Cardio-metabolic risk modeling and assessment through sensor-based measurements

OBJECTIVE

Cardio-metabolic risk assessment in the general population is of paramount importance to reduce diseases burdened by high morbility and mortality. The present paper defines a strategy for out-of-hospital cardio-metabolic risk assessment, based on data acquired from contact-less sensors.

METHODS

We employ Structural Equation Modeling to identify latent clinical variables of cardio-metabolic risk, related to anthropometric, glycolipidic and vascular function factors. Then, we define a set of sensor-based measurements that correlate with the clinical latent variables.

RESULTS

Our measurements identify subjects with one or more risk factors in a population of 68 healthy volunteers from the EU-funded SEMEOTICONS project with accuracy 82.4%, sensitivity 82.5%, and specificity 82.1%.

CONCLUSIONS

Our preliminary results strengthen the role of self-monitoring systems for cardio-metabolic risk prevention.

The novel Mechanical Ventilator Milano for the COVID-19 pandemic

This paper presents the Mechanical Ventilator Milano (MVM), a novel intensive therapy mechanical ventilator designed for rapid, large-scale, low-cost production for the COVID-19 pandemic. Free of moving mechanical parts and requiring only a source of compressed oxygen and medical air to operate, the MVM is designed to support the long-term invasive ventilation often required for COVID-19 patients and operates in pressure-regulated ventilation modes, which minimize the risk of furthering lung trauma. The MVM was extensively tested against ISO standards in the laboratory using a breathing simulator, with good agreement between input and measured breathing parameters and performing correctly in response to fault conditions and stability tests. The MVM has obtained Emergency Use Authorization by U.S. Food and Drug Administration (FDA) for use in healthcare settings during the COVID-19 pandemic and Health Canada Medical Device Authorization for Importation or Sale, under Interim Order for Use in Relation to COVID-19. Following these certifications, mass production is ongoing and distribution is under way in several countries. The MVM was designed, tested, prepared for certification, and mass produced in the space of a few months by a unique collaboration of respiratory healthcare professionals and experimental physicists, working with industrial partners, and is an excellent ventilator candidate for this pandemic anywhere in the world.

Long-Term Sequelae of Breast Cancer Surgery

Background

Quality of care is today a major issue in oncology, and much attention is given to research on the outcome of breast cancer care. Too little attention has been devoted in the scientific literature to the consequences of treatment in long-term survivors, and in particular to the possible side effects. The specific aim of this contribution is to present population-based data about the long-term impact of breast cancer care in women who had an incident cancer in 1985/1986.

Patients and Methods

The cases are 476 breast cancers incident in the City of Florence in 1985-86. Women still living 5 years later were invited to have an interview and a physical examination. Lymphedema, peripheral nerve lesions and damage to the shoulder were assessed.

Results

Of the 346 5-year survivors, 238 accepted our invitation: 35.2% of the women reported some early postoperative sequelae, 30.2% had a chronic lymphedema and 18.9% a shoulder deficit. Comparing breast-conserving surgery with radical mastectomy, the risk of chronic lymphedema (OR=1.62; 95% CI: 0.91-2.88) and other lesions was higher for women who had a radical surgery. Women who had a breast-conserving surgery more often reported an early lymphedema (OR=1.60; 95% CI: 0.88-2.88).

Conclusions

The proportion of women who complained of (or manifested at the physical examination) a minor or major disability of the arm in our study was high. The impact of these functional problems in terms of quality of life should also be assessed, but it is our impression that there is need for much greater attention to the issue of long-term survivor sequelae.

First Results of a Mammographic Screening Program in Two Municipalities of Massa-Carrara Province (Italy)

Aims and Background

A mammographic screening for breast cancer was started in 1989 in two municipalities of Massa-Carrara province. This paper describes the results of the first two years and evaluates the quality of the program via early indicators.

Methods

We calculated the attendance rate at first screening, the proportion of women recalled for further examinations (recall rate), the ratio between benign lesions and carcinomas detected by screening, the staging of the screen detected cancers and the ratio between detection rate and expected incidence (P/l ratio).

Results

Out of 14826 invited women 10407 (70.2 %) attended the first screening; 266 (2.6%) of them were referred for further investigations but only 63 (0.6%) required surgical biopsy. A histological confirmed malignancy was found in 39 women corresponding to a detection rate of 3.7/1000. According to pTNM classification 89.1 % of all cancers were either Tis or in stage T1; and in two third of the cases there was no nodes involvment.

Conclusion

The results achieved so far, evaluated via early indicators, show a good start of the program.

Breast Cancer Screening: Characteristics and Results of the Italian Programmes in the Italian Group for Planning and Evaluating Breast Cancer Screening Programmes (GISMa)

In 1990, GISMa (Italian Group for planning and evaluating Mammographic Screening - Gruppo Italiano per la pianificazione e la valutazione dei programmi di Screening Mammografico), a working group of operators (radiographers, radiologists, epidemiologists, clinicians, surgeons) involved in screening programmes ongoing in Italy, was created within the Italian School of Senology. The aim of this study is to illustrate data, presented at the GISMa meeting held in April 1994, concerning the characteristics of each programme and some early indicators of effectiveness. To assess these parameters (concerning compliance level, recall rate, benign/malignant biopsy ratio, detection rate, stage distribution, nodal involvement and number of cancers with a diameter under 1 cm, rate of cancer, etc.), ‘acceptable’ and ‘desirable’ standards obtained from Italian and North-European cancer screening experiences have been adopted. Most programmes have shown an acceptable standard for most of the indicators, and many of them have attained desirable levels. In most screening programmes the occurrence of interval cancers has not yet been measured, but all centres have (or are working to set up) a systematic active procedure to collect the data. The results indicate that common guidelines can be adopted, even when working in very heterogeneous contexts, and that it is possible to achieve a very high effectiveness and efficacy level. As regards quality control and cost/benefit issues, the goal of extending centralised, population-based screening programmes to other Italian regions becomes a priority.

General Practitioners and Mammographic Screening Uptake: Influence of Different Modalities of General Practitioner Participation

Aims and background

To compare the impact of different modalities of general practitioner (GP) involvement, including the introduction of target payments, on the attendance rate of organized population-based screening programs for breast cancer in Italy.

Study design

The study was conducted between 1994 and 1996 in four Italian cities where mammographic screening programs are active: Caltanissetta (CL), Firenze (Fl), Modena (MO) and Torino (TO). The impact on attendance rate of different invitation strategies based on active GP involvement was tested in each center. The additional effect of economic incentives was also assessed. The incentives were proportional to the level of compliance attained by each GP and weighted by the size of his eligible patients’ list.

Results

In the Firenze project, an invitation signed by the GP and the project co-ordinator attained a statistically significant higher participation (difference: 4.2%, χ2 = 7.42, P = 0.006). In Caltanissetta and Torino there was a significant increase of about 7% in the response rate to the postal reminder in the groups contacted by the GPs. No difference was observed in the Modena project between the two groups.

Conclusions

The main contributions of GP involvement can be: “cleaning up'’ the invitation lists, especially when computerized archives with the mammographic history of the target population are not available; increasing the women's participation by signing the invitation letter, by counseling and active participation in the invitation phase; co-operating in the reminder phase by recalling women non responders at first invitation. The offer of target payment had a certain impact on the screening uptake, but not easily distinguishable from GP signature of the invitation letter; further studies of appropriate design should be planned. Organizational factors, such as availability of a list of non-responders, might be crucial in order to enhance the effect of the GPs’ action.

