Residential exposure to traffic-borne pollution as a risk factor for acute cardiocerebrovascular events: a population-based retrospective cohort study in a highly urbanized area

Background

Long-term exposure to traffic-borne noise and air pollution has been variably associated with incidence of acute vascular events, namely acute myocardial infarction, ischaemic stroke and haemorrhagic stroke. This study aims at exploring this association within a highly urbanized city.

Methods

This is a population-based retrospective dynamic cohort study including all residents aged ≥ 35 years in the municipality of Milan over the years 2011–18 (1 087 110 inhabitants). Residential exposure to road traffic noise (day-evening-night levels) and nitrogen dioxide was estimated using a noise predictive model and a land use regression model, respectively. Cox proportional hazards regression analyses were performed to assess the incidence of acute vascular events and specific outcomes in single-exposure and two-exposure models including adjustment for sociodemographic confounders, fine particulate matter and surrounding greenness.

Results

A total of 27 282 subjects (2.5%) had an acute vascular event. Models using nitrogen dioxide produced inconsistent results. The strongest effect was observed for noise, with an optimal cut-off for dichotomization set at 70 dBA (hazard ratio 1.025, 95% confidence interval 1.000–1.050). This association was observed specifically for ischaemic and haemorrhagic stroke. When stratifying by age group and sex, a remarkable effect was found for haemorrhagic stroke in men aged <60 years (hazard ratio 1.439, 95% confidence interval 1.156–1.792).

Conclusions

Living by roads with a day-evening-night noise level above 70 dBA exerts a small but tangible independent effect on the risks of both ischaemic and haemorrhagic stroke. It is urgent to propose mitigation measures against pollution and noise originating from vehicular traffic in order to reduce their impact, especially in the population younger than 60 years.

Development of a multivariable model predicting mortality risk from comorbidities in an Italian cohort of 18,286 confirmed COVID-19 cases aged 40 years or older

OBJECTIVES

to develop a risk prediction model for 30-day mortality from COVID‑19 in an Italian cohort aged 40 years or older.

DESIGN

a population-based retrospective cohort study on prospectively collected data was conducted.

SETTING AND PARTICIPANTS

the cohort included all swab positive cases aged 40 years older (No. 18,286) among residents in the territory of the Milan's Agency for Health Protection (ATS-MI) up to 27.04.2020. Data on comorbidities were obtained from the ATS administrative database of chronic conditions.

MAIN OUTCOME MEASURES

to predict 30-day mortality risk, a multivariable logistic regression model, including age, gender, and the selected conditions, was developed following the TRIPOD guidelines. Discrimination and calibration of the model were assessed.

RESULTS

after age and gender, the most important predictors of 30-day mortality were diabetes, tumour in first-line treatment, chronic heart failure, and complicated diabetes. The bootstrap-validated c-index was 0.78, which suggests that this model is useful in predicting death after COVID-19 infection in swab positive cases. The model had good discrimination (Brier score 0.13) and was well calibrated (Index of prediction accuracy of 14.8%).

CONCLUSIONS

a risk prediction model for 30-day mortality in a large COVID-19 cohort aged 40 years or older was developed. In a new epidemic wave, it would help to define groups at different risk and to identify high-risk subjects to target for specific prevention and therapeutic strategies.

Vaccine-preventable diseases screening and vaccination programs for healthcare professions students

Background

Students in Healthcare Professions (SHPs) present an increased risk of contracting and transmitting Vaccine-Preventable Diseases (VPDs). Our study aimed to investigate the organizational strategies (screening and immunization for VPDs and vaccination promotion among SHPs) implemented by the healthcare facilities accredited with the University of Milan.

Methods

we sent an e-survey by e-mail to medical residents and first- and last-year students in nursing, midwifery and healthcare assistance.

