subjects

People aged 65 years old and older of both genders living at home holding a medical certificate for suitability in non-competitive physical activity.

Methods

Participants were randomized to a 12-week, 3 sessions per week moderate physical activity program or to a control condition focused on cultural and recreational activities in groups of the same size and timing as the active intervention group. The active phase integrated a mixture of aerobic and anaerobic exercises, including drills of "life movements", strength and balance. The primary outcome was: any change in Addenbrooke's Cognitive Examination Revised (ACE-R) and its subscales.

Results

At the end of the trial, 52 people completed the active intervention, and 53 people completed the control condition. People in the active intervention improved on the ACE-R (ANOVA: F(1;102)=4.32, p=0.040), and also showed better performances on the memory (F(1;102)=5.40 p=0.022) and visual-space skills subscales of the ACE-R (F(1;102)=4.09 p=0.046).

Conclusion

A moderate-intensity exercise administered for a relatively short period of 12 weeks is capable of improving cognitive performance in a sample of elderly people who live independently in their homes.Clinical Trials Registration No: NCT03858114.

Principal Component Analysis of the Social and Behavioral Rhythms Scale in elderly

BACKGROUND

Changes in social and behavioral rhythms (SBR) in elderly are related to health status. Nevertheless, there is no data on factor analysis of the Brief Social Rhythm Scale (BSRS) an internationally well-known tool in this field. The aim was to analyze, in elderly, the factorial structure of the Italian version of BSRS.

DESIGN AND METHODS

Principal Component Analysis of the BSRS carried out in elderly living at home.

RESULTS

 Sample of 141 participants (83 Females, 58,9%), aged 72.3±4.8. All the items of the questionnaire were related and could compose a single factor, explaining 56% of variance. A solution adopting two factors, the first (including items 1,2,3,4,9,10), the second (including items 5,6,7,8), covered cumulatively 78.8% of the variance.

CONCLUSION

 The study confirms that the BSRS is consistent with the idea for which it was built and can be useful for the study of regularity of SBR in old adults.

Exercise improves long-term social and behavioral rhythms in older adults: Did it play a role during the COVID-19 lockdown?

The study aimed to verify whether exercise training in older adults can improve social behavioral rhythms (SBR) and if any modification is maintained over time. Older adults (n=120) from a previous randomized controlled trial (RCT), were randomly allocated to either a moderate-intensity exercise group or a control group. SBR was evaluated at t0, t26, and t48 weeks (during the COVID-19 lockdown), using the brief social rhythms scale (BSRS). Seventy-nine participants completed the follow-up (age 72.3±4.7, women 55.3%). An improvement in the BSRS score was found in the exercise group at 26 weeks (p=0.035) when the exercise program was concluded, and it was still maintained at 48 weeks (p=0.013). No improvements were observed in the control group. To conclude, social behavioral rhythms (SBR), previously found as a resilience factor in older adults during Covid-19, appear to improve after a moderate 12 weeks exercise program, and the improvement persisted even after stopping exercise during the COVID-19 lockdown.

The COVID-19 incidence in Italian regions correlates with low temperature, mobility and PM10 pollution but lethality only with low temperature

BACKGROUND

The aim was to verify whether the density of particulate matter (PM10), the climate, and the mobility of people can influence the pandemic in the 19 regions and in the two autonomous Italian provinces as incidence rate and lethality.

DESIGN AND METHODS

The incidence rates per 100,000 inhabitants and the case fatality ratio (CFR) (dependent variables) in all Italian regions were calculated in January 2021 at John Hopkins University Coronavirus Center. The independent variables were: Minimum average temperatures in the same month (January) of 2020; average pollution of PM10 in the air in each region in the last year available reported on a 0-10 scale to 0 = total absence of PM10 to 10 maximum pollutions; number of places in hotels occupied per inhabitants in 2020. Linear regression and Multiple Regression Analysis were carried out.

RESULTS

The spread of the COVID-19 in the Italian regions seems to be related to pollution of PM10, the number of beds occupied in hotels (as an index of mobility and temperature (indirect correlation). On the contrary, the CFR correlates inversely with temperature but not with pollution. Measuring the concomitant effect of two independent variables by means of Multiple Regression Analysis, temperature and pollution show a synergistic effect on COVID-19 incidence.

CONCLUSIONS

The study seems to confirm the literature on the influence of temperature on the lethality of COVID-19 but adds the new results of an inverse relationship between the spread of the virus and low temperature in regions between the Mediterranean area (which includes southern Italy and Sicily and Sardinia islands) and the cold European temperate zone which includes the northern regions under the Alps. A new date also concerns the summation effect of the risk between cold weather and PM10 air pollution was found. Due to several methodic weaknesses, the study has an exploratory than conclusive relevance.

The COVID-19 incidence in Italian regions correlates with low temperature, mobility and PM10 pollution but lethality only with low temperature

BACKGROUND

The aim was to verify whether the density of particulate matter (PM10), the climate, and the mobility of people can influence the pandemic in the 19 regions and in the two autonomous Italian provinces as incidence rate and lethality.

DESIGN AND METHODS

The incidence rates per 100,000 inhabitants and the case fatality ratio (CFR) (dependent variables) in all Italian regions were calculated in January 2021 at John Hopkins University Coronavirus Center. The independent variables were: Minimum average temperatures in the same month (January) of 2020; average pollution of PM10 in the air in each region in the last year available reported on a 0-10 scale to 0 = total absence of PM10 to 10 maximum pollutions; number of places in hotels occupied per inhabitants in 2020. Linear regression and Multiple Regression Analysis were carried out.

RESULTS

The spread of the COVID-19 in the Italian regions seems to be related to pollution of PM10, the number of beds occupied in hotels (as an index of mobility and temperature (indirect correlation). On the contrary, the CFR correlates inversely with temperature but not with pollution. Measuring the concomitant effect of two independent variables by means of Multiple Regression Analysis, temperature and pollution show a synergistic effect on COVID-19 incidence.

CONCLUSIONS

The study seems to confirm the literature on the influence of temperature on the lethality of COVID-19 but adds the new results of an inverse relationship between the spread of the virus and low temperature in regions between the Mediterranean area (which includes southern Italy and Sicily and Sardinia islands) and the cold European temperate zone which includes the northern regions under the Alps. A new date also concerns the summation effect of the risk between cold weather and PM10 air pollution was found. Due to several methodic weaknesses, the study has an exploratory than conclusive relevance.

Active elderly and health-can moderate exercise improve health and wellbeing in older adults? Protocol for a randomized controlled trial

Background

Aging is marked by a progressive rise in chronic diseases with an impact on social and healthcare costs. Physical activity (PA) may soothe the inconveniences related to chronic diseases, has positive effects on the quality of life and biological rhythms, and can prevent the decline in motor functions and the consequent falls, which are associated with early death and disability in older adults.