Cancer Mortality in Migrant Populations within Italy

Italian death certification rates from all causes of death, all diseases of the circulatory system, all neoplasms, and cancers of the upper digestive and respiratory tract, stomach, intestines, lung and breast in middle age (45-64 years) were analyzed according to selected geographic areas of birth and residence at death. For total cancer mortality and most neoplasms considered, the rates in middle age were closer to those of place of birth than to those of area of residence, although this pattern was more evident for some sites (e.g., mouth or pharynx, esophagus, larynx, stomach or bladder) than for others (e.g., intestines or breast). In most cases, migration had an adverse effect on cancer rates, and the lowest mortality was reported among stable populations (i.e., those with the same area of birth and death). These findings are discussed in relation to the major migration fluxes within Italy during the current century. Moreover, these analyses give information on the quality of Italian cancer death certification, since the observation that area of birth is often a more important determinant of cancer rates than area of residence provides indirect evidence that cancer death certification in various Italian geographic areas is satisfactorily reliable and consistent.

The professional quality criteria of Italian breast screening radiologists: results from a national survey comparing the programmes started in 2000-2012 versus the ones started in 1990-1999

INTRODUCTION

In Italy, due to increasing healthcare budget and staff shortages, the recently created regional mammography screening programmes were established under worse radiology practice quality criteria than the previously created programmes.

METHODS

Using available data from a national questionnaire survey conducted at the end of 2013 and involving 222 responder radiologists, we compared the main professional quality standards of radiologists working in the screening programmes established during the period 2000-2012 with those working in the screening programmes created from 1990 to 1999.

RESULTS

The former reported more years of clinical experience in breast imaging and a greater clinical mammogram reading volume than the latter. Conversely, they dedicated less working time to breast imaging, were less likely to participate in the diagnostic assessment of screen-detected lesions, to work in large-staffed screening centres, and to have a screening and a total mammogram reading volume (SMRV and TMRV) ≥ 5000 per year.

CONCLUSIONS

The level of most professional quality criteria of Italian mammography screening radiologists has decreased over time. As SMRV and TMRV are important predictors of diagnostic accuracy, we can expect a lower interpretation performance of radiologists working in the recently created screening programmes.

Face morphology: Can it tell us something about body weight and fat?

This paper proposes a method for an automatic extraction of geometric features, related to weight parameters, from 3D facial data acquired with low-cost depth scanners. The novelty of the method relies both on the processing of the 3D facial data and on the definition of the geometric features which are conceptually simple, robust against noise and pose estimation errors, computationally efficient, invariant with respect to rotation, translation, and scale changes. Experimental results show that these measurements are highly correlated with weight, BMI, and neck circumference, and well correlated with waist and hip circumference, which are markers of central obesity. Therefore the proposed method strongly supports the development of interactive, non obtrusive systems able to provide a support for the detection of weight-related problems.

Breast cancer screening in Italy: evaluating key performance indicators for time trends and activity volumes

Together with the National centre for screening monitoring (ONS), GISMa supports annual collection of data on national breast screening activities. Aggregated data on implementation and performance are gathered through a standardized form to calculate process and impact indicators. Analyzed data belong to 153 local programmes in the period 2006-2011 (2006-2012 for participation rate only). During the whole period, Italian crude participation rate exceeded GISMa's acceptable standard (50%), even though a higher participation in northern and central Italy compared to southern Italy and Islands was observed. Time trend analysis of diagnostic indicators confirmed in 2011 an adequate quality of breast screening performance, especially at subsequent screening. Recall rate at initial screening did not reach the acceptable standard (<7%) and rose slightly over the period. On the contrary, a good performance was achieved at subsequent screening. The same trend was followed by the overall detection rate and positive predictive value. They both showed a progressive reduction (from 6.2‰ in 2006 to 4.5‰ in 2011 for DR and from 8.0% in 2006 to 5.2% in 2011 for PPV, respectively) at initial screening and a good, stable trend at subsequent screening. Activity volume analysis shows that in programmes with greater activity (test/year ≥10,000) RR at both initial and subsequent screening has a better performance. This is also true for DR and PPV where programmes with high volumes of activity do better, especially when compared with those that interpret fewer than 5,000 mammograms per year. In spite of a few limits, these results are reassuring, and they reward the efforts made by screening professionals. It is therefore important to continue to monitor screening indicators and suggest, test, and evaluate new strategies for continuous improvement.

Problems, solutions, and perspectives in the evaluation of interval cancers in Italian mammography screening programmes: a position paper from the Italian group for mammography screening (GISMa)

In this position paper, a self-convened team of experts from the Italian Group for Mammography Screening (Gruppo italiano screening mammografico, GISMa) pointed out the problems that increasingly hamper the feasibility and validity of the estimate of the proportional incidence of interval breast cancer (IBC) in Italy, suggested potential solutions and an agenda for research, and proposed that the question of the sensitivity of mammography be viewed in a larger perspective, with a greater attention to radiological review activities and breast radiology quality assurance programmes. The main problems are as follows: the coverage of cancer registration is incomplete; the robustness of using the pre-screening incidence rates as underlying rates decreases with time since the start of screening; the intermediate mammograms performed for early detection purposes may cause an overrepresentation of IBCs; the classification of many borderline screening histories is prone to subjectivity; and, finally, the composition of cohorts of women with negative screening results is uncertain, because several mammography reports are neither clearly negative nor clearly positive, and because of the limitations and instability of the electronic mammography records. Several possibilities can be considered to cope with these issues: standard methods for using the hospital discharge records in the identification of IBCs should be established; for the calculation of regional estimates of the underlying incidence, a suitable mathematical model should be identified; the definition of IBC according to the 2008 GISMa guidelines needs to be updated, especially with respect to in situ cancers and to invasive cancers with borderline screening histories; a closer adherence to standard screening protocols, with a simplified patient management, would make it easier to objectively identify IBCs; alternative methods for estimating the sensitivity of mammography should be taken into consideration; and, finally, analysis could be restricted to the absolute incidence rate of IBC, which would make comparison of the risk between neighbouring populations possible. Epidemiologists must extend their attention to the prevention of the risk of IBC and the implementation of breast radiology quality assurance practices. Epidemiologists and radiologists can share common objectives: it is necessary to promote the idea that the availability of a registry-based series of IBCs is not a prerequisite for their radiological review; radiological review of breast cancers greater than 20mm in size detected at second and subsequent screens, that are potential substitutes for IBCs, needs radiological and epidemiological validation studies; the advent of digital mammography brings about the possibility to create libraries of mammograms accessible online, which enables the conduct of large studies of the diagnostic variability of radiologists; and, finally, epidemiologists and radiologists have the responsibility to monitor the effects that a loss of cumulative professional experience in screening centres, due to the imminent retirement of a substantial proportion of healthcare workforce, could cause on their performance.

Mammographic breast cancer screening in Italy: 2011-2012 survey

This report is an update of a number of papers that have been published by the ONS (Osservatorio nazionale screening, National centre for screening monitoring) since 2002. Data for the survey come from several programmes that may have changed over time, and may have different settings of organization and management. During 2011-2012, a slight increase in actual extension was recorded compared to the previous years. Currently, all Italian regions have implemented screening programmes. In 2011-2012, almost 5,300,000 women aged 50-69 years were invited to have a screening mammogram, and almost 3,000,000 were screened.While potential extension was 94.4%, actual extension was 73.3%. An imbalance in extension is still present when comparing northern and central Italy, that have an actual screening extension of 94% and 86% respectively, to southern Italy, that has less than 40%. During the last few years, participation rates have been substantially stable, at around 56%for crude rate, and 60% for adjusted rate, respectively. Women actually screened during 2011-2012 were 38.9%of the national target population. Referral rates of 9.2%at first screening and 4.7%at repeat screening were recorded, showing an increasing trend in recent years. Detection rate was 4.8x1,000 at first screening and 4.4x1,000 at repeat screening, while benign to malignant surgical biopsy ratio for first and repeat screening was 0.2 and 0.1, respectively. Detection rate of small (≤10 mm) invasive cancers was 1.3x1,000 at first screening and 1.4x1,000 at repeat screening; the proportion of in situ carcinomas was 13.3%and 12.0%for first and repeat screening, respectively. Indicators by 5-year age group confirm greater diagnostic problems at younger ages (50-54 years), with higher referral rates and a substantially lower detection rate as compared to older age groups.

