Taste and Smell Disorders in COVID-19 Patients at a Local Healthcare Trust in Northern Italy: a Cross-Sectional Study

BACKGROUND

In Italy, since the beginning of the COVID-19 pandemic, patients testing positive for SARS-CoV-2 through nasopharyngeal swab have reported taste and smell alterations. As these symptoms are quite uncommon in other respiratory infections, their specificity and prevalence are useful features for the differential diagnosis of COVID-19. The objective was to describe taste and smell alterations in patients diagnosed with SARS-CoV-2 infection and to define the onset of those disorders during the clinical course of the disease.

STUDY DESIGN

Cross-sectional study.

METHODS

This study was conducted on adult patients testing positive for SARS-CoV-2 infection through nasopharyngeal swab at a Local Healthcare Trust in Northern Italy between April 27th and May 27th, 2020. In order to investigate the clinical course, the onset of the first symptoms, smell and/or taste alterations, a phone-based questionnaire was administered during the programming of the second nasopharyngeal swab.

RESULTS

We recruited 168 patients; the mean age was 52 years old, and 94 (56.0%) were female. Among the 135 symptomatic patients, 87 (64.4%) reported taste and smell alterations. Patients with a mild clinical course showed the highest prevalence for taste and smell disorders (76.6%), which were also associated with a more benign clinical course of the disease (P = 0.0166). Furthermore, in 33 (37.9%) of these patients, changes in smell and taste perception appeared before the acute phase of the disease. Among the 14 patients with a severe clinical course of SARS-CoV-2 infection, 8 reported a variation of taste and smell perception before the hospitalization, with a median of 4 days (IQR 2-7).

CONCLUSIONS

Smell and taste disorders can be listed among the first symptoms of SARS-CoV-2 infection and may anticipate the acute phase of the disease. Noteworthy, they seem to be associated with a more benign clinical course.

Obesity in Prader-Willi syndrome: physiopathological mechanisms, nutritional and pharmacological approaches

Prader-Willi syndrome (PWS) is a genetic disorder caused by the lack of expression of genes on the paternally inherited chromosome 15q11.2-q13 region. The three main genetic subtypes are represented by paternal 15q11-q13 deletion, maternal uniparental disomy 15, and imprinting defect. Clinical picture of PWS changes across life stages. The main clinical characteristics are represented by short stature, developmental delay, cognitive disability and behavioral diseases. Hypotonia and poor suck resulting in failure to thrive are typical of infancy. As the subjects with PWS age, clinical manifestations such as hyperphagia, temperature instability, high pain threshold, hypersomnia and multiple endocrine abnormalities including growth hormone and thyroid-stimulating hormone deficiencies, hypogonadism and central adrenal insufficiency due to hypothalamic dysfunction occur. Obesity and its complications are the most common causes of morbidity and mortality in PWS. Several mechanisms for the aetiology of obesity in PWS have been hypothesized, which include aberration in hypothalamic pathways of satiety control resulting in hyperphagia, disruption in hormones regulating appetite and satiety and reduced energy expenditure. However, despite the advancement in the research field of the genetic basis of obesity in PWS, there are contradictory data on the management. Although it is mandatory to adopt obesity strategy prevention from infancy, there is promising evidence regarding the management of obesity in adulthood with current obesity drugs along with lifestyle interventions, although the data are limited. Therefore, the current manuscript provides a review of the current evidence on obesity and PWS, covering physiopathological aspects, obesity-related complications and conservative management.

Dietary Habits, Internal Migration and Social Class in a Sample of a Northern Italian Population

The study of migrants has generated interesting hypotheses on the etiology of different types of cancer. In particular, it has been suggested that both colon and breast cancer could be related to living conditions, including diet, in the country of immigration. Considerable internal migration occurred in Italy in the sixties. We studied a random sample of 1,400 subjects living in the city of Torino and the province of Varese. They were interviewed with a detailed questionnaire about their dietary habits, and the consumption of several nutrients was considered according to the area of birth and social class. The hypothesis we tested was whether, after controlling for social class, there were different dietary habits among the migrants and the native population, and whether such differences could help in the formulation of etiologic hypotheses on cancer. We found that the intake of saturated fatty acids and cholesterol was lower among the migrants from the south, whereas they consumed higher levels of vegetables than people born in the north. The different intake of saturated fatty acids and cholesterol seemed to be attributable mainly to the consumption of butter, for which the south/north ratio was as low as 0.47 in men and 0.56 in women. Important gradients by social class were also suggested for several nutrients.