Methods

We randomized 120 over-65 males and females into groups of similar size and timing and will give each either moderate physical activity or cultural and recreational activities. Being younger than 65 years, inability to participate in physical activity for any medical reason, and involvement in a massive program of physical exercise are the exclusion criteria. The primary outcome measures are: quality of life, walking speed, and postural sway. Participants are tested at baseline, post-treatment, and 6-month (24 weeks) and 12-month (48 weeks) follow-ups.

Discussion

This study aims at improving the quality of life, wellness, and cognitive functioning in the elderly through a low-cost affordable program of moderate physical activity. Given the growing aging of the world population and the social and economic burden of disability in the elderly, our results might have a major impact on future practices.

Trial registration

ClinicalTrials.gov NCT03858114. Registered on 28 February 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05278-6.

The effect of sucralfate-containing ointment on quality of life in people with symptoms associated with haemorrhoidal disease and its complications: the results of the EMOCARE survey

Background and aim:

A rectal ointment containing 3% of sucralfate and herbal extracts (calendula, witch hazel leaf (hamamelis), chamomile), became available in Italy in 2019 for the treatment of symptoms associated with haemorrhoidal disease. This survey evaluated the effect of the mentioned sucralfate ointment, on quality of life (QoL) and symptom frequency in participants seeking treatment for haemorrhoidal disease from community pharmacies in Italy.

Methods:

EMOCARE was a multicentre prospective survey conducted at community pharmacies in Italy. Eligible participants (≥18 years) were those with haemorrhoidal symptoms in the last 7 days and were willing to initiate a treatment with the sucralfate ointment and herbal extracts (calendula, witch hazel leaf (hamamelis), chamomile). A survey was administered by the investigating pharmacists at the beginning and end (~14 days) of treatment. The primary endpoint was the change in HEMO-FISS-QoL scores.

Results:

Of the 290 (mean age 53.1 years old; 58.3% female) enrolled, 287 attended the follow-up visit. After a mean duration of 13 days, the sucralfate ointment significantly improved total HEMO-FISS-QoL scores (mean change from baseline: –10.41; 95%CI –11.95, –8.86; P<0.001) and mean scores for all domains of the HEMO-FISS-QoL scale (–11.13 [95%CI –12.95, –9.30] for physical disorders, –6.14 [95%CI –7.42, –4.85] for psychology, –18.79 [95% CI –21.67, –15.90] for defaecation, and –6.46 [95%CI –8.40, –4.51] for sexuality; all P<0.001 versus baseline). At the end of treatment, 39.4% of participants reported that they no longer had haemorrhoidal symptoms and the frequency of all assessed symptoms were reduced significantly from baseline (all P<0.05).

Conclusions:

After a mean 13 days of treatment the sucralfate ointment with herbal extracts improved HEMO-FISS-QoL scores and reduced symptoms in people with haemorrhoidal disease. (www.actabiomedica.it)

Community pharmacist's professional adaptation amid Covid-19 emergency: a national survey on Italian pharmacists

Background Italy has been the first non-Asian country affected by Coronavirus Disease 19 (COVID-19) pandemic. Community pharmacies are essential services authorized to continue their activity during the emergency. To date, a clear image is lacking of the critical issues Italian community pharmacists had to face and of how they responded in their daily work.. Objective To describe procedures and critical logistical-organizational issues encountered by Italian community pharmacists and to collect the main requests reported by patients to pharmacists. Setting A national survey on Italian community pharmacists. Method A cross-sectional survey using a reasoned questionnaire was sent during the pandemic peak to Italian pharmacies, divided in two groups according to the incidence of COVID-19: "Red Zones" and "non-Red Zones". Main outcome measure Exploring the most frequently adopted measures by the pharmacists. Results 169 community Pharmacists answered the questionnaire. The most frequently adopted measures were the use of gloves, surgical masks and protective barriers at the drug counter. Most implemented services for customers were: booking of prescriptions, delivery of medications and implementation of phone consultations. Overall, the questionnaire highlighted an increase in the number of health-related consultations and requests by customers. In Red Zones, there was a higher use of FFP2 and FFP3 masks by pharmacists, where customers were mainly interested in gaining information about specific classes of medications. Conclusion Community pharmacists adapted to lockdown measures by implementing a number of measures. There was an overall increase in pharmacists' personal protective equipment in Red Zones possibly linked to increased risk perception.

Broad Spectrum project: factors determining the quality of antibiotic use in primary care: an observational study protocol from Italy

INTRODUCTION

The overuse of antibiotics is causing worldwide spread of antimicrobial resistance (AMR). Compared with other countries, Italy has both high antibiotic consumption rates and high rates of AMR. Due to the fact that around 90% of antibiotics are prescribed by general practitioners (GPs), this study aims to measure the impact of knowledge, attitudes and sociodemographic and workplace-related factors on the quality of antibiotic prescriptions filled by GPs in the Italian Region of Sardinia.

METHODS AND ANALYSIS

Knowledge, attitude, sociodemographic and workplace-related factors deemed to influence physicians prescribing behaviour will be evaluated in a cross-sectional study conducted among all GPs of the Italian Region of Sardinia (n=1200). A knowledge and attitudes questionnaire (Knowledge and Attitudes on Antibiotics and Resistance - Italian version: ITA-KAAR) accompanied by a sociodemographic form will be linked to drug prescription data reimbursed by the National Health System. European Surveillance of Antibiotic Consumption quality indicators for outpatient antibiotic use will be calculated from drug prescription records. Every GP will be deemed to have demonstrated an adequate quality of prescriptions of antibiotics if half of the indicator score plus one is better than the median of the region. A multivariate Poisson regression model with robust variance estimation will be used to evaluate the impact of the determinants of antibiotic prescriptions on the actual prescribing quality of each physician.

ETHICS AND DISSEMINATION

The project has been approved by the ethics committee of the Regional Health Trust of Sardinia (176/2019/CE, 24 September 2019). The results will be useful to inform evidence-based interventions to tackle irrational antibiotic use in the community.