A comparison of different strategies used to invite subjects with a positive faecal occult blood test to a colonoscopy assessment. A randomised controlled trial in population-based screening programmes

OBJECTIVE

The purpose of this parallel randomised controlled trial was to compare compliance with different modalities used to invite patients with a positive immunochemical faecal occult blood test (FIT+) for a total colonoscopy (TC).

METHOD

FIT+ patients from nine Italian colorectal cancer screening programmes were randomised to be invited for a TC initially by mail or by phone and, for non-compliers, to be recalled by mail, for counselling with a general practitioner, or to meet with a specialist screening practitioner (nurse or healthcare assistant).

RESULTS

In all, 3777 patients were randomised to different invitation strategies. Compliance with an initial invitation by mail and by phone was similar (86.0% vs. 84.0%, relative risk - RR: 1.02; 95%CI 0.97-1.08). Among non-responders to the initial invitation, compliance with a recall by appointment with a specialist practitioner was 50.4%, significantly higher than with a mail recall (38.1%; RR:1.33; 95%CI 1.01-1.76) or with a face-to-face counselling with the GP (30.8%; RR:1.45;95%CI 1.14-1.87).

CONCLUSION

Compliance with an initial invitation for a TC by mail and by phone was similar. A personal meeting with a specialist screening practitioner was associated with the highest compliance among non-compliers with initial invitations, while the involvement of GPs in this particular activity seemed less effective.

A wize mirror for lifestyle improvement

This paper discusses the problem of fostering lifestyle changes towards healthier habits via tailored user guidance. We present a novel multisensory device, the Wize Mirror, which will be able to detect semeiotic face signs related to cardio-metabolic risk, and encourage users to reduce their risk by improving their lifestyle. Offering a proper user guidance requires solving three main issues: user profiling, definition of a wellness index based on biophysical data, and personalized guidance by means of coaching and supportive messages. For each of these issues, the solutions proposed in the EU FP7 Project SEMEOTICONS are presented, highlighting their advantages with respect to the state-of-the-art.

[Mammography breast cancer screening in Italy: 2010 survey]

This report is an update of similar previous papers that have been published by the ONS (Osservatorio nazionale screening, National Centre for Screening Monitoring) since 2002. Data for the survey come from several different programmes that may have changed over time, and may have different settings of organisation and management. During 2010, the first slight decrease in theoretical extension was recorded. Currently, all Italian regions have implemented screening programmes. In 2010, almost 2,496,000 women aged 50-69 years were invited to have a screening mammogram, and more than 1,382,000 were screened. Theoretical extension was 91.7%, while actual extension was 69.1%. An imbalance in extension is still present when comparing northern and central Italy to southern Italy, which only has a 75% coverage by organised screening. The Italian mean value (69%) of two-year extension (period 2009-2010) suggests that, at full capacity, Italian programmes are able to invite only three quarters of the target population. The percentage of women screened during 2010 was 36.7% of the national target population. During the last few years, participation rates were substantially stable, around 55-57% for crude rate, and 59-61% for adjusted rate, respectively. A decreasing trend towards the South of Italy is evident for this parameter, too. Many programmes work with low volumes of activity (below 10,000 or even 5,000 examinations per year), and only one region surpassed the desirable level of at least 20,000 examinations for each programme. Referral rates of 8.8% at first screening and 4.6% at repeat screening were recorded. Direct standardised detection rate was 6.2x1,000 at first screening and 4.3x1,000 at repeat screening, while benign to malignant ratio for first and repeat screening was 0.26 and 0.12, respectively. Detection rate of invasive cancers ≤10 mm was 1.36x1,000 at first screening and 1.49x1,000 at repeat screening; the proportion of in situ carcinomas was 13.9% and 13.4% for first and repeat screening, respectively. Indicators by 5-year age group confirm greater diagnostic problems at younger ages (50-54 years), with higher referral rates, higher frequency of surgical procedures with benign outcome (B/M ratio), and a substantially lower detection rate as compared to older age groups.

[Time trends of process and impact indicators in Italian breast screening programmes (2000-2010)]

Since its establishment in 1990, one of the main tasks of the Italian group for breast cancer screening (GISMa) is the systematic data collection on the activity of the organised breast cancer screening programmes implemented in Italy. Data are collected in an aggregated way and gathered through a standardised form to calculate process and impact parameters. Data analysis from 2000-2010 shows that crude attendance rate reached the acceptable 50% standard, presenting a higher level of participation in Northern and Central Italy compared to Southern Italy/Islands, where attendance rates are still inadequate and do not reach the acceptable standard. In areas where a more complete regional extension (referring frequently to a more centralised management) exists, the participation rate was higher compared to those with partial regional extension and no centralised management. The differences range from 5% in 2005 to 22% in 2010. The time trends of the other analysed parameters showed, in 2010, a good overall quality of the performance. For example, benign/malignant surgical biopsy ratio (B/M ratio) reached 0.19 at first screening and 0.11 at subsequent screening; detection rate for in situ and small cancers (≤10 mm) showed a good trend, reaching 0.9‰ and 1.2‰, respectively, at first screening, and 0.6‰, and 1.5‰ for subsequent screening, respectively. On the contrary, excess referral rate at first screening persisted (9.2%) in the year 2010, while RR is improved at subsequent screening (from 4.2% in 2009 to 3.9% in 2010). The overall detection rate is improved both at first and subsequent screening (5.2‰ in 2010 vs. 5.7‰ in 2009 and 4.7‰ in 2010 vs. 5.7‰ in 2009, respectively). Although further analyses are needed to better interpret these trends, results continue to be consistent with those achieved by other European programmes, and they are reassuring for all Italian breast cancer screening professionals.

Effectiveness of vision rehabilitation treatment through MP-1 microperimeter in patients with visual loss due to macular disease

PURPOSE

To evaluate the effectiveness of biofeedback treatment for low-vision rehabilitation in patients affected by macular disease.

MATERIALS AND METHODS

171 eyes of 99 patients (42 female and 57 male) between 50 to 75 years old (mean age: 64.6) were included in this study. All patients were suffering from age-related macular degeneration (AMD) (122 eyes) or macular myopic degeneration (MMD) (49 eyes). All patients underwent an assessment of examinations including visual acuity, reading speed test, slit lamp examination and tonometry, ophthalmoscopic fundus examination, microperimetry, fixation test, retinal sensitivity, fluorangiography (FAG), optical coherence tomography (OCT). The treatment was divided in 16 sessions, the patients underwent other examination assessment at 6 and 12 months, except for FAG and OCT. Statistical analysis was performed using Student's t-test, and p-value <=0.05 was considered statistically significant.

RESULTS

After training 130 eyes of 171 in the study group (76.02%) had a statistically significant improvement of the distant visual acuity (p<0.01): 38 eyes suffering from MMD and 92 eyes suffering from AMD. After 12 months of follow-up a group of 25 eyes of 130 (19.23%) had a loss of benefits that were observed at the end of the treatment sessions: 16 eyes and 9 eyes were suffering from MMD and AMD respectively. Examination assessment during follow-up showed that 4 eyes and 2 eyes of the group that lost benefits had a worsening of MMD and AMD primary disease respectively.

CONCLUSIONS

It is not yet understood how biofeedback produces amelioration of visual function. According to the 'Eccentric fixation' theory, with biofeedback rehabilitation patients are trained to use the non-damaged retina areas to develop a new preferred retinal locus. In our study group we found a significant improvement in both visual acuity and fixation.