Incidence of Breast Cancer in Piedmont: 1979–1981

A population-based survey of histologically diagnosed breast cancer was carried out among residents in Piedmont. A total of 5267 incident cases occurring in 1979–1981 was collected, corresponding to an age-standardized (on the world population) incidence rate of 49.5/100,000 per year. Rates (standardized on the population of Piedmont in 1981) were highest in the city of Torino (112.4/100,000 per year) and lowest in the province of Cuneo (67.5), whereas in the other provinces they ranged between 85.3 and 90.0. Estimation of rates in the 54 Local Health Authorities of Piedmont detected up to 2-fold differences between adjacent areas. A correlation was found between rates and size of the population of town of residence. Comparison with age-specific incidence rates from the Cancer Registry of the nearby province of Varese suggested a loss of nonhistologically confirmed cases selectively in older age groups. The distribution of cases diagnosed in 1979 by histologic type is presented. The proportion of diagnoses reported in terms which were consistent with the 1978 WHO Histological Typing of Breast Tumours was 61.3%. It was highest among cases identified in Pathology Services located in University Hospitals and/or diagnosing more than 50 breast cancers per year.

Are physical activity interventions equally effective in adolescents of low and high socio-economic status (SES): results from the European Teenage project

The aim was to study whether physical activity (PA) interventions in European teenagers are equally effective in adolescents of low versus high socio-economic status (SES). Based on a systematic review (Project TEENAGE), three school-based studies for secondary analyses were selected. SES stratified analyses were run in: (i) a Belgian multi-component intervention, (ii) a French multi-component intervention and (iii) a Belgian computer-tailored education trial. Results of the secondary analyses showed that no overall significant differences between low and high SES groups were found, but some interesting specific effects were revealed. Results from the first study showed an increase in objective PA in the low SES group (P = 0.015) compared with no significant effects in the high SES group. In the second study, larger effects were found in adolescents of high SES (increase of 11 min day(-1) P < 0.001), compared with adolescents of lower SES (increase of 7 min day(-1), P = 0.02) at the longer term. The third study showed a positive effect on school-related PA in adolescents of high SES (P < 0.05) and on leisure time transportation in adolescents of low SES (P < 0.05). To conclude, we were not able to show a significant widening or narrowing of inequalities in European adolescents.

Effects of clinical pathways in the joint replacement: a meta-analysis

BACKGROUND

A meta-analysis was performed to evaluate the use of clinical pathways for hip and knee joint replacements when compared with standard medical care. The impact of clinical pathways was evaluated assessing the major outcomes of in-hospital hip and knee joint replacement processes: postoperative complications, number of patients discharged at home, length of in-hospital stay and direct costs.

METHODS

Medline, Cinahl, Embase and the Cochrane Central Register of Controlled Trials were searched. The search was performed from 1975 to 2007. Each study was assessed independently by two reviewers. The assessment of methodological quality of the included studies was based on the Jadad methodological approach and on the New Castle Ottawa Scale. Data analysis abided by the guidelines set out by The Cochrane Collaboration regarding statistical methods. Meta-analyses were performed using RevMan software, version 4.2.

RESULTS

Twenty-two studies met the study inclusion criteria and were included in the meta-analysis for a total sample of 6,316 patients. The aggregate overall results showed significantly fewer patients suffering postoperative complications in the clinical pathways group when compared with the standard care group. A shorter length of stay in the clinical pathway group was also observed and lower costs during hospital stay were associated with the use of the clinical pathways. No significant differences were found in the rates of discharge to home.