The Burden of Comorbidity Between Bipolar Spectrum and Obsessive-Compulsive Disorder in an Italian Community Survey

Background: The impact of the comorbidity between Obsessive-Compulsive Disorder (OCD) and Bipolar Disorder Spectrum (BDS) remains to be clarified. The objective of this study was to examine the lifetime prevalence of OCD, the strength of the association of OCD with comorbid BDS and the role of comorbidity of OCD with BDS in the impairment of health-related quality of life (HRQoL) in an Italian community survey. Methods: The study is a community survey. The sample (N = 2,267; women: 55.3%) was randomly selected after stratification by sex and four age groups from the municipal records of the adult population of one urban, one suburban, and at least one rural area in six Italian regions. Physicians using a semi-structured interview (Advanced Tools and Neuropsychiatric Assessment Schedule, ANTAS-SCID) made Diagnostic and Statistical Manual of Mental Disorders - 4th revision (DSM-IV) diagnoses of OCD, Major Depressive Disorder (MDD) and Bipolar Disorder (BD). HR-QoL was measured by the Health Survey Short Form (SF-12). Lifetime Hypomania and subthreshold hypomania were screened by the Mood Disorder Questionnaire (MDQ). BDS was defined as the sum of people shown to be positive for hypomania by the MDQ-with or without a mood disorder diagnosis-plus people with a BD-DSMIV diagnosis even if negative for hypomania at the MDQ. Results: Overall, 44 subjects were diagnosed with OCD, 6 with MDD and 1 with BD. The lifetime prevalence of OCD was 1.8% in men (n = 18) and 2.0% in women (n = 26). MDD with lifetime subthreshold hypomania (i.e., people screened positive at the MDQ, even without diagnosed mania or hypomania at the interview) was associated with OCD (OR = 18.15, CI 95% 2.45-103.67); MDD without subthreshold hypomania (and screened negative at the MDQ) was not (OR = 2.33, CI 95% 0.69-7.01). People with BDS were strongly associated with OCD (OR = 10.5, CI 95% 4.90-12.16,). People with OCD and BDS showed significantly poorer HR-QoL than people with OCD without BDS (F = 9.492; P < 0.003). Discussion: The study found a strong association between BDS and OCD. BDS comorbid with OCD was associated with more severe impairment of HR-QoL than OCD without comorbid BDS. Identification of symptoms of hypomania, including subthreshold symptoms, may therefore be important in people with OCD as they might predict a course with poorer HR-QoL.

Could an Innovative Training Program Including Contact Sports and Counseling Help Young People With Traits of Psychopathy and A History of School Dropout?

Background

The aim was to assess the effects of a training program inclusive of contact sports and counseling on school dropout, quality of life (QoL) and psychopathologic symptoms in the youth with a history of school dropout and psychopathic personality traits.

Methods

The Experimental Group (EG) consisted of 32 subjects (male 90.6%; age 19.6±4.3 years); the Control Group (CG) consisted of an equal number matched for gender and age with the same psychological features. At the beginning of the experimental Training Program (T0), both cohorts were assessed by a diagnostic psychiatric interview (SCID ANTAS), the Short Form Health Survey (SF-12) to evaluate QoL, the Psychopathy Checklist - Revised (PCL-R) for the assessment of psychopathic traits, the Self Reporting Questionnaire (SRQ) to measure general psychopathology. At the end of the program (T1), the coorths were evaluated by SF-12 and SRQ.

Results

Twenty-seven subjects in the EG (84.4%) completed the course and underwent the evaluation at T1. The SF-12 score significantly increased from T0 to T1 in both groups, albeit this was more evident in the EG than in the CG, owing to an interaction between time and group. SRQ score significantly decreased in the EG from T0 to T1, while in the CG it did not, although the interaction between time and group was not significant.

Conclusion

The experimental training program was effective in improving QoL and countering school dropout in young citizens with psychopathic traits. Further studies are needed to clarify if such results are due to a relationship between the practical tasks approach including contact sports and an improvement in mentalization processes.

The impact of fibromyalgia syndrome and the role of comorbidity with mood and post-traumatic stress disorder in worsening the quality of life

BACKGROUND:

The aim is to measure the association between fibromyalgia syndrome (FMS) and post-traumatic stress disorder (PTSD), mood and anxiety disorders using reliable psychiatric diagnoses according to Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) and with a case-control design.

METHODS:

Case-control study with cases (71 consecutive female patients with FMS) and controls (284 subjects without FMS), randomly drawn after a gender- and age-matching technique from the database of an epidemiological survey. Psychiatric diagnoses were conducted according to DSM-IV and carried out by clinical staff using a structured interview (Advanced Neuropsychiatric Tools and Assessment Schedule). QoL was measured by Short Form Health Survey (SF-12).

RESULTS:

The lifetime prevalence of major depressive disorder (MDD; 43.7% vs 8.1%, p < .0001), bipolar disorder (BD; 21.1% vs 0.7%, p  < .0001), PTSD (8.4% vs 1.4%, p < .0001) and panic disorder (28.2% vs 5.6%, p < .001) was higher in people with FMS than in controls. People with FMS showed a poorer QoL than controls on the SF-12 (26.43 ± 6.04 vs 37.45 ± 5.80, p < .0001). Those with comorbidity with MDD and BD showed a mean SF-12 score of 24.75 ± 6.31 versus 29.52 ± 4.84 ( N = 25) of people with FMS without any mood disorder ( p = .002). The attributable burden of FMS in worsening QoL was found comparable to that of serious chronic diseases such as multiple sclerosis.

CONCLUSION:

FMS is a disorder that 'in itself' can have a devastating impact on an individual's life. The frequency of the association with major depressive and bipolar disorders increases the impact on the QoL of people with FMS. One of the causes of this association appears to be the extreme vulnerability to chronic stress that this disorder involves. The findings have important clinical significance: the physician must interpret in the right dimension and with dignity the suffering of the people with FMS.

Colorectal Cancer Screening: The Role of Psychological, Social and Background Factors in Decision-making Process

Since ColoRectal Cancer (CRC) remains the third cause of cancer death in the world, a better understanding of the reasons underlying poor adherence to and delay in undergoing CRC screening programs is important. CRC screening decision-making process can be conceptualized as the relationship between intention and behavior and needs to be investigated including the impact on patients' decision of a broad range of psychological factors and personal predisposition as fear of a positive screening test, poor understanding of the procedure, psychological distress, anxiety, anticipation of pain, feelings of embarrassment and vulnerability. Also socioeconomic, ethnic and sociological influences, and organizational barriers have been identified as factors influencing CRC screening adherence. Decision-making process can finally be influenced by the healthcare background in which the intervention is promoted and screening programs are carried out. However, there is still a gap on the scientific knowledge about the influences of diverse elements on screening adherence and this deserves further investigations in order to carry out more focused and effective prevention programs.

A Follow-Up on Psychiatric Symptoms and Post-Traumatic Stress Disorders in Tuareg Refugees in Burkina Faso

INTRODUCTION

The aim of this study was to carry out a 2-year follow-up of refugees in a camp in Burkina Faso who had been interviewed previously. We also aimed to verify whether the general conditions in which they lived (e.g., protection by international organizations and the conclusion of negotiations and new hope of returning to Mali and reunification with surviving family members) would affect their mental health state.