Mammography screening in Italy: 2009 survey

This report is an update of similar previous papers that have been published by the ONS (Osservatorio nazionale screening, National Centre for Screening Monitoring) since 2002. Data for the survey come from several different programmes that may have changed over time, and may have different settings of organisation and management. During 2009, an increase in theoretical extension was recorded; however, this was not followed by an increase in actual extension, which remained stable. Currently, all Italian regions have implemented screening programmes. In 2009, almost 2,522,000 women aged 50-69 years were invited to have a screening mammogram, and more than 1,362,000 were screened. Theoretical extension was 93.8%, while actual extension was 69.5%. An imbalance in coverage is still present when comparing northern and central Italy to southern Italy, which only has a 78% coverage by organised screening. The Italian mean value (78.5%) of two-year extension (period 2008-2009) suggests that, at full capacity, Italian programmes are able to invite only three quarters of the target population. The percentage of women screened during 2009 accounted for 36.5% of the national target population. During the last few years, participation rates were substantially stable, around 55-57%for crude rate, and 59-61%for adjusted rate, respectively. A decreasing trend towards the South of Italy is evident for this parameter, too. Many programmes work with low volumes of activity (below 10,000 or even 5,000 examinations per year), and only one region surpassed the desirable level of at least 20 000 examinations for each programme. Referral rates of 8% at first screening and 4.6% at repeat screening were recorded. Direct standardised detection rate was 6.2 x 1,000 at first screening and 4.4 x 1,000 at repeat screening, while benign to malignant ratio for first and repeat screening was 0.25 and 0.12, respectively. Detection rate of invasive cancers ≤ 10 mm was 1.34 x 1,000 at first screening and 1.51 x 1.000 at repeat screening; the proportion of in situ carcinomas was 14.1% and 14.4% for first and repeat screening, respectively. Indicators by 5-year age group confirm greater diagnostic problems at younger ages (50-54 years), with higher referral rates, higher frequency of surgical procedures with benign outcome (B/M ratio), and a substantially lower detection rate as compared to older age groups.

Time trends of process and impact indicators in Italian breast screening programmes (1999-2009)

Since its establishment in 1990, one of the main tasks of the Italian group for mammography screening (GISMa) is the systematic data collection on the activity of the organised mammography screening programmes implemented in Italy. Data are collected in an aggregated way and gathered through a standardised form to calculate process and impact parameters. Data analysis from 1999-2009 shows that crude attendance rate reached the acceptable 50% standard, presenting a higher level of participation in northern and central Italy compared to southern Italy/Islands, where attendance rates are still inadequate and do not reach the acceptable standard. In areas where centralised management is more established or complete, the participation rate was higher compared to areas without such characteristics, with differences from 5% in 2005 (reaching 22% in 2008) to 10% in 2009. The time trends of the other parameters included in the analysis showed, in 2009, a good average performance. For example, benign/malignant surgical biopsy ratio (B/M ratio) reached 0.21 at first screening and 0.08 at subsequent screening; detection rate for in situ and small cancers (≤10 mm) showed a good trend, reaching 0.9‰, and 1.5‰, respectively, for first screening, and 0.9‰, and 1.4‰ for subsequent screening. On the contrary, excess referral rate at first screening persisted, and the overall detection rate presented a negative trend in the last period (8.9% and 5.7‰, respectively). Although further analyses are needed to better interpret these trends, results continue to be consistent with those achieved by other European programmes, and are reassuring for all Italian mammography screening professionals.

Mammography screening in Italy: 2008 survey

This report is an update of similar previous papers that have been published by the ONS (Osservatorio Nazionale Screening, National Centre for Screening Monitoring) since 2002. Data for the survey come from several different programmes that may have changed over time, and may have different settings of organisation and management. During 2007, a further increase in screening activity was recorded, with the inclusion of all Northern and Central Italian Regions, and a further development in the Southern Regions and Islands, so today all Italian Regions have implemented screening programmes. In 2008, almost 2,509,000 women aged 50-69 years were invited to have a screening mammogram, and more than 1,361,000 were screened. Theoretical extension was 89.9%, while actual extension increased from 62.3% in 2007 to 69.4%in 2008. An imbalance in coverage is still present when comparing Northern and Central Italy to Southern Italy, which only has a 69% coverage by organised screening. The Italian mean value (72.8%) of two-year extension (period 2007-2008) suggests that, at full capacity, Italian programmes are able to invite only two thirds of the target population. The percentage of women screened during 2008 accounted for 36.7% of the national target population. During the last few years, participation rates were substantially stable around 55-57% for crude rate, and 59-61% for adjusted rate, respectively. A decreasing trend towards the South of Italy is evident for this parameter, too. Many programmes work with low volumes of activity (below 10,000 or even 5,000 examinations per year), and only one Region surpassed the desirable level of at least 20,000 examinations for each programme. Referral rates of 7.5% at first screening and 4.4% at repeat screening were recorded. Direct standardised detection rate was 6.2x1,000 at first test and 4.2 at repeat test, while benign to malignant ratio for first and repeat screening was 0.25 and 0.15, respectively. Detection rate of invasive cancers ≤10 mm was 1.39x1,000 at first test and 1.44 at repeat test; the proportion of in situ carcinomas was 12.5% and 14.2% for first and repeat test, respectively. Indicators by 5-year age group confirm greater diagnostic problems at younger ages, with higher referral rates, higher frequency of surgical procedures with benign outcome (B/M ratio), and a substantially lower detection rate as compared to older age groups.

Time trends of process and impact indicators in Italian breast screening programmes: 1998-2008

Since its establishment in 1990, one of the main tasks of the Italian Group for Mammography Screening (GISMa) is the systematic data collection on the activity of the organised mammography screening programmes implemented in Italy. Data are collected in an aggregated way and gathered through a standardised form to calculate process and impact parameters. Data analysis referring to the period 1998-2008 shows that crude attendance rate reached the acceptable 50% standard, presenting a higher level of participation in Northern and Central Italy compared to Southern Italy/Islands, where attendance rates are still inadequate and do not reach the acceptable standard. In areas where the centralised management is more established or complete, the participation rate was higher compared with areas without such characteristics, with differences from 5% to 22% (in 2008). The time trends of the other parameters included in the analysis showed, in 2008, a good average performance. For example, benign/malignant surgical biopsy ratio (B/M ratio) reached 0.21 at first screening and 0.11 at subsequent screening; overall detection rate, detection rate for in situ and small cancers (≤10 mm) showed a good trend, reaching 5.7‰, 1.1‰, and 1.4‰, respectively, for first screening, and 5.0‰, 0.7‰, and 1.4‰ for subsequent screening. On the contrary, excess referral rate at first screening persists over time. These results continue to be consistent with those achieved by other European programmes and reassuring for all Italian mammography screening professionals.

Mammography screening in Italy: 2007 survey

This report is an update of similar previous papers that have been published by the ONS (Osservatorio Nazionale Screening, National Centre for Screening Monitoring) since 2002. Data for the survey come from several different programmes that may have changed over time, and may have different settings of organisation and management. During 2007, a further increase in screening activity was recorded, with the inclusion of all Northern and Central Italian Regions, and a further development in the Southern Regions and Islands. In 2007, screening activity also started in Puglia, so today all Italian Regions have implemented screening programmes. In 2007, almost 2,210,000 women aged 50-69 years were invited to have a screening mammogram, and over 1,225,000 were screened. Theoretical extension was 81.4%, while actual extension increased from 57.2% in 2006 to 62.3% in 2007, finally rising over the critical value of about 50% registered during the last years. An imbalance in coverage is still present when comparing Northern and Central Italy to Southern Italy, which only has a 52% coverage by organised screening. The percentage of women screened during 2007 accounted for 33.3% of the national target population. During the last few years (2004-2007), participation rates were substantially stable around 55-57% for crude rate, and 59-61% for adjusted rate, respectively. A decreasing trend towards the South of Italy is evident for this parameter, too. Many programmes work with low volumes of activity (below 10,000 or even 5,000 examinations per year), and no regional mean value surpassed the desirable level of at least 20,000 examinations for each programme. Referral rates of 7.9% at first screening and 4.0% at repeat screening were recorded. Direct standardised detection rate was 6.5x1,000 at first test and 3.8 at repeat test, while benign to malignant ratio for first and repeat screening was 0.21 and 0.14, respectively. Detection rate of invasive cancers </=10 mm was 1.18x1,000 at first test and 1.28 at repeat test; the proportion of in situ carcinomas was 13.3% and 14.7% for first and repeat test, respectively. Indicators by 5-year age group confirm greater diagnostic problems at younger ages, with higher referral rates, higher frequency of surgical procedures with benign outcome (B/M ratio), and a substantially lower detection rate as compared to older age groups.