CONCLUSION

The results of this meta-analysis show that clinical pathways can significantly improve the quality of care even if it is not possible to conclude that the implementation of clinical pathways is a cost-effective process, because none of the included studies analysed the cost of the development and implementation of the pathways. Based on the results we assume that pathways have impact on the organisation of care if the care process is structured in a standardised way, teams critically analyse the actual organisation of the process and the multidisciplinary team is highly involved in the re-organisation. Further studies should focus on the evaluation of pathways as complex interventions to help to understand which mechanisms within the clinical pathways can really improve the quality of care. With the need for knee and hip joint replacement on the rise, the use of clinical pathways might contribute to better quality of care and cost-effectiveness.

Is universal prevention against youths' substance misuse really universal? Gender-specific effects in the EU-Dap school-based prevention trial

BACKGROUND

Studies of effectiveness of school-based prevention of substance misuse have generally overlooked gender differences. The purpose of this work was to analyse gender differences in the effectiveness of a new European school-based curriculum for prevention of substance misuse among adolescents.

METHODS

The European Drug Abuse Prevention (EU-Dap) trial took place in seven European countries during the school year 2004-05. Schools were randomly assigned to either a control group or a 12-session standardised curriculum ("Unplugged") based on a comprehensive social influence model. The analytical sample consisted of 6359 students (3324 boys and 3035 girls). The use of cigarettes, alcohol and illicit drugs, adolescents' knowledge and opinions about substances, as well as social and personal skills were investigated through a self-completed anonymous questionnaire administered at enrollment and 3 months after the end of the programme. Adjusted Prevalence Odds Ratios were calculated as the measure of association between the intervention and behavioural outcomes using multilevel regression modelling.

RESULTS

At enrollment, boys were more likely than girls to have used cannabis and illicit drugs, whereas girls had a higher prevalence of cigarette smoking. At the follow-up survey, a significant association between the programme and a lower prevalence of all behavioural outcomes was found among boys, but not among girls. Age and self-esteem emerged as possible modifiers of these gender differences, but effects were not statistically significant.

CONCLUSIONS

Comprehensive social influence school curricula against substance misuse in adolescence may perform differently among girls and boys, owing to developmental and personality factors.

Recombinant interferon beta or glatiramer acetate for delaying conversion of the first demyelinating event to multiple sclerosis

BACKGROUND

Immunomodulatory drugs have been shown to be only modestly effective in clinically definite relapsing remitting multiple sclerosis (RRMS). It has been hypothesized that their efficacy could be higher if used at the first appearance of symptoms, that is in the clinically isolated syndromes (CIS) suggestive of demyelinating events, a pathology which carries a high risk to convert to clinically definite MS (CDMS).

OBJECTIVES

The objective of this review was to assess the effects of immunomodulatory drugs compared to placebo in adults in preventing conversion from CIS to CDMS which means the prevention of a second attack.

SEARCH STRATEGY

We searched the Cochrane MS Group Trials Register (June 2007), Cochrane Central Register of Controlled Trials (CENTRAL)The Cochrane Library Issue 3, 2007, MEDLINE (January 1966 to June 2007), EMBASE (January 1974 to June 2007) and reference lists of articles. We also contacted manufacturers and researchers in the field.

SELECTION CRITERIA

The trials selected were double-blind, placebo-controlled, randomised trials of CIS patients treated with immunomodulatory drugs.

DATA COLLECTION AND ANALYSIS

Study selection have been independently done by two reviewers. Two further reviewers independently assessed trial quality and extracted and analysed data. Study authors were contacted for additional informations. Adverse effects information was collected from the trials.

MAIN RESULTS

Only three trials tested the efficacy of interferon (IFN) beta including a total of 1160 participants (639 treatment, 521 placebo); no trial tested the efficacy of glatiramer acetate (GA). The metanalyses showed that the proportion of patients converting to CDMS was significantly lower in IFN beta-treated than in placebo-treated patients both after one year (pooled OR 0.53; 95% CI, 0.40 to 0.71; p <0.0001) as well as after two years of follow-up (pooled OR 0.52; 95% CI, 0.38 to 0.70; p <0.0001). Early treatment with IFN beta was associated with the side effect profile reported by the randomised controlled trials with this drug. Since side effects were reported with some heterogeneity in the three studies the metanalysis was possible only for the frequency of serious adverse events, not significantly different in IFN beta-treated or placebo-treated patients.