METHODS

This is a cross-sectional study repeated over time on a cohort of refugees. People living in the Subgandé camp who had participated in the first survey in 2012 were identified using informational chains and approached for follow-up. Those who agreed were interviewed using the Short Screening Scale for post-traumatic stress disorder (PTSD) and the K6 scale, French versions, to measure general psychopathology and the level of impairment.

RESULTS

The second survey shows a dramatic decrease in psychopathological symptoms (positivity at K6 scale). Improvement was also conspicuous in the frequency of people with stress symptoms (positivity at Short Screening Scale for PTSD and simultaneous positivity to K6 scale). The frequency of people screened positive at the Short Screening Scale for PTSD had also decreased, but the level of improvement was not pronounced.

CONCLUSION

Our findings confirm that when physical conditions improve, psychological symptoms can also improve. Although in the studied sample psychological factors, such as the hope of returning to their own land and thus the possibility of maintaining ethnic cohesion, may have played a role, future research carried out with a proper methodology and sufficient resources to identify protective factors is needed.

The Improvement of Laparoscopic Surgical Skills Obtained by Gynecologists after Ten Years of Clinical Training Can Reduce Peritoneal Adhesion Formation during Laparoscopic Myomectomy: A Retrospective Cohort Study

OBJECTIVE

To evaluate if improvement of laparoscopic skills can reduce postoperative peritoneal adhesion formation in a clinical setting.

STUDY DESIGN

We retrospectively evaluated 25 women who underwent laparoscopic myomectomy from January 1993 to June 1994 and 22 women who underwent laparoscopic myomectomy from March 2002 to November 2004. Women had one to four subserous/intramural myomas and received surgery without antiadhesive agents or barriers. Women underwent second-look laparoscopy for assessment of peritoneal adhesion formation 12 to 14 weeks after myomectomy. Adhesions were graded according to the Operative Laparoscopy Study Group scoring system. The main variable to be compared between the two cohorts was the proportion that showed no adhesions at second-look laparoscopy.

RESULTS

Demographic and surgical characteristics were similar between the two cohorts. No complications were observed during surgery. No adverse events were recorded during postoperative course. At second-look laparoscopy, a higher proportion of adhesion-free patients was observed in women who underwent laparoscopic myomectomy from March 2002 to November 2004 (9 out of 22) compared with women who underwent the same surgery from January 1993 to June 1994 (3 out of 25).

CONCLUSION

The improvement of surgeons' skills obtained after ten years of surgery can reduce postoperative adhesion formation.

Lack of respect, role uncertainty and satisfaction with clinical practice among nursing students: the moderating role of supportive staff

BACKGROUND AND AIMS

Clinical learning placements provide a real-world context where nursing students can acquire clinical skills and the attitudes that are the hallmark of the nursing profession. Nonetheless, nursing students often report dissatisfaction with their clinical placements. The aim of this study was to test a model of the relationship between student's perceived respect, role uncertainty, staff support, and satisfaction with clinical practice.

METHOD

A cross-sectional, descriptive survey was completed by 278 second- and third-year undergraduate nursing students. Specifically, we tested the moderating role of supportive staff and the mediating role of role uncertainty.

RESULTS

We found that lack of respect was positively related to role uncertainty, and this relationship was moderated by supportive staff, especially at lower levels. Also, role uncertainty was a mediator of the relationship between lack of respect and internship satisfaction; lack of respect increased role uncertainty, which in turn was related to minor satisfaction with clinical practice.

CONCLUSION

This study explored the experience of nursing students during their clinical learning placements. Unhealthy placement environments, characterized by lack of respect, trust, and support increase nursing students' psychosocial risks, thus reducing their satisfaction with their clinical placements. Due to the current global nursing shortage, our results may have important implications for graduate recruitment, retention of young nurses, and professional progression.

An evolutionary approach to mania studying Sardinian immigrants to Argentina

Objective:

To ascertain lifetime prevalence of positivity to a screening questionnaire for bipolar disorders (BD) in Sardinian immigrants to Argentina and residents of Sardinia and assess whether such positivity affects quality of life (QoL) in either group. Our hypothesis is that screen positivity for BD may be more frequent in immigrants.

Methods:

Observational study. Subjects were randomly selected from the membership lists of associations of Sardinian immigrants in Argentina. A study carried out in Sardinia using the same methodology was used for comparison. The Mood Disorder Questionnaire was used to screen for mania/hypomania and the Short-Form Health Survey-12 to measure QoL.

Results:

A higher prevalence of manic/hypomanic episodes was found in Sardinian immigrants to Argentina (p < 0.0001; odds ratio = 3.0, 95% confidence interval 1.87-4.77). Positivity at screening was associated with a lower QoL both in Sardinian immigrants to Argentina and in residents of Sardinia.

Conclusions:

To the best of our knowledge, this is the first study to show a higher lifetime prevalence of manic/hypomanic episodes in a general-population sample of individuals who migrated to a foreign country. Our results are in agreement with the hypothesis that hyperactive/novelty-seeking features may represent an adaptive substrate in certain conditions of social change.

Quality of Life of Sardinian Immigrants in Buenos Aires and of People Living in Italy and Sardinia: Does the Kind of Care have a Role for People with Depression?

BACKGROUND / OBJECTIVES

The aim of the study was to compare the Quality of Life (QoL) of Sardinian immigrants to Argentina with Sardinians residing in Sardinia. The hypothesis was that a different availability of effective treatments for mood disorders may impact the well being of persons with these disorders.

METHODS

One out of five families of Sardinian origin was randomly selected. An Italian study (including Sardinia) was adopted as the control. The Mood Disorder Questionnaire was used for screening mania/hypomania; the diagnosis of Current Major Depressive Disorder was conducted by means of the Patient Health Questionnaire in immigrants and by means of a clinical interview in the control study and in an immigrant subsample (to verify comparability); the Short-Form Health Survey-12 was applied to measure QoL.

RESULTS

The Sardinian immigrants showed a higher QoL than Italians in Italy (but not with Sardinians residing in Sardinia). On the contrary, the attributable burden worsening QoL due to lifetime manic/hypomanic episodes, as well as to current depressive episodes, was found higher among Sardinian immigrants with respect to both Sardinian residents in Sardinia and the total Italian sample. The use of effective treatment for mood disorder was higher in Italy.