Time trends of process and impact indicators in Italian breast screening programmes: 1998-2007

Since its establishment in 1990, one of the main tasks of the Italian Group for Mammography Screening (GISMa) has been that of collecting, as systematically and thoroughly as possible, data on the activity of the Italian mammography screening programmes. Data are collected in an aggregated way and gathered through a standardised form to calculate process and impact parameters. Analysis of data referring to the period 1998-2007 shows that crude attendance rate reached the acceptable 50% standard, presenting a higher level of participation in Northern and Central Italy compared to Southern Italy/Islands, where attendance rates are still inadequate and do not reach the acceptable standard. In areas where the centralised management is more established or complete, the participation rate was higher compared with areas without such characteristics, with differences of about 4-9%. The time trends of the other parameters included in the analysis showed a good average performance. For example, benign/malignant surgical biopsy ratio (B/M ratio) continued to progressively decrease, reaching 0.20 at first screening and 0.10 at subsequent screening in 2007; overall detection rate, detection rate for in situ and small cancers (< or =10 mm) showed a good trend, reaching 5.4 per thousand, 0.9 per thousand, and 1.6 per thousand, respectively, for fi rst screening, and 4.8 o/oo, 0.8 o/oo, and 1.2 o/oo for subsequent screening in 2007. On the contrary, excess referral rate at first screening persists over time. Data comparing activity volume and programme duration were also considered. In programmes with greater activity volume (average test number: 24,596) the referral rate for first screening was higher if compared with programmes with lower activity volume, but still within acceptable standards. Nevertheless, this performance is compensated by better specificity and sensitivity. An improvement in quality with the increase of programmes experience continues to be evident: compared with new programmes, programmes with more than 6 years of activity showed lower recall rates, higher positive predictive values and higher overall detection rates in the first screening round. Outcomes related to subsequent screening rounds present analogous performances. These results continue to be consistent with those achieved by other European programmes and reassuring for all Italian mammography screening professionals.

Physical activity and mammographic breast density in a Mediterranean population: the EPIC Florence longitudinal study

A protective effect of physical activity (PA) on breast cancer (BC) risk has been suggested. Few studies have examined the influence of PA on mammographic breast density (MBD), a strong risk factor for BC. In a prospective study in Florence, Italy, we identified 2,000 healthy women with a mammogram taken 5 years after enrollment. Individual mammograms were retrieved (83%) and MBD assessed according to Wolfe's classification. Detailed information on PA at work and during leisure time, reproductive history, lifestyle and anthropometric measurements at enrollment were available for 1,666 women. Information on hormone replacement therapy (HRT) was also obtained at mammogram. Women with high-MBD (P2 + DY Wolfe's patterns) were compared with women with low-MBD (N1 + P1) by multivariate logistic models. Overall, high-MBD was inversely associated with increasing levels of leisure time PA (p for trend = 0.04) and among peri-/postmenopausal women, also with increasing levels of recreational activities (p for trend = 0.02). An interaction between PA and HRT emerged, with a stronger inverse association of highest level of recreational activity with MBD among HRT nonusers (p for interaction = 0.02). A modifying effect by body mass index (BMI) was evident among 1,025 peri-/postmenopausal women who did not use HRT at the time of mammogram, with a stronger inverse association between recreational PA and MBD in the highest BMI tertile (OR = 0.34; 95% CI 0.20-0.57; p for interaction = 0.03). This large study carried out in Mediterranean women suggests that leisure time PA may play a role in modulating MBD, particularly in overweight/obese peri-/postmenopausal women.

[Interval cancers as indicators of performance in screening programmes]

GISMa analyses the interval cancer (IS) topic providing guidelines and reference standards in addition to CE recommendations. IC identification is based on Cancer Registries (CR), if existing, or on hospital discharge records, in alternative. The optimal measure of IC frequency (inversely correlated with sensitivity) is the IC proportional incidence (observed IC/carcinomas expected in absence of screening). Other formulas (IC/IC + screen detected cancers; IC rate per 1000 negative screens) look less reliable. IC stage at diagnosis (if available through CR) must be compared with screen detected cancer and cancer detected in non-attenders. Review of mammograms preceding the IC (coded as screening error, minimal signs, or occult) should be done mainly with a blind procedure (IC mixed with negative controls), as this procedure is more representative of the original scenario and more respectful of radiologist's rights.

Mammography screening in Italy: 2005 survey and 2006 preliminary data

Mammography screening programmes in Italy have been implemented since the early 90's. Over the last ten years, national and international institutions have strongly supported screening programme implementation with several laws. Since 2004, the Italian Ministry of Health, together with the Commission of Regions and Self-governing Provinces Health Officials, has officially entrusted the ONS (Osservatorio Nazionale Screening, National Centre for Screening Monitoring) with monitoring and promoting nationwide screening programmes. Previously, for several years, GISMa (Gruppo Italiano per lo Screening Mammografico) carried out a yearly survey to collect process indicators of mammography screening and compare them, using national and international standard values as reference. In 2006, an updated version of the operative report of process indicators was published by GISMa, and in November 2006 the updated national screening guidelines, prepared by the workgroups on oncological screening set up by the Ministry, was published. This report is an update of similar previous papers published by the ONS since 2002. Data for the survey come from several different programmes that may have changed over time, and may have different settings of organisation and management. During 2005, an increase in screening activity was recorded with the inclusion of all Northern and Central Italian Regions, and 2006 showed a further development n the Southern Regions and Islands. Only one Region is missing (Puglia), but it started its activity in 2007; so starting from 2007, all Italian Regions have implemented screening programmes. In 2006, more than 2 million women aged 50-69 years were invited to have a screening mammogram, and over 1,150,000 were screened. Theoretical extension was 76.4% in 2005 and 78.2% in 2006. This year shows an important increase in actual extension, improving from 50.3% in 2005 to 57.2% in 2006 and finally rising over the critical value of about 50% registered during the last years. An imbalance in coverage is still present when comparing Northern and Central Italy (more than 90%) to Southern Italy, which only has a 46% coverage by organised screening. The percentage of women screened during 2005 accounted for 28.6% of the national target population, and increased up to 31.8% in 2006. During the three-year period 2004-2006, participation rates were substantially stable around 55-57% for crude rate, and 59-60% for adjusted rate, respectively. A decreasing trend towards the South of Italy is evident for this parameter, too, but in 2005-2006 the Central Regions registered the highest increase in attendance: crude and adjusted participations rose from 52-54% in 2004 to 56-58% in 2005-2006. Many programmes work with low volumes of activity (below 10,000 or even 5,000 examinations per year), and no regional mean value surpassed the desirable level of at least 20,000 examinations for each programme. Referral rates of 8.3% at first screening and 4.5% at repeat screening were recorded. Direct standardised detection rate was 5.7 x 1,000 at first test and 4.6 at repeat test, while benign to malignant ratio for first and repeat screening was 0.28 and 0.21, respectively. Detection rate of invasive cancers < or =10 mm was 1.44 x 1,000 at first test and 1.58 at repeat test; the proportion of in situ carcinomas was 12.9% and 14.7% for first and repeat test, respectively. Indicators by 5-year age group confirm greater diagnostic problems at younger ages, with higher referral rates, higher frequency of surgical procedures with benign outcome (B/M ratio), and a substantially lower detection rate as compared to older age groups.