AUTHORS' CONCLUSIONS

The efficacy of IFN beta treatment on preventing the conversion from CIS to CDMS was confirmed over two years of follow-up. Since patients had some clinical heterogeneity (length of follow-up, clinical findings of initial attack), it could be useful for the clinical practice to further analyse the efficacy of IFN beta treatment in different patient subgroups.

[Quality of central venous catheter management protocols in Oncology centres of an Italian region]

The aim of this study was to evaluate the quality of central venous catheter (Port-a-cath, Groshong and Hohn) management protocols in Oncology centres in an Italian region. A retrospective study was performed in 25 hospitals, only 10 of which provided evidence that they utilized a central venous catheter management protocol. The submitted protocols were evaluated in terms of completeness and of adherence to manufacturers' indications and to recommendations of the Centre for Diseases Control. Study results show that overall, there is poor adherence to the basic quality requirements considered and only two of the ten protocols examined were found to be complete. Also, there is wide variability between the protocols with significant differences in the type of instructions provided in the different hospitals.

Prenatal screening for congenital heart disease with four-chamber and outflow-tract views: a multicenter study

OBJECTIVE

Congenital heart diseases (CHD) are the most common congenital anomalies, and most cases occur in the low-risk population. Prenatal ultrasound screening based on visualization of the four-chamber view has had disappointing results in detecting these anomalies thus far. The aim of this study was to evaluate the diagnostic accuracy of ultrasound screening based on the combination of the four-chamber and outflow-tract views.

METHODS

We conducted a multicenter prospective observational study in 15 obstetric units in the Piedmont Region, Italy. All operators received specific training. Data were recorded regarding visualization of the four-chamber view and the outflow tracts at each routine scan in pregnancies without any risk factor. When an anomaly was suspected, the patient was sent to the referral center. We obtained the follow-up data of the newborns until discharge from hospital and calculated the diagnostic accuracy of the test.

RESULTS

9074 ultrasound scans were performed on 7041 women and complete follow-up information was available for 6368 of them. Fifty-eight cases of CHD were observed at birth or postmortem (prevalence 9.1 per thousand); 38 of them were diagnosed in utero. The sensitivity of the test was 65.5%, the specificity 99.7%, the positive predictive value 70.4% and the negative predictive value 99.7%. The sensitivity of the four-chamber view alone was 60.3%.

CONCLUSIONS

The sensitivity was significantly higher than that in a similar study performed in 1997 in the same setting. This improvement can be attributed in part to extension of the examination to the outflow-tract view, but also to technological developments and better training of the operators.

Quality of systematic reviews used in guidelines for oncology practice

BACKGROUND

Systematic reviews are an important tool for developing clinical recommendations. Those of high quality assure a good level of confidence on the strength of the recommendations.

METHODS

A QUOROM-based checklist was applied to the reviews cited in a sample of guidelines on breast and colon cancer prevention and therapy. The checklist provided a weight for each criterion and a total quality score. Each review was independently evaluated by two reviewers; disagreements were solved by consensus.

RESULTS

Eighty reviews (96%) were retrieved and evaluated; 36 focused on breast, and 44 on colorectal cancer. Twenty-three reviews (29%) did not match the definition of systematic review. In 17 (21%) the searching methods were unclear or described elsewhere. Forty (50%) were systematic. Not systematic, low and very low quality reviews accounted for 70% of the total. No review obtained the A+ class score; only 5 (6%) the A- and 7 (9%) the B+.

CONCLUSIONS

The results of this assessment provide a sober picture of the quality of the sources used to build guidelines. Oncologists should be aware that they could be relying on poor underlying documents. Writing groups should be aware of methodological problems, and should consult the existing manuals for the preparation of guidelines.