Results

among 3397 invited SHPs, 645 participated. We included in the analysis 522 SHPs, distributed in 24 facilities across the Lombardy region (mean age 27,4 years; 69,5% female; 69% medical residents, 28% nursing, 2% healthcare assistance, and 1% midwifery students). Although most participants underwent occupational health visit before the traineeship start (47,5%) or within 6 months (29,5%), others hadn't undergone yet (15,1%). The visits included the collection of vaccination history (72,6%; 64,6% from written documentation), serological tests for VPDs (hepatitis B 76,1%, measles and rubella 58,4%, varicella 54,4%), and screening for latent TB (69,7%). Vaccinations were recommended to 226 participants, but only 173 fully (76,5%) or partially (8%) complied. Full compliance was associated with nudges like in-hospital (Chisq. 18,7; p = 0.00) and free vaccinations (Chisq. 31; p = 0.00). Reported facility vaccination policies included campaigns (posters 37,4%, intranet 39,5%, social media 11,5%, general/personalized letters 30,3%/11,5%), time-off incentives (7,7%), on-site (30,5%) and opinion leaders' vaccinations (9,8%). However, SHPs were often unaware of those strategies (mean 48,6%), and intra-facility answers were sometimes discordant (agreement &lt;70% for facilities with &gt;30 respondents).

Conclusions

SHPs are often unaware or discordant regarding vaccination policies carried out by traineeship facilities, suggesting the need of inclusive communication strategies.

Key messages

About half of students in healthcare professions are screened for VPDs after the start of the traineeship. Students in healthcare professions are often unaware of vaccination promotion strategies.

Traffic noise, air pollutants and incidence of diabetes mellitus: a population cohort study in Milan

Background

Recent evidence suggests a link between long-term exposure to traffic-related pollution and incidence of type 2 diabetes mellitus, a leading cause of morbidity and mortality in adults. The present study aims at exploring this association in a highly urbanized setting such as the city of Milan.

Methods

This is a population-based retrospective dynamic cohort study in the municipality of Milan. All residents aged &gt;35 years with no prior diagnosis of diabetes were included (N = 1096654), with follow-up ranging from January 2011 to June 2019. The residential address of each subject was geocoded and assigned mean values of traffic noise at the day-evening-night level (Lden, dB) and NO2 concentration (µg/m3) using a noise predictive model and a NO2 land-use regression model with 30x30 m grid resolution. Associations with a new diagnosis of diabetes were assessed with Cox proportional hazards models adjusted for age, sex, nationality and a socio-economic deprivation index. A dichotomous classification of addresses as city center/suburban based on the External Ring Road as a delimiter was also used for a stratified analysis.

Results

New diagnoses of diabetes occurred in 26134 subjects (2.4%). Models using NO2, either continuous or ranked into quintiles, yielded no significant results. When using noise to categorize traffic intensity (&lt;65/65-69/70-74/≥75 dB), a positive yet non-significant trend was shown. At stratified analysis, increases in risk were found for the two highest levels of exposure in the city center (70-74 dB: HR 1.141, 95% C.I. 1.013-1.284; ≥75 dB: HR 1.185, 95% C.I. 1.058-1.328).

Conclusions

Residential proximity to high-traffic roads categorized according to traffic noise was found to be associated with an increased risk of being diagnosed with diabetes. The effect is evident in the city center, whereas in the suburban area it might be masked by individual and lifestyle factors that ought to be investigated in future studies.

Key messages

Living close to high-traffic roads in a highly urbanized environment increases the risk of diabetes. Policies aimed at reducing traffic intensity in large cities may lower the incidence of this highly prevalent chronic condition.

Traffic-borne pollution as a risk factor for acute vascular events: a population study in Milan

Background

Traffic-borne noise and air pollution have both been associated with cardiovascular and cerebrovascular diseases, albeit with inconsistent findings and issues of collinearity/mutual confounding. The present study aims at evaluating the role of long-term exposure to traffic-borne pollution as a risk factor for acute vascular events in a highly urbanized setting.

Methods

This is a population-based retrospective dynamic cohort study including all residents aged &gt;35 years in the municipality of Milan over the years 2011-2018 (N = 1087110). A noise predictive model and a NO2 land-use regression model were used to assign mean values of traffic noise at the day-evening-night level (Lden, dB) and NO2 concentration (µg/m3) to the residential address of each subject. Cox proportional hazards models were performed to assess the incidence of acute vascular events, with adjustment for potential confounders (age, sex, nationality, a socio-economic deprivation index) and sub-analyses for different outcomes (acute myocardial infarction, ischemic stroke, hemorrhagic stroke).