CONCLUSION

The study found that in a sample of Sardinian immigrants in Buenos Aires the impact of a mood disorder affects QoL more incisively than in Sardinians residing in Sardinia. The suggested hypothesis of a possible role of beliefs guiding the search for treatments will be verified in future studies.

Depression in Sardinian immigrants in Argentina and residents in Sardinia at the time of the Argentinian default (2001) and the Great Recession in Italy (2015)

BACKGROUND

The aim of this study is to measure in two samples of Sardinian immigrants in Buenos Aires and representatives of the population in Sardinia the prevalence of depressive symptoms at the time of an economic crisis in Sardinia and to compare these results with those collected at the time of a similar crisis in Argentina more than 10 years before.

METHODS

Observational study. The associations of Sardinian immigrants in Buenos Aires provided the lists of families of Sardinian origin. A random sample of one fifth of registered families was selected. The sample of a study carried out in Sardinia was used as the control. The results were compared with those of the previous study performed in 2001-2002. The Patient Health Questionnaire (PHQ9) was used for the screening of depression.

RESULTS

The Sardinian immigrants show a lower rate of scoring positively on PHQ9 (i.e. less risk of being depressed) and reach statistical significance after standardization (8.7% vs. 13.1%, P = 0.046). Young women (≤40) are at higher risk. On the contrary, the risk of depression was higher in Sardinian immigrants in Argentina during the 2001-2002 crises.

CONCLUSION

The study indicates a risk for depressive episodes linked to the fallout of the economic crisis (in Argentina in 2001-2002, in Sardinia in 2015) and specifically more in females than in males. Due to the associated socio-demographic risk factors, these results could be interpreted as due to an increase in non-bipolar depression.

Lack of respect, role uncertainty and satisfaction with clinical practice among nursing students: the moderating role of supportive staff

BACKGROUND AND AIMS

Clinical learning placements provide a real-world context where nursing students can acquire clinical skills and the attitudes that are the hallmark of the nursing profession. Nonetheless, nursing students often report dissatisfaction with their clinical placements. The aim of this study was to test a model of the relationship between student's perceived respect, role uncertainty, staff support, and satisfaction with clinical practice.

METHOD

A cross-sectional, descriptive survey was completed by 278 second- and third-year undergraduate nursing students. Specifically, we tested the moderating role of supportive staff and the mediating role of role uncertainty.

RESULTS

We found that lack of respect was positively related to role uncertainty, and this relationship was moderated by supportive staff, especially at lower levels. Also, role uncertainty was a mediator of the relationship between lack of respect and internship satisfaction; lack of respect increased role uncertainty, which in turn was related to minor satisfaction with clinical practice.

CONCLUSION

This study explored the experience of nursing students during their clinical learning placements. Unhealthy placement environments, characterized by lack of respect, trust, and support increase nursing students' psychosocial risks, thus reducing their satisfaction with their clinical placements. Due to the current global nursing shortage, our results may have important implications for graduate recruitment, retention of young nurses, and professional progression.

Association between the ACE insertion/deletion polymorphism and pterygium in Sardinian patients: a population based case-control study

OBJECTIVE

The purpose of the study was to examine whether the insertion (I) and/or deletion (D) polymorphism of ACE confers susceptibility to primary pterygium in Sardinian patients in a case-control study.

METHODS AND RESULTS

Polymorphism genotyping was performed by nested PCR using genomic DNA extracted from the whole peripheral blood of participants with (n=251) and without (n=260) pterygium. DD, ID and II genotype frequencies were: 48%, 39% and 13%, respectively, for patients with pterygium, and 15%, 40% and 44%, respectively, for the control group. A statistically significant difference was found between the pterygium and control groups for the ACE I/D polymorphism (p<0.001). Moreover, a statistically significant difference was found between the DD and II groups (p<0.01; OR=10.49; 95% CI 6.18 to 17.79), DD+ID versus II group (p<0.01; OR=5.23; 95% CI 3.37 to 8.13) and DD versus ID groups (p<0.01; OR=3.21; 95% CI 2.04 to 5.04).

CONCLUSIONS

Statistical analysis showed that the DD genotype is associated with an increased risk of developing pterygium, and with a good chance that the D allele may play an important role in the development of disease.

Activated Notch1 expression is associated with angiogenesis in cutaneous melanoma

An early event in melanocytic tumor growth is the upregulation of Notch signaling. When an active form of Notch1 is overexpressed in primary human melanocytes, it increases cell growth, survival and invasive properties, promoting melanoma progression. Recent evidence suggested that tumor initiation and growth are driven by a subset of tumor-initiating cells termed cancer stem cells. Notch1 plays a predominant role in the maintenance of melanoblasts, including melanocyte stem cells, by preventing initiation of apoptosis. Moreover, the importance of Notch1 in the regulation of tumor angiogenesis is supported by growing evidence in various cancers. Nestin has been widely used as a marker for melanocyte stem cells as well as an angiogenic marker to evaluate neovascularity of endothelial cells in tumors. To gain an insight into the impact of Notch1 activation on the maintenance of melanocyte stem cells and angiogenesis in melanoma, the expression levels of activated Notch1 and nestin were analyzed by immunohistochemistry in 114 primary cutaneous melanomas and 35 lymph node metastases. Activated Notch1 and nestin expression was also evaluated in four dysplastic melanocytic nevi. This study provides evidence that activated Notch1 is overexpressed in cutaneous melanoma, in tumor cells as well as in microvessel endothelium, and that it can promote tumor angiogenesis. Indeed, the overexpression of activated Notch1 in both tumor and vascular endothelial cells was significantly associated with microvascular density in melanoma samples. Thus, activated Notch1 inhibitors may provide a therapeutic strategy in the treatment of melanoma by blocking tumor-associated vascularization.

Oxytocin nasal spray in fibromyalgic patients

Fibromyalgia is a pain disorder associated with frequent comorbid mood, anxiety, and sleep disorders. Despite the frequent use of a complex, poly-drug pharmacotherapy, treatment for fibromyalgia is of limited efficacy. Oxytocin has been reported to reduce the severity of pain, anxiety, and depression, and improve the quality of sleep, suggesting that it may be useful to treat fibromyalgia. To evaluate this hypothesis, 14 women affected by fibromyalgia and comorbid disorders, assuming a complex pharmacotherapy, were enrolled in a double-blind, crossover, randomized trial to receive oxytocin and placebo nasal spray daily for 3 weeks for each treatment. Order of treatment (placebo-oxytocin or oxytocin-placebo) was randomly assigned. Patients were visited once a week. At each visit, the following instruments were administered: an adverse drug reaction record card, Visual Analog Scale of Pain Intensity, Spielberger State Anxiety Inventory, Zung Self-rating Depression Scale, and SF-12. Women self-registered painkiller assumption, pain severity, and quality of sleep in a diary. Unlikely, oxytocin nasal spray (80 IU a day) did not induce positive therapeutic effects but resulted to be safe, devoid of toxicity, and easy to handle.