School-based prevention for illicit drugs' use

BACKGROUND

Drug addiction is a chronic, relapsing disease. Primary interventions should be aimed to reduce first use, or prevent the transition from experimental use to addiction. School is the appropriate setting for preventive interventions.

OBJECTIVES

To evaluate the effectiveness of school-based interventions in improving knowledge, developing skills, promoting change, and preventing or reducing drug use versus usual curricular activities or a different school-based intervention .

SEARCH STRATEGY

MEDLINE , EMBASE, ERIC, PSYCHINFO, Cochrane Library, ACP Journal Club, Cochrane Drug and Alcohol Group Register, updated to February 2004, were searched. Bibliography of papers was checked and personal contacts were made to identify other relevant studies.

SELECTION CRITERIA

RCTs, CCTs or Controlled Prospective Studies (CPS) evaluating school-based interventions designed to prevent substance use.

DATA COLLECTION AND ANALYSIS

Data were selected and extracted independently by two reviewers. Quality was assessed with the CDAG checklist. Interventions were classified as skills, affective, knowledge-focused and other characteristics were also studied (teaching, follow-up implementation, context activation).

MAIN RESULTS

32 studies (29 RCTs and 3 CPSs) were included. 28 were conducted in the USA; most were focused on 6th-7th grade students, and based on post-test assessment. RCTs: (1) Knowledge vs usual curricula: Knowledge focused programs improve drug knowledge (SMD=0.91; 95% CI: 0.42, 1.39).(2) Skills vs usual curricula: Skills based interventions increase drug knowledge (WMD=2.60; 95% CI: 1.17-4.03), decision making skills (SMD=0.78; CI95%: 0.46-1.09), self-esteem (SMD=0.22; CI95%: 0.03-0.40), peer pressure resistance (RR=2.05; CI95%: 1.24-3.42), drug use (RR=0.81; CI95%: 0.64, 1.02), marijuana use (RR=0.82; CI95%: 0.73, 0.92) and hard drug use (RR=0.45; CI95%: 0.24-0.85). (3) Skills vs knowledge: No differences are evident.(4) Skills vs affective: Skills-based interventions are only better than affective ones in self-efficacy (WMD=1.90; CI95%: 0.25, 3.55). (5) Affective vs usual curricula: Affective interventions improve drug knowledge (SMD=1.88; CI95%: 1.27, 2.50) and decision making skills (SMD=1.35; CI95%: 0.79, 1.9). (6) Affective vs knowledge: Affective interventions improve drug knowledge (SMD=0.60; CI95%: 0.18,1.03), and decision making skills (SMD=1.22; CI95%: 0.33, 2.12). Results from CPSs: No statistically significant results emerge from CPSs.

AUTHORS' CONCLUSIONS

Skills based programs appear to be effective in deterring early-stage drug use. The replication of results with well designed, long term randomised trials, and the evaluation of single components of intervention (peer, parents, booster sessions) are the priorities for research. All new studies should control for cluster effect.

Tuberculosis incidence in Turin, Italy, 1973-1999

SETTING

Turin, Italy, 1973-1999.

OBJECTIVE

To estimate tuberculosis (TB) incidence rates in Turin between 1973 and 1999.

DESIGN

Incidence study. An active search of new TB cases was carried out by examining the clinical records of the three major TB care services in the city. New cases were defined as patients treated for the first time. To evaluate the completeness of this series, data were linked with the TB Notification Register and the Regional Hospital Discharges Register for the years 1997-1999.

RESULTS

TB incidence rates declined from 25.6 cases per 100,000 population in 1973 to 6.4 in 1999. TB/human immunodeficiency virus (HIV) co-infection increased after 1985, reaching a peak (16.5%) in 1994-1996, and significantly decreasing in 1997-1999. Foreign-born cases started to increase after 1988, reaching 25.8% of total cases in 1997-1999. TB infections in Italian-born, non-HIV-infected cases occurred mostly among the elderly, while HIV/TB co-infections and TB in immigrants occurred mostly in younger age groups. The study captured 59% of cases diagnosed in Turin in 1997-1999.