Results

A total of 27282 subjects (2.5%) had an acute vascular event. Models using NO2 yielded inconsistent results. When using Lden as a proxy of traffic intensity, there was a positive trend in risk with increasing levels of exposure, with an optimal cut-off for dichotomization set at 70 dB (HR 1.025, 95% C.I. 1.000-1.050). The association was observed specifically for ischemic stroke (HR 1.043, 95% C.I. 1.003-1.085) and hemorrhagic stroke (HR 1.036, 95% C.I. 0.969-1.107). When stratifying by age group and sex, a remarkable effect was found for hemorrhagic stroke in men aged &lt;60 (HR 1.439, 95% C.I. 1.156-1.792).

Conclusions

Living close to high-traffic roads was found to exert a small but tangible effect on the risk of stroke. The varying effects observed for specific outcomes and in different age and sex groups are likely due to different pathogenetic mechanisms at play, which warrant further investigation.

Key messages

Residential proximity to roads with high traffic intensity (mean traffic noise level over 70 dB) is a risk factor for stroke, especially for hemorrhagic stroke in middle-aged men. Further interventions aimed at reducing traffic intensity in highly urbanized cities may be justified in order to reduce morbidity and mortality from stroke.

Consumption of sexually explicit internet material and its effects on minors' health: latest evidence from the literature

BACKGROUND

Nowadays adolescents and children are more and more exposed to sexually explicit internet material (SEIM), but most parents and healthcare professionals neglect this issue. The aim of the present study is to evaluate the impact of online pornography on minors' health with a specific focus on the effects produced on their behavioural, psychophysical and social development.

METHODS

A literature search was performed on PubMed and ScienceDirect in March 2018 with the query "(pornography OR sexually explicit internet material) AND (adolescent OR child OR young) AND (impact OR behaviour OR health)". Results published between 2013 and 2018 were analysed and compared with previous evidence.

RESULTS

According to selected studies (n = 19), an association between consumption of online pornography and several behavioral, psychophysical and social outcomes - earlier sexual debut, engaging with multiple and/or occasional partners, emulating risky sexual behaviors, assimilating distorted gender roles, dysfunctional body perception, aggressiveness, anxious or depressive symptoms, compulsive pornography use - is confirmed.

CONCLUSIONS

The impact of online pornography on minors' health appears to be relevant. The issue can no longer be neglected and must be targeted by global and multidisciplinary interventions. Empowering parents, teachers and healthcare professionals by means of educational programs targeting this issue will allow them to assist minors in developing critical thinking skills about pornography, decreasing its use and obtaining an affective and sex education that is more suitable for their developmental needs.

Correction: Long-term follow-up of low-risk branchduct IPMNs of the pancreas: is main pancreatic duct dilatation the most worrisome feature?

In the HTML version of this paper Pietro Magnoni was incorrectly tagged as the corresponding author. The corresponding author should have been Maria Chiara Petrone. This has now been corrected in the HTML version of the paper.

Long-term follow-up of low-risk branch-duct IPMNs of the pancreas: is main pancreatic duct dilatation the most worrisome feature?

OBJECTIVES

The management of branch-duct IPMN remains controversial due to the relatively low rate of malignant degeneration and the uncertain predictive role of high-risk stigmata (HRS) and worrisome features (WFs) identified by the 2012 International Consensus Guidelines. Our aim was to evaluate the evolution of originally low-risk (Fukuoka-negative) BD-IPMNs during a long follow-up period in order to determine whether the appearance of any clinical or morphological variables may be independently associated with the development of malignancy over time.

METHODS

A prospectively collected database of all patients with BD-IPMN referring to our Institute between 2002 and 2016 was retrospectively analyzed. Univariate and multivariate analysis of association between changes during follow-up, including appearance of HRS/WFs, and development of malignancy (high-grade dysplasia/invasive carcinoma) was performed.