Time trends of process and impact indicators in Italian breast screening programmes--1996-2005

Since its establishment in 1990, one of the main tasks of the Italian Group for Mammography Screening (GISMa) has been that of collecting, as systematically and thoroughly as possible, data on the activity of the various mammography screening programmes implemented in Italy. Data are collected in an aggregated way and gathered through a standardised form to calculate process and impact parameters. Analysis of data collected in the period 1996-2006 shows that the number of Italian women involved in mammography screening has constantly increased over time. In 2006, almost 8 out of 10 Italian women in the 50-69 year age range lived in areas where an organised screening activity had been implemented. The geographical distribution of the screening activity in Italy continues to present differences between Northern and Central Italy, where the coverage ranges from 95.7% to 89.6%, and Southern Italy and the Islands, where this value is still lower (45.9%). The discrepancy between annual theoretical coverage and actual coverage still persists (21%). Throughout the period, crude attendance rate reached the acceptable 50% standard, presenting the same North-South trend as the coverage rate distribution. In areas where the centralised management is more established or complete, the participation rate was higher compared with areas without such characteristics, with differences of about 4-9%. The time trends of the other parameters included in the analysis showed a good average performance. For example, benignant/malignant surgical biopsy ratio (B/M ratio) continued to progressively decrease, reaching 0.24 at first screening and 0.14 at subsequent screening in 2005; overall detection rate, detection rate for in situ and small cancers (< or =10 mm) showed a good trend, reaching 6.0 per thousand, 0.7 per thousand, and 1.3 per thousand, respectively, for first screening, and 5.2 per thousand, 0.8 per thousand, and 1.6 per thousand for subsequent screening in 2005. On the contrary, excess referral rate at first screening persists over time. Data comparing activity volume and programme duration were also considered. In programmes with greater activity volume (average test number: 24,596) the referral rate for first screening was higher if compared with programmes with lower activity volume, but still within acceptable standards. Nevertheless, this performance is compensated by better specificity and sensitivity. An improvement in quality with the increase of programmes experience continues to be evident: compared with new programmes, programmes with more than 6 years of activity showed lower recall rates and higher positive predictive values and overall detection rates in first screening. Outcomes related to subsequent screening present analogous performances. These results continue to be consistent with those achieved by other European programmes and reassuring for all Italian mammography screening professionals.

Mammography screening in Italy: 2004 survey and 2005 preliminary data

In 2004 regions were required to provide the ONS (Osservatorio Nazionale Screening, National Centre for Screening Monitoring) with data on screening activity. Previously, GISMa (Gruppo Italiano Screening Mammografico) had for several years carried out a yearly survey to collect process indicators of mammography screening and compare them, using standard values agreed on at a national and international level. In 2006, an updated version of the operative report of process indicators was published by GISMa and ONS. Data for the survey came from several different programmes that may have changed over time, and may have different settings of organisation and management. The year 2004 can be considered almost exhaustive of the situation of Italian mammography screening; data were provided by 117 programmes from 18 different regions. In ten regions, the individual programmes are part of a comprehensive regional project. In 2004, about 1,870,000 women aged 50-69 years were invited to have a screening mammography, and over 1,050,000 were screened. Theoretical extension was 71.9%, while 52% of the target population received an invitation to screening. An imbalance in coverage is still present when comparing Northern (more than 80%) and Central Italy (almost 100%) to Southern Italy, that only has a 40% coverage by organised screening. The national crude attendance rate was 55.6%, slightly lower than the previous year. A decreasing trend was evident from the North to the Centre to the South of Italy: 60.2%, 51.8%, and 39.1%, respectively. Referral rates of 8.8% at first screening and 4.2% at repeat screening were recorded. Direct standardised detection rate was 6.6 x 1000 at the first test and 5.0 at repeat test, while benign to malignant ratio for first and repeat screening was 0.34 and 0.20, respectively. Indicators by 5-year age group confirm greater diagnostic problems at younger ages, with higher referral rates, higher frequency of surgical procedures with benign outcome (B/M ratio), and a substantially lower detection rate as compared to older age groups. Preliminary data for the year 2005 shows a further increase in screening coverage: 76.4 % of the Italian target population was enrolled in screening programmes, and 50.3% received an invitation to have a mammography. Imbalance in coverage still exists between Northern and Central Italy and the South: figures are 92.4%, 98.6%, and 39.3%. The national crude attendance rate was 5 7.8%.

Time trends of process and impact indicators in Italian mammography screening programmes--1996-2004

Since 1990, the Italian Group for Mammography Screening (GISMa) has been promoting the development of new organised programmes and performing a yearly systematic survey of data activity. The screening extension has increased over time, reaching an overall 76.4% of coverage in 2005. The geographical extension is still heterogeneous, with a higher distribution in Northern and Central Italy compared with Southern and Insular Italy, where the screening activity was implemented only recently. Notwithstanding the continuity in implementation, the actual coverage reached only 50.3% of the target population, due to a reduced flow of invitations over time as a consequence of a chronic lack of invested resources and of well-plannedpolicies. The overall Italian rate for crude attendance was above the acceptable 50% standard even though a North-South trend is still confirmed; in Southern/Insular Italy participation was still inadequate (<40%) and did not reach the standard considered acceptable. Participation was higher in centralised programmes compared with those without regional coordination (+5-8%). The time trends for the other key performance indicators showed good average performance: the benign/malignant surgical biopsy ratio (B/M ratio) progressively decreased, reaching an 0.25 ratio (both for first and subsequent screening) in 2004; overall detection rate, detection rate for in situ and small cancers (< or =10 mm) showed a good trend, reaching 6.7% per hundred, 0.7% per hundred, and 1.6% per hundred, respectively, for the first screening, and 5.1% per hundred, 0.9% per hundred, and 1.7% per hundred for the subsequent screening in 2004. The only exception was the referral rate (RR) at first screening, which exceeded standards (> 7% in 2002-2004). Data comparing activity volume and programme duration were also analysed. In programmes with greater activity (average test number: 22,506) the referral rate for the first screening was higher, but still within acceptable standards. 6.3% per hundred; RR: 1.01 (0.98-1.04). This performance is compensated by better specificity and sensitivity: Positive Predictive Value (PPV). 12.8; RR:1.16 (1.05-1.27); overall detection rate: 8.1% per hundred, RR 1.19 (1.07-1.31). An improvement in quality with the increase of programme experience is evident. programmes with more than 6 years of activity, compared with newer programmes, show a recall rate in first screening of 6.5%; RR. 0.87 (0.84-0.89), a PPV of 1.7, RR:1.61 (1.48-1.75) andan overall detection rate of 7.6% per hundred, RR:1.41 (1.29-1.55). These results are consistent with those observed in other European programmes and encourage to explore new analysis strategies. The website of the National Centre for Screening Monitoring (ONS) is http://www.osservatorionazionalescreening.it.