CONCLUSIONS

In recent years, new cases of TB have been diagnosed mostly among HIV-positive people and immigrants. Preventive and control strategies should focus on these population groups, improving quick identification and effective treatment of cases, and implementing accessible services.

Methadone maintenance at different dosages for opioid dependence

BACKGROUND

Methadone maintenance treatment (MMT) is a long term opioid replacement therapy, recognised as effective in the management of opioid dependence. Even if MMT at high dosage is recommended as therapy for reducing illicit opioid use and promoting longer retention in treatment, at present day "the organisation and regulation of the methadone maintenance treatment varies widely".

OBJECTIVES

To evaluate the efficacy of different dosages of MMT for opioid dependence in modifying health and social outcomes and in promoting patients' familial, occupational and relational functioning.

SEARCH STRATEGY

The following sources were scanned: - MEDLINE (OVID 1966-2001)- EMBASE (1988-2001)- ERIC (1988-2001)- Psychinfo (1947-2001)- Cochrane Controlled Trials Register (CCTR) (1947-2001)- Register of the Cochrane Drug and Alcohol Group (CDAG) (1947-2001)The CDAG search strategy was applied together with a specific MESH strategy. Further studies were searched through: letters to the authors of selected trials or to experts in order to obtain unpublished data. check of references of relevant reviews.

SELECTION CRITERIA

Randomised Controlled Trials (RCT) and Controlled Prospective Studies (CPS) evaluating methadone maintenance at different dosages in the management of opioid dependence were included in the review. Non-randomised trials were included when proper adjustment for confounding factors was performed at the analysis stage.

DATA COLLECTION AND ANALYSIS

Extraction of data was performed separately by two reviewers. Discrepancies were resolved by a third reviewer. RevMan software was used for analysis. Quality assessments of the methodology of studies were carried out using CDAG checklist.

MAIN RESULTS

22 studies were excluded from the review. 21 studies were included; of them, 11 were RCTs with 2279 people randomised and 10 were CPSs with 3715 people followed-up.

OUTCOMES

Retention rate - RCTs: High vs low doses at shorter follow-ups: RR=1.36 [1.13,1.63], and at longer ones: RR=1.62 [0.95,2.77]. Opioid use (self reported), times/w - RCTs: high vs low doses WMD= -2.00 [-4.77,0.77] high vs middle doses WMD= -1.89[-3.43, -0.35] Opioid abstinence, (urine based) at >3-4 w - RCTs: high vs low ones: RR=1.59 [1.16,2.18] high vs middle doses RR=1.51[0.63,3.61] Cocaine abstinence (urine based) at >3-4 w - RCTs: high vs low doses RR=1.81 [1.15,2.85]Overdose mortality - CPSs: high dose vs low dose at 6 years follow up: RR=0.29 [0.02-5.34] high dose vs middle dose at 6 years follow up: RR=0.38 [0.02-9.34] middle dose vs low dose at 6 years follow up: RR=0.57 [0.06-5.06]

REVIEWER'S CONCLUSIONS

Methadone dosages ranging from 60 to 100 mg/day are more effective than lower dosages in retaining patients and in reducing use of heroin and cocaine during treatment. To find the optimal dose is a clinical ability, but clinician must consider these conclusions in treatment strategies.

Thyroid function and anti-thyroid antibodies in MS patients screened for interferon treatment. A multicenter study