Both thyroid autoimmunity and increased serum TSH are independent risk factors for malignancy in patients with thyroid nodules

AIM

To assess the relevance of thyroid autoimmunity and TSH as risk factors for malignancy in thyroid nodules (TN).

SUBJECTS AND METHODS

Retrospective analysis on 2053 patients with single/prevalent TN submitted to fine needle aspiration cytology (FNAC). Anti-thyroid autoantibodies (ATA) [anti-thyroperoxidase (TPOAb), anti-thyroglobulin (TgAb)] and TSH were measured. Cytology was classified as benign (class II), indeterminate (class III), and suspicious or malignant (class IV). Histology was available in 301 patients. Associations of malignancy with independent variables were determined by multivariate logistic regression analysis.

RESULTS

Higher prevalence of class IV (14.2% vs 6.8%: p<0.001) and class III (23.5% vs 17.1%: p<0.001) were found in ATA+ vs ATA- TN. Histology confirmed increased prevalence of cancer in ATA+ (p<0.05) TN and in those with diffuse lymphocytic thyroid infiltration (p<0.05). Interestingly, the prevalence of malignancies observed in operated class III nodules was strikingly lower in ATA+ (1/20, 5%), than in ATA- patients (34/67, 50.7%; p<0.001). Increased independent odds ratio (OR) for malignancy was conferred by any ATA [OR 2.21; 95% confidence interval (CI)=1.49-3.29, p<0.0001]; TPOAb (OR 2.15; CI=1.42-3.25, p<0.0001) and TgAb (OR 1.67; CI=1.05-2.67, p<0.05), by serum TSH>1.0 μUI/ml (OR 1.95; CI=1.01-3.76, p<0.05), and by young age (10-29 yr: OR 2.09; CI=1.02-4.26, p<0.05). A formula was calculated to assess the relative contribution of ATA, TSH, and age to the risk of TN malignancy.

CONCLUSIONS

Both thyroid autoimmunity and increased TSH represent independent risk factors for TN malignancy.

The role of FTO genotype on eating behavior in obese Sardinian children and adolescents

AIM

We aimed to study the influence of the fat mass and obesity-associated (FTO) gene on eating behavior in 412 obese Sardinian children and adolescents. Genome-wide association studies (GWAS) have identified several susceptibility loci for obesity. Among these, the polymorphisms in the intron 1 of the FTO gene has been found associated to weight gain and obesity in various populations.

METHODS

All obese patients were genotyped for the FTO single nucleotide polimorphysm (SNP) rs9939609. In all subjects we evaluated eating behavior using the Child Eating Behaviour Questionnaire (CEBQ).

RESULTS

We found no differences in eating behavior according to the genotype, either in the entire cohort, or when subjects were subdivided into four different age groups.

CONCLUSIONS

FTO genotype is associated with body mass index but does not influence eating behavior in a selected cohort of obese children from the isolated genetic population of Sardinia.

Nestin and vimentin colocalization affects the subcellular location of glucocorticoid receptor in cutaneous melanoma

AIMS

  Nestin (a neuronal stem cell/progenitor cell marker of central nervous system development), vimentin (which is ubiquitously expressed in mesenchymal cells), and the glucocorticoid receptor (GR, which is involved in the immune response, cell proliferation, and apoptosis) have been shown to interact in embryonic and undifferentiated tissues in modulating cell proliferation. The aim of this study was to analyse nestin, vimentin and GR expression in tumour tissue (melanoma), and their association with clinicopathological variables, to evaluate any effect on tumour progression.

METHODS AND RESULTS

  Immunohistochemistry, double-label immunofluorescence and confocal laser scanning microscopy were performed on biopsy specimens of cutaneous melanoma from 81 patients. Fisher's and Pearson's tests showed a correlation between nestin, vimentin and subcellular GR location (P = 0.008). Their concomitant expression also correlated with Clark level and thickness (P = 0.02 and P = 0.029, respectively). Kaplan-Meier analysis revealed a poorer outcome for stage III and IV patients with associated expression of nestin, vimentin and cytoplasmic GR in tumour tissue (P = 0.02).

CONCLUSIONS

  These results suggest the presence in melanoma of growth mechanisms involving nestin, vimentin, and GR, similarly to that occurring in embryonic and undifferentiated cells, and may help in understanding tumour biology to provide a molecular basis for clinical therapies.

Is there a dose-response relationship of metformin treatment in patients with polycystic ovary syndrome? Results from a multicentric study

STUDY QUESTION

Do different dosages of metformin account for different clinical and biochemical outcomes in women with polycystic ovary syndrome (PCOS) and do basal anthropometric and metabolic characteristics of the patients provide any indications regarding the dose required to reach the target effect?

SUMMARY ANSWER

Different doses of metformin exerted the same effects on clinical, biochemical and metabolic parameters in patients affected by PCOS.

WHAT IS KNOWN AND WHAT THIS PAPER ADDS

Since the insulin-sensitizing agents came into use in the management of PCOS, metformin has shown a positive benefits-risks ratio. Nonetheless, therapeutic schedules are not well standardized. This is the first study which systematically analyses the effect of different doses of metformin on clinical, hormonal and metabolic features of PCOS. On the basis of our results, higher doses are no more effective than lower doses.

DESIGN

A multicentric cohort prospective study. A total of 250 PCOS women were enrolled, 49 lost to follow-up. Menstrual cyclicity, hormonal assays, oral glucose tolerance test, lipid profile and ultrasonographic pelvic examination were evaluated at the baseline and after 6 months of metformin treatment at different doses (1000, 1500 and 1700 mg).

PARTICIPANTS AND SETTING

A total of 201 PCOS patients completed the study without protocol violations in three university hospitals: seventy-three patients from Centre A (treated with metformin 500 mg twice a day), 60 patients from Centre B (treated with metformin 500 mg three times a day) and 68 patients from Centre C (treated with metformin 850 mg twice a day).

MAIN RESULTS AND THE ROLE OF CHANCE

Metformin exerted an overall positive effect on the clinical and endocrine-metabolic features of PCOS. The degree of these effects was independent of the administered dosage in every range of basal body mass index (BMI). When patients were stratified according to their insulinaemic status, scattered inter-doses differences were found in some of the outcome measures. Patients who exhibited an increase of >2 menstrual cycles/year were considered as responders to treatment. Responders had a higher basal BMI than non-responders and showed a greater reduction in plasma testosterone levels after metformin treatment, but other outcome measures did not differ significantly. Total insulin secretion in the 180 min following the glucose tolerance test before metformin treatment (basal AUC-I) was significantly correlated with the decrease in insulin secretion induced by metformin in both the whole group and in responders, but only correlated with the variation in the number of cycles in responders.