Dietary and lifestyle determinants of mammographic breast density. A longitudinal study in a Mediterranean population

High mammographic breast density (H-MBD) has been associated with increased breast cancer (BC) risk, even after adjustment for established BC risk factors. Only a few studies have examined the influence of diet on MBD. In a longitudinal study in Florence, Italy, we identified about 2,000 women with a mammogram taken 5 years after enrollment, when detailed information on dietary and lifestyle habits and anthropometric measurements had been collected. Original mammograms have been identified and retrieved (1,668; 83%), and MBD was assessed by 2 experienced readers, according to Wolfe's classification and a semiquantitative scale. By logistic analysis, we compared women with H-MBD (P2 + DY according to Wolfe's classification) with those with low-MBD (N1 + P1). H-MBD was confirmed to be inversely associated with BMI, number of children and breast feeding, while it was directly associated with higher educational level, premenopausal status and a previous breast biopsy. In multivariate analyses adjusted for non-dietary variables, H-MBD was inversely associated with increasing consumption of vegetables (p for trend = 0.005) and olive oil (p for trend = 0.04). An inverse association was also evident between H-MBD and frequent consumption of cheese and high intakes of beta-carotene, vitamin C, calcium and potassium (p for trend < or = 0.05). On the other hand, we found a positive association with increasing consumption of wine (p for trend = 0.01). This large longitudinal study, the first carried out in Mediterranean women, suggests that specific dietary components may play a key role in determining MBD in this population, thus possibly modulating BC risk.

[Process indicators and standards for the evaluation of breast cancer screening programmes]

In order to obtain the maximum benefit from breast cancer screening it is essential for every programme to reach high levels of sensitivity and specificity. This can only be achieved if skill and a comprehensive quality assurance system is applied to the entire process, involving each individual part of the programme. Monitoring of outcomes and continuous evaluation of the entire screening process are key operational objectives for a successful population screening programme. The aim of this document, born in the framework of the Italian Group for Mammography Screening (GISMa), is to propose a unique methodology for collecting and reporting screening data using commonly agreed terminology, definitions and classifications. The indicators considered are those referred to the entire screening process and its sequelae, such as organizational, logistic and performance indicators. The indicators are provided under form of a synthetic and easy to use card. Every card is structured in short sections: definition, aim of the indicator, the data necessary to build it, the summarizing formula, possible problems of interpretation, the acceptable and desirable standards (derived both from the experience of national and European breast cancer screening programmes).

Mammography screening in Italy: 2003-2004 survey

GISMa performs a yearly survey to collect process indicators of mammography screening and compare them, using standard values agreed on a national and international basis. This survey is highly representative of the Italian situation, providing summary data stratified by region and by age group. Data come from several different programmes that may have changed over time, and may have different model of organisation and management. Eighty-eight programmes from 15 different regions (out of 21) provided data for 2003. In nine regions individual programmes are part of a comprehensive regional project. During this year about 1,480,000 women aged 50-69 years were invited to have a screening mammogram, and over 843,000 were screened. Theoretical coverage was 56.2%, while 41.4% of the target population received an invitation to screening. An imbalance in coverage can be seen when comparing Northern and Central Italy, where over 3/4 of the population is covered, to Southern Italy, with only a 10.6% coverage by organised screening. National crude attendance rate was 58.3%. A decreasing trend was evident from the North to the Centre to the South of Italy: 61.2%. 56.2%, and 38.1% respectively. Referral rates of 7.8% at first screening and 4.5% at repeat screening were recorded. Direct standardised detection rate was 6.9 x 1000 at first test and 4.8 at repeat test, while benign to malignant ratio for first and repeat screening was 0.33 and 0.23 respectively. Detection rate of "small" cancers (< or =10 mm in size) was 1.5 and 1.4 x 1000 for first and repeat test. Indicators by 5-year age groups confirm greater diagnostic problems at younger ages, with higher referral rates, higher frequency of surgical procedures with benign outcome (B/M ratio), and a substantially lower detection rate as compared to older age groups. The year 2004 was the first in which regions were required to provide data on screening activity to the ONS; data were provided by 120 programmes from 18 regions. Preliminary data showed a coverage rate of 69.4%, while 51.1% of the target population received an invitation to screening. Although a substantial increase in coverage was observed also in Southern Italy. a major imbalance in coverage still exists between Northern-Central and Southern Italy: 82.3%, 98.2% and 30.5% respectively. National crude attendance rate was 55.8%.

Time trends of some indicators of mammography screening programmes in Italy, 1996-2003

Since 1992, the Italian Group for Mammography Screening (GISMa) has been performing a yearly systematic survey of ongoing activities. The screening extension increased from 1996, reaching an overall 68.7% coverage in 2004. This progression has been more evident in Central-Northern Italy while in Southern Italy a real, but still limited (30%), increase has been recorded only recently. Despite this geographical extension, the actual coverage reached only 5 1.1% of the target population, due to a reduced flow of invitations over time as a consequence of a chronic lack of invested resources and of well planned political actions. The time trends for the key performance indicators show a good average performance: crude attendance rate exceeds over the years the acceptable 50% standard; BIM ratio is progressively decreasing, reaching a ratio of 0.7:1 (both for first/subsequent screening) in 2003; overall detection rate, detection rate for in situ and small cancers (< or =10 mm) show a good trend, reaching 6.6% per hundred, 1.5% per hundred and 0.7% per hundred respectively for the first screening in 2003. An exception is the referral rate at first screening which exceeds the reference standards (> 7% in the last 2 years). Data have been analysed also according to activity volume and programme duration. In programmes with greater activity (average test number: 24,702) the referral rate for the first screening is higher, but still within acceptable standards: 5.8%; RR: 1.05 (1.02-1.10). This performance is compensated by better specificity and sensitivity: PPV = 13.3: RR: 1.14 (1.03-1.27); overall detection rate = 6.7% per hundred; RR: 1.22 (1.09-1.36). An improvement of quality with the increase of experience is evident: programmes with more than 6 years of activity, compared with newer programmes, show a recall rate in first screening of 6.0%; RR:0.86 (0.86-0.92), a PPV of 13.4; RR: 1.65 (1.40-1.69) and an overall detection rate of 8.1% per hundred; RR: 1.44 (1.25-1.53). These results are consistent with those observed in other European programmes, and encourage new analysis strategies. The web site of the National Centre for Monitoring Screening is http://wwuw.osservatoriotumori.it.

Monitoring surgical treatment of screen-detected breast lesions in Italy

The object of this study was to assess quality of care and adherence to treatment guidelines of screen-detected lesions in Italy using a new audit system. Data on screen-detected cases surgically treated in 1997 were collected using a system (QT 2.3) developed within the Italian Group for Planning and Evaluating Mammographic Screening Programmes (GISMa) and the European Breast Cancer Screening Network. Results of 18 performance parameters were considered compared with the reference standards. In 1997, 515 lesions (335 invasive, 60 in situ and 120 benign) in 496 patients were collected from 14 departments in the Central and Northern area of Italy. The 18 indicators were analysed and grouped according to six quality objectives. Some results were good and others were excellent, such as intraoperative identification, breast conservation surgery, adequate axillary procedures and completeness of pathology reports, but most of them failed: waiting times, preoperative diagnosis, employment of frozen section on small lesions and avoiding axillary procedures in ductal carcinoma-in-situ. This work is a first attempt in Italy to evaluate and uniform the criteria adopted for quality control of breast cancer treatment, using a standardised system. Some results are good or excellent, the overall level of compliance with quality indicators is not satisfactory and corrective actions should be undertaken for a number of issues. A continuous monitoring should be performed and appropriate action taken in order to verify the effectiveness of the corrective actions and to provide screen-detected patients with the best quality of care.

Olfactory receptors

Olfaction is an ancient sensory system allowing an organism to detect chemicals in its environment. The first step in odor transduction is mediated by binding odorants to olfactory receptors (ORs) which belong to the heptahelical G-protein-coupled receptor (GPCR) superfamily. Mammalian ORs are disposed in clusters on virtually all chromosomes. They are encoded by the largest multigene family (approximately 1000 members) in the genome of mammals and Caenorhabditis elegans, whereas Drosophila contains only 60 genes. Each OR specifically recognizes a set of odorous molecules that share common molecular features. In mammals, signal transduces through the G-protein-dependent signal pathway in the olfactory sensory neurons that synapse ultimately in the glomeruli of the olfactory bulb, and is finally processed in higher brain structures. The expression of a given OR conditions neuron and glomerulus choices. To date, the processes which monitor OR expression and axon wiring have emerged but are not completely elucidated.