Interferon beta (IFNB) treatment for multiple sclerosis (MS) has been associated with thyroid disorders (TD), in particular in patients with subclinical TD or anti-thyroid (AT) autoantibodies (autoAb) before starting treatment. TD and AT autoAb frequency was reported increased in MS. To determine whether MS patients have subclinical thyroid function abnormalities or anti-thyroid autoimmunity predisposing to develop TD, we performed a prospective multicenter screening of thyroid function and autoimmunity in 152 relapsing-remitting (RR) MS patients selected to receive IFNB treatment and in 437 healthy normothyroidal controls. Thyroid-related hormones and anti-thyroid microsomal antigen (anti-TMA) autoAb were tested with sensitive immunoradiometric or chromatographic assays. Cases were stratified for different progressively decreasing or increasing cutoff values of thyroid-stimulating hormone (TSH) (0.3, 0.2, 0.1, 3 and 5 mIU/l), and odds ratios (OR) with 95% confidence intervals (CI) calculated using logistic regression adjusted for gender, age, and anti-TMA autoAb positivity. The frequency of cases below or above the TSH cutoff values was not significantly different in MS patients and controls, and the risk to have an abnormal TSH level was not significantly increased in MS patients (OR ranging 0.37-0.84; CI, 0.05-3.01), even if anti-TMA autoAb positive (OR ranging 0.35-0.85; CI, 0.04-3.00). Frequencies of subclinical hypothyroidism and of anti-TMA autoAb positivity were, however, trending higher in MS men (ranging 5-7%) than in controls (3%). MS patients do not have an increased risk of subtle thyroid function abnormalities, subclinical TD, or anti-TMA autoAb positivity that may predispose to develop thyroid dysfunction during IFNB treatment. The positive trend for subclinical hypothyroidism and anti-TMA autoAb positivity, however, advises a longitudinal study of thyroid function and autoimmunity during IFNB treatment to see whether patients with baseline subclinical thyroid dysfunction develop clinically significant alteration during treatment.

Patterns of drug use among young men in Piedmont (Italy)

Increasing alarm is shown regarding patterns of polydrug use among young people, particularly regarding recreational drugs. Prevalence of recreational drug usage in Europe is not clearly defined, varying for ecstasy, from 0.2% (Finland, 1995) to 9.2% (UK, 1995) and suggesting a tendency to increase in the last years. The aim of this study is to present patterns of polydrug use among a sample of the general population of young males in Piedmont (Northern Italy), focusing particularly on ecstasy consumption. A cross sectional study was carried out between September and November 1998 on a continuous sample of 3274 18-year-old conscripts. A self-administered anonymous questionnaire on socio-demographic characteristics and substances use was submitted during routine tests. Results showed that the overall lifetime prevalence of drug use is 36.6%; prevalence of polydrug use is 30% and the more frequently associated drugs are LSD, cocaine, inhalants and ecstasy. One hundred and forty five (4.6%) subjects reported having taken ecstasy at least once in their life; 20 of the 145 (13.8%) suffered from negative effects and three (2%) presented to a hospital or to a physician. The risk of ever taking ecstasy is inversely related to father's education, with a trend that is quite similar to that of heroin consumption but that is different from the trend for cannabis. In conclusion the four major results of this study are: (i) a prevalence of drug consumption similar to other European estimates, with a clear tendency to polydrug use; (ii) for ecstasy, a very high association rate with other substances; (iii) the moderately high prevalence of self-reported symptoms, and (iv) a social distribution of use similar to the one observed for heroin. This last consideration suggests that a high level of attention and further research should be addressed to the natural history of ecstasy use.

Decennial trends of social differentials in smoking habits in Italy

OBJECTIVE

To present social trends of smoking habits in Italy during the period 1980-1994.

METHODS

Data from five national health surveys (1980, 1983, 1986-1987, 1990-1991, 1994) were analyzed in order to calculate smoking prevalences. Education attained was used as social class indicator.

MAIN MEASURES

SDPs (prevalence rate standardized on the 1981 Italian population) and PRs (prevalence ratios primary school/degree). Confidence intervals and p-values were calculated as indicators of statistical significance.

RESULTS

Among men SDP decreased from 59.5% in 1980 to 37.3% in 1994 and PRs for social classes varied from 1.21 in 1980 to 1.47 in 1994. Corresponding results for women were 17.9% to 20.0% and 0.36 to 0.73.