BIAS, CONFOUNDING AND OTHER REASONS FOR CAUTION

The different doses were administered in different centres, and between-centre variation is a potential confounding factor.

GENERALIZABILITY TO OTHER POPULATIONS

The paradigm of using the minimum effective dose of metformin could be pursued in other pathological conditions characterized by insulin resistance.

STUDY FUNDING/COMPETING INTEREST(S)

No funding or competing interests to declare.

The natural history of the normal/mild elevated TSH serum levels in children and adolescents with Hashimoto's thyroiditis and isolated hyperthyrotropinaemia: a 3-year follow-up

OBJECTIVE

  The natural history of Hashimoto's thyroiditis (HT) and isolated hyperthyrotropinaemia (IH) is not well defined. We therefore studied the natural course of patients with HT and IH and looked for possible prognostic factors.

DESIGN

  This is retrospective cross-sectional study.

PATIENTS

  Three hundred and twenty-three patients with HT (88 boys and 235 girls) and 59 with IH (30 boys and 29 girls), mean age 9·9 ± 3·8 years were included in the study. When first examined, 236 of the children with HT had a normal TSH (G0) and in 87, it was elevated but <100% of the upper limit (G1). All IH subjects had elevated TSH. Potential risk factors for thyroid failure were evaluated after 3 years and included the presence or familiarity for endocrine/autoimmune diseases, premature birth, signs and symptoms of hypothyroidism, TSH levels, antithyroid antibodies and thyroid volume.

RESULTS

  HT: Of those with HT, 170 G0 patients remained stable, 31 moved to G1 and 35 to G2 (hypothyroidism). Thirty-six G1 children moved to G0, 17 remained stable and 34 moved to G2. Of patients with IH: 23 normalized, 28 remained stable and eight became overtly hypothyroid. In patients with HT, the presence of coeliac disease, elevated TSH and thyroid peroxidase antibodies (TPOAb) increased the risk of developing hypothyroidism by 4·0-, 3·4- and 3·5-fold, respectively. The increase in TSH levels during follow-up was strongly predictive of the development of hypothyroidism. In patients with IH, no predictive factor could be identified.

CONCLUSIONS

  Coeliac disease, elevated TSH and TPOAb at presentation and a progressive increase in TSH are predictive factors for thyroid failure in HT patients.

P3-14-07: Relative Risk of Recurrence (RR) over Time in ER Positive and Negative T4 Breast Cancer Patients Achieving Less Than pCR (&lt;pCR) after Primary Chemotherapy: A Reversal Trend of Recurrence beyond 60 Months after Diagnosis

Background

It is widely assumed that patients (pts) who achieve a pCR have a good prognosis and better outcomes compared with pts with &lt;pCR, regardless of hormone receptor status. Emerging data suggest that achieving &lt;pCR identifies a heterogeneous group with different risks of recurrence and death, being ER negative the subgroup with the worst prognosis.

Aim of our study was to evaluate the relative risk of recurrence (RR) over time in ER-positive (ER+) and ER-negative (ER-) &lt;pCR patients.

Material and Methods: We analyzed 139 consecutive &lt;pCR T4 pts, of whom 85 were ER+ (cut-off 10%) and 54 were ER-. Median age was 53 y ( range 29–73). Median follow up was 137 months (range 8–233). All pts received primary anthra-based chemotherapy with or without taxanes followed by endocrine therapy for 5 years, if hormone receptor positive. We examined the RR of recurrence at 0–24, 25–60, 61–120 and beyond 120 months (m) interval after diagnosis.

Results: For all 139 pts, the total number of pts with recurrence was 95 (68%), 54 (63%) in ER+ and 41 (76%) in ER-.tumors. For the entire group and both in ER+ and in ER-, the RR of recurrence was greatest for the interval between 0–24 months, then decreased rapidly in ER- and slowly in ER+ through the 25–120 m interval. For the 0–24 m and 25–60 m intervals the RR of recurrence was higher for ER-pts and after 60 m it crossed and beyond 60 m the RR of recurrence was higher in ER+ than in ER- pts. Notably, beyond 120 months we observed a little second peak of recurrence, higher in ER+ (7) than in ER- (3) pts. Nine of these 10 relapses occurred between 120 to 180 m interval, 7 in ER+ (13%) and 2 in ER- (5%) subgroup. In the first 24 m ER- pts were 86% more likely to relapse compared with ER+, vice versa between 61–120 and beyond 120 m intervals, ER- pts were 19% and 18% less likely to relapse, respectively, compared with ER+ pts.

Conclusions: The present study confirmed the previous reports which showed unfavorable prognosis of the &lt;pCR patients with negative ER status, due to their significantly higher relative risk of recurrence between 0 to 60 months interval. The ER+ recurrences occurred more frequently in late follow-up. A reversal of recurrence between ER positive and negative patients beyond 60 months after diagnosis was detected. The fact might indicate the importance of long term adjuvant hormone therapy for T4 ER positive breast cancer patients with &lt;pCR after primary chemotherapy.

Nestin expression associates with poor prognosis and triple negative phenotype in locally advanced (T4) breast cancer

Nestin, an intermediate filament protein, has traditionally been noted for its importance as a neural stem cell marker. However, in recent years, expression of nestin has shown to be associated with general proliferation of progenitor cell populations within neoplasms. There is no reported study addressing nestin expression in T4 breast cancer patients. Thus, the aim of the present study was to investigate, through immunohistochemistry, the expression and distribution of nestin in T4 breast cancer, in order to determine its association with clinical and pathological parameters as well as with patients' outcome. Nestin was detectable in tumoral cells and in endothelial cells of blood microvessels, and it is significantly expressed in triple-negative and in inflammatory breast cancer (IBC) subgroups of T4 breast tumours. The Kaplan-Meier analysis showed that the presence of nestin in tumoral cells significantly predicted poor prognosis at 5-years survival (P=0.02) and with borderline significance at 10-years of survival (P=0.05) in T4 breast cancer patients. On the basis of these observations, we speculate that nestin expression may characterize tumours with an aggressive clinical behavior, suggesting that the presence of nestin in tumoral cells and vessels may be considered an important factor that leads to a poor prognosis. Further studies are awaited to define the biological role of nestin in the etiology of these subgroups of breast cancers.