RESULTS

A total of 167 patients were selected for analysis, and seven developed malignant disease (4.2%). During a median follow-up time of 55 months, HRS appeared in only three cases but predicted malignancy with 100% specificity. Worrisome features, on the other hand, appeared in 44 patients (26.3%). Appearance of mural nodules and MPD dilatation >5 mm showed a significant association with malignancy in multivariate analysis (p = 0.004 and p = 0.001, respectively). MPD dilatation in particular proved to be the strongest independent risk factor for development of malignancy (OR = 24.5).

CONCLUSIONS

The risk of pancreatic malignancy in this population is low but definite. The presence of major WFs, and especially MPD dilatation, should prompt a tighter follow-up with EUS and a valid cytological analysis whenever feasible.

[18F]FDG-PET/CT texture analysis in thyroid incidentalomas: preliminary results

Background

significance of incidental thyroid 2-deoxy-2-[¹⁸F]fluoro-D-glucose ([¹⁸F]FDG) uptake on positron emission tomography/computed tomography (PET/CT) scans remains controversial. We aimed to evaluate the ability of [¹⁸F]FDG-PET/CT texture analysis to predict final diagnosis in thyroid incidentaloma.

Methods

We retrospectively evaluated medical records of all patients who performed a [¹⁸F]FDG-PET/CT from January 2012 to October 2016. Those patients who presented a thyroid incidentaloma described in the medical records and performed a fine needle aspiration in our institution were considered for the analysis. Cytological and/or histological results were used as reference standard to define the final diagnosis. In case of negative cytology, the nodule was considered benign. In case of non-diagnostic or inconclusive results ultrasound, follow-up and further cytology/histology were used as final diagnosis. For suspected or positive cytological result, histology was used as reference standard. PET images were segmented using a General Electric AW workstation running PET VCAR software (GE Healthcare, Waukesha, WI, USA) settled with a threshold of 40% SUV_max. LifeX software (http://www.lifexsoft.org) was used to perform texture analysis. Statistical analysis was performed with R package (https://www.r-project.org).

Results

We identified 55 patients with incidental thyroid [¹⁸F]FDG uptake. Five patients were excluded from the analysis because a final diagnosis was not available. Thirty-two out of 50 patients had benign nodules while in 18/50 cases a malignancy (primary thyroid cancer = 15, metastases = 3) was diagnosed. Conventional PET parameters and histogram-based features were calculated for all 50 patients, while other matrices-based features were available for 28/50 patients. SUV_max and skewness resulted significantly different in benign and malignant nodules (p = 0.01 and = 0.02, respectively). Using ROC analysis, seven features were identified as potential predictors. Among all the textural features tested, skewness showed the best area under the curve (= 0.66). SUV-based parameters resulted in the highest specificity while MTV, TLG, skewness and kurtosis, as well as correlation_GLCM resulted better in sensitivity.

Conclusions

[¹⁸F]FDG-PET/CT texture analysis seems to be a promising approach to stratify the patients with thyroid incidentaloma identified on PET scans, with respect to the risk of the diagnosis of a malignant thyroid nodule and thus, could refine the selection of the patients to be referred for cytology.

[Giant fibroadenoma of the breast. Its clinical picture and differential diagnosis. A report of a clinical case]

An 18-year-old girl came to our Institute with a large tumefaction at the right breast, that during the last year had risen slowly but continuously. She underwent some clinical and instrumental exams that allow us to diagnose a giant adenofibroma or cystosarcoma phyllodes without excluding either of them. Then she undergoes a subcutaneous mastectomy with an application of a prosthesis. From the histologic point of view it is a giant adenofibroma. Giant adenofibroma is a rare breast pathology, always benign. Nowadays we have some difficulties distinguishing it from cystosarcoma phyllodes, which has both a benign and malignant form. It is important to distinguish the two pathologies before operation as they have a different therapeutic approach and a different follow-up. Cystosarcoma phyllodes can in fact relapse and when malignant can cause metastasis.