Colorectal cancer screening programme by faecal occult blood test in Tuscany: first round results

Screening with faecal occult blood test (FOBT) has been shown to be effective in reducing mortality from colorectal cancer. Tuscany was the first region in Italy in which a screening programme for colorectal cancer by FOBT was initiated region-wide. The aim of the paper was to describe organizational aspects, a quality control model and the results of this experience. From June 2000 to December 2001, 192583 subjects aged 50-70 were invited to undergo a 1-day immunochemical test without any dietary restriction. A total of 78505 subjects (41%) performed the screening test, of whom 4537 responders had a positive test result (5.8%). Among them, 1122 refused any form of assessment or underwent a colonoscopy outside the screening referral centres, with an overall assessment compliance of 75.3%. Malignancies were found in 193 patients and at least a high-risk adenomatous polyp in 692 patients. In about a quarter of the positive subjects who underwent assessment, cancer or high-risk adenoma was detected. In conclusion, data from this experience supported the feasibility of biennial colorectal screening programme by FOBT, particularly regarding invitation compliance and positivity rate. Further efforts are necessary to implement screening extension and to improve data collection.

Blood pressure independent association of microalbuminuria and left ventricular hypertrophy in hypertensive men

BACKGROUND

Rather unique amongst the prognostic predictors, microalbuminuria (MA, albuminuria: 15-200 microg min-1) is associated with several cardiovascular risk factors including left ventricular hypertrophy (LVH). The relationship, usually assumed to reflect an increased blood pressure (BP) load on the heart and the kidney, may, however, represent more than a haemodynamic correlate.

METHODS

To evaluate this possibility, we related MA to left ventricular mass index (LVMI) and other functional and structural echocardiographic parameters, office and 24-h BP, weight, lipids and smoking status in 330 never treated nondiabetic hypertensive men.

RESULTS

The risk of MA increased linearly by ascending quartiles of LVMI and was 2.3-fold higher in the presence of LVH after adjustment for age, left atrial size, mean fractional shortening. Systolic BP, either office or 24 h, and smoking status were the only additional independent predictors in multivariate logistic regression models. The BP-adjusted risk of MA was about twofold higher in patients with LVH, either concentric or eccentric, and neutral in those with concentric remodelling compared with normal geometry.

CONCLUSIONS

The association between elevated LVMI and MA independent of several other potential confounders, systolic BP in particular, is consistent with the existence of cardiac albuminuric factors, possibly of hormonal nature, which are to be identified more precisely. The extent to which LVH explains the predictive power of MA for morbid events independent of the BP load remains unknown.

Isolation and characterization of S genome specific sequences from Aegilops sect. sitopsis species

Three S genome specific sequences were isolated from Aegilops sect. sitopsis species using different experimental approaches. Two clones, UTV86 and UTV39, were isolated from a partial genomic library obtained from DNA of Aegilops sharonensis, whereas a third clone, UTV5, was isolated from Aegilops speltoides. The three clones were characterized by sequencing, analysis of methylation, and sequence organization and abundance in some Aegilops and Triticum species. The clones UTV39 and UTV5 belong to the same family of tandem repeated sequences and showed high homology with a sequence already present in nucleotide databases. The UTV86 clone from Ae. sharonensis corresponded to an interspersed low frequency repeated sequence and did not show any significant homology with reported sequences. Southern hybridization experiments, using the cloned sequences as probes, detected polymorphism in the restriction patterns of all the five Aegilops species in section sitopsis. Aegilops speltoides showed the most divergent hybridization pattern. A close relationship was detected between the S genome of Ae. speltoides and the G genome of the wild Triticum timopheevii. In situ hybridization revealed a telomeric and (or) subtelomeric location of the sequences UTV39 and UTV5.

Coronary microcirculation into different models of left ventricular hypertrophy-hypertensive and athlete's heart: a contrast echocardiographic study

The study was carried out in two different models of left ventricular hypertrophy: athlete's heart and essential arterial hypertension. Three groups of strictly age-matched males were studied: one group of 10 young adult untreated essential hypertensive patients (H), a second group of 10 athletes (A), and a group of 10 healthy individuals as controls (C). A Sonos 5500 echograph with S4 harmonic transducer was used with Levovist (ultrasonic tracer) before and after dipyridamole injection; digitised images of quantitative myocardial contrast echocardiography were collected with Power Harmonic Doppler. Angio images were analysed using dedicated PC software by placing a region-of-interest on the septum. Peak intensity, half-time (HT), the area under the curve of appearance and disappearance of microbubbles at 2/3 of PI, both in absolute and indexed values (/LVMi), were sampled. The per cent increase of PI after dipyridamole was significantly higher in C (+73%, P < 0.01) than in H (+31%) and in A (+33%) (P < 0.05). The area of appearance was significantly lower in H in comparison with C and A, both at rest and after vasodilatation. The disappearance area after dipyridamole was significantly higher in C and in A (+124%) than in H (+104%) (P < 0.05). Some hypothesis could be made: an impairment in the coronary microcirculatory function in hypertensive patients could be because of an in-crease in the arteriolar resistance. Angiogenesis and several different functional adaptations are the mechanisms that allow an optimal distribution of oxygen and of substrates to the hypertrophied myocardium of the athletes.

Monitoring interval cancers in mammographic screening: the Florence District programme experience

The aim of the present study was to monitor the occurrence of interval (breast) cancers (IC) as an interim outcome measure of quality assurance in the mammographic screening programme of the District of Florence. IC were identified by linking breast screening data with registrations of breast cancers from the Tuscany Tumour Registry. The main outcome measures were the numbers, rates, and the proportionate incidence of IC. Overall, 90 invasive IC were observed among women who attended the breast screening programme in the District of Florence from 1 January 1985 to 31 December 1993, respectively, 23, 50, on 17 cases, at 1, 2, and 3 years after the last negative screening test. Expressed as a proportion of underlying incidence, the figures are 16, 44, and 46%. As to risk factors for IC, mammographic density was the most important one in the present survey, whereas no effect of age emerges from the present study.

Quantification of the effect of mammographic screening on fatal breast cancers: The Florence Programme 1990-96

Breast cancer cases diagnosed in women aged 50-69 since 1990 to 1996 in the City of Florence were partitioned into those who had been invited to screening prior to diagnosis and those who had not. All cases were followed up for vital status until 31 December 1999. The cumulative number of breast cancer deaths among the cases were divided by screening and invitation status, to give the rates of cancers proving fatal within a period of 8 years of observation (incidence-based mortality). We used the incidence-based mortality rates for two periods (1985-86, 1990-96), pre and during screening. The incidence-based mortality ratio comparing 1990-96 and 1985-86 was 0.50 (95% CI : 0.38-0.66), a significant 50% reduction. For noninvited women, compared to 1985-86, there was a 41% significant mortality reduction (RR=0.59, 95% CI : 0.42-0.82). The comparable reduction in those invited was a significant 55% (RR=0.45, 95% CI : 0.32-0.61). The incidence ratio of rates of cancers stage II or worse was close to one when the noninvited in 1990-96 were compared with 1985-86 (RR=0.97, 95% CI : 0.78-1.21). Excluding prevalent cases, the rate of stage II+ breast cancer cases was 42% lower in Screened women compared with the noninvited (RR=0.58, 95% CI : 0.45-0.74). This study confirmed that new treatments and the first rounds of the screening programme contributed to reducing mortality from breast cancer.