Prevalence of human papillomavirus infection in women in Benin, West Africa

BACKGROUND

Cervical cancer ranks as the first most frequent cancer among women in Benin. The major cause of cervical cancer now recognized is persistent infection of Human Papillomavirus (HPV). In Benin there is a lack of screening programs for prevention of cervical cancer and little information exists regarding HPV genotype distribution.

METHODS

Cervical cells from 725 women were examined for the presence of viral DNA by means of a polymerase chain reaction (PCR) multiplex-based assay with the amplification of a fragment of L1 region and of E6/E7 region of the HPV genome, and of abnormal cytology by Papanicolaou method. The association between HPV status and Pap test reports was evaluated. Socio-demographic and reproductive characteristics were also related.

RESULTS

A total of 18 different HPV types were identified, with a prevalence of 33.2% overall, and 52% and 26.7% among women with and without cervical lesions, respectively. Multiple HPV infections were observed in 40.2% of HPV-infected women. In the HPV-testing group, the odds ratio for the detection of abnormal cytology was 2.98 (95% CI, 1.83-4.84) for HPV positive in comparison to HPV negative women. High risk types were involved in 88% of infections, most notably HPV-59, HPV-35, HPV-16, HPV-18, HPV-58 and HPV-45. In multiple infections of women with cytological abnormalities HPV-45 predominated.

CONCLUSIONS

This study provides the first estimates of the prevalence of HPV and type-specific distribution among women from Benin and demonstrates that the epidemiology of HPV infection in Benin is different from that of other world regions. Specific area vaccinations may be needed to prevent cervical cancer and the other HPV-related diseases.

Quality of life and associated clinical distress in fibromyalgia

OBJECTIVES

Fibromyalgia (FM) is a syndrome characterized by chronic, diffuse musculoskeletal pain and by a low pain threshold at specific anatomical points (tender points). Numerous other conditions (Irritable bowel syndrome, tension-type headache, migraine headaches, etc.) may overlap with FM. Aim of this study was to evaluate the quality of life and associated clinical distress in patients with FM.

METHODS

53 females affected by primary fibromyalgia and 40 healthy females were examined were examined by an experienced rheumatologist and interviewed using the Fibromyalgia Impact Questionnaire (FIQ). Clinical monitoring included Visual Analogue Scale for pain and pain pressure threshold measurements.

RESULTS

Mean FIQ scores were 66.39+/-14.94 in FM patients and 13.15+/-5.37 in control subjects and the difference was statistically significant. Among associated clinical distress higher frequencies have been found for paraesthesia (87%), sleep disturbance (72%), tension type headache (70%), oto-vestibule syndrome (72%) and irritable colon (60%). An R.O.C. bend was developed in the presence of paraesthesias and oto-vestibule syndromes at the same time. This allowed us to identify a FIQ cut off value of 66.85 so FM patients were divided into 2 groups according to their FIQ scores: severe degree and mild or slight degree.

CONCLUSIONS

Based on our data, it would appear possible to use a FIQ value equal to or higher than 66.85 for the clinical picture of FM to be classified as severe.

Effect of body mass index on the growth hormone response to clonidine stimulation testing in children with short stature

OBJECTIVES

An inverse relationship has been shown between body mass index (BMI) and the peak growth hormone (GH) response to stimulation in adults and in children with short stature. This relation is observed even within a normal range of BMI. The aim of this study was to investigate the effect of BMI on the GH response to clonidine in a large number of children with short stature.

DESIGN

We conducted a retrospective study on the GH response to clonidine in a single centre.

METHODS

We studied 202 children with short stature (135 M and 67 F) who underwent clonidine testing from 2007 to 2009.

RESULTS

One hundred and twenty-eight patients had a GH peak >10 μg/l. In univariate regression analysis, the peak GH after clonidine was negatively correlated with BMI-standard deviation score (BMI-SDS) and positively correlated with height velocity-SDS and IGF-I-SDS. Only the relationship between peak GH and BMI-SDS remained significant in children with a BMI-SDS from -2 to +2. In the multivariate stepwise regression analysis, BMI-SDS and IGF-I-SDS were the only significant variables in the entire cohort, explaining 19·5% of the variance in peak GH. When only subjects with BMI-SDS between -2·0 and +2·0 were included in the analysis (n = 173), BMI-SDS alone explained 21·4% of the variability in peak GH. The number of patients who failed the clonidine test increased with increasing BMI-SDS.

CONCLUSIONS

BMI affects the GH response to clonidine in children with short stature and should be considered when interpreting the results to the stimulation test.

[Use of the complex network theory to study inpatient flow between health facilities in Sardinia (Italy)]

Analysing the organizational structure and functioning of health systems is fundamental for improving healthcare services and for using available resources efficiently. In this study, data regarding the flow of hospital inpatients to and from the various healthcare facilities in the Sardinia Region (Italy) were analysed, by using techniques borrowed from the theory of complex networks. First data regarding the total number of patients were analysed, then data were analysed according to clinical specialty and finally a more detailed analysis was performed for the clinical specialties of general surgery, haematology, cardiology and ophthalmology. Factors that were found to influence patient transfers between hospitals in the healthcare network in Sardinia (Italy) are the type of route, including the distance to cover, and the type of specialty clinics present in the various facilities.

Nuclear factor-κB expression is predictive of overall survival in patients with cutaneous melanoma

Nuclear factor (NF)- κB is one of the most important transcription factors that plays a crucial role in the regulation of a wide spectrum of genes involved in modulating the cell cycle, apoptosis, cell growth, angiogenesis, inflammation and the tissue invasiveness of highly malignant cells. NF-κB activity has been found to be constitutively elevated in a number of human tumors from either a haematological or solid origin, such as melanomas. In several studies, NF-κB activation was shown to be an adverse prognostic factor, and in melanoma it was proposed as an event that promotes tumor progression. This study aimed to evaluate whether NF-κB activation in tumor tissues, assessed by the expression of the NF-κB p65 subunit, has an effect on the survival of melanoma patients. The expression of NF-κB was immunohistochemically investigated, and the correlation with survival was analyzed. Furthermore, the immunostaining for p53 and survivin was evaluated, and the relationship of these apoptotic and anti-apoptotic factors with NF-κB expression was analyzed. Kaplan-Meier analysis showed that patients with low levels of NF-κB in the nuclei of tumor cells had a significantly longer survival compared to those with high levels. Multivariate analysis confirmed the predictive value of nuclear NF-κB, showing that its expression maintains significance after the model was adjusted using clinicopathological factors. The results demonstrate the correlation of NF-κB p65 nuclear staining with the disease-specific 5-year survival of melanoma patients and suggest that nuclear NF-κB p65 may be promising as an early independent prognostic factor in patients with primary cutaneous melanoma.