CONCLUSIONS

Lower-educated men smoke more than those in higher social categories, and data collected during 1980-1994 in Italy show a tendency to increase such differentials. Among women this pattern was the opposite in 1980, with a tendency to reduce differences over time. Therefore, for both genders data show a progressive disadvantage for the low-educated categories. The greater compliance of better-educated groups with anti-smoking interventions must be taken into account, and should suggest "unequal" interventions that can be more effective among disadvantaged social groups.

Cochrane Drugs and Alcohol Group: the development of systematic reviews of treatment outcome

- The aim of the Cochrane Collaboration is to promote review processes which address all aspects of health care and which can be viewed by clinicians to guide their day-to-day clinical practice. Recently, a Cochrane review group on drugs and alcohol has been developed. The Cochrane Review Group Editorial base is in Rome, Italy. There is an international editorial board with editors in the UK, Italy, France, Australia and the USA. So far, the group has published five reviews addressing treatment for opioid, cocaine and alcohol dependence. Additional reviews and protocols are in progress. A growing number of titles are registered with the group. Interested readers and potential reviewers and/or referees can contact the Cochrane Drugs and Alcohol Group Coordinator in Rome at the e-mail address: dacochrane@asplazio.it

Effect of Sardinian heritage on risk and age at onset of type 1 diabetes: a demographic case-control study of Sardinian migrants

BACKGROUND

Children of Sardinian heritage are at high risk of type 1 diabetes, whereas no data are available in young adults. Age at onset of type 1 diabetes could be associated with different relative weight of genetic susceptibility and environmental determinants in the pathogenesis of the disease. We test this hypothesis in subjects with Sardinian heritage 0-29 years of age living in the city of Turin, a highly industrialized area in Northern Italy.

METHODS

In all, 202 cases with onset of type 1 diabetes aged 0-29 years during 1984-1991 and 1010 controls randomly selected from residents of the city of Turin, frequency-matched by sex and year of birth to cases, were included in this study. Name and place of birth of parents were ascertained by postal inquiry and linkage with city population and census files. Social class was based on the highest educational level of parents abstracted from 1991 and 1981 census files.

RESULTS

Differential effects on risk of type 1 diabetes of Sardinian heritage and social class in the age groups 0-14 and 15-29 years were found. In children with one and both Sardinian parents the odds ratios (OR) were 2.09 (95% CI : 0.85-5.15) and 3.20 (95% CI : 0.75-13.64); in young adults 0.81 (95% CI : 0.18-3.64) and 1.95 (95% CI : 0.51-7.40), respectively. In subjects with low social class the OR were 1.16 (95% CI : 0.68-1.97) in children and 0.66 (95% CI : 0.41-1.05) in young adults.

CONCLUSIONS

This study shows higher risk of type 1 diabetes in subjects of Sardinian heritage; higher risk in children than in young adults and a protective effect of low social class in young adults. These findings are consistent with the hypothesis of heterogeneity of type 1 diabetes by age at onset, with prevailing genetic effect in childhood and environmental determinants in adulthood.

Socioeconomic inequalities in mortality among women and among men: an international study

OBJECTIVES

This study compared differences in total and cause-specific mortality by educational level among women with those among men in 7 countries: the United States, Finland, Norway, Italy, the Czech Republic, Hungary, and Estonia.

METHODS

National data were obtained for the period ca. 1980 to ca. 1990. Age-adjusted rate ratios comparing a broad lower-educational group with a broad upper-educational group were calculated with Poisson regression analysis.

RESULTS

Total mortality rate ratios among women ranged from 1.09 in the Czech Republic to 1.31 in the United States and Estonia. Higher mortality rates among lower-educated women were found for most causes of death, but not for neoplasms. Relative inequalities in total mortality tended to be smaller among women than among men. In the United States and Western Europe, but not in Central and Eastern Europe, this sex difference was largely due to differences between women and men in cause-of-death pattern. For specific causes of death, inequalities are usually larger among men.

CONCLUSIONS

Further study of the interaction between socioeconomic factors, sex, and mortality may provide important clues to the explanation of inequalities in health.

[Social differences in cancer incidence, fatality, and mortality in Turin]

INTRODUCTION

The study of social differences in health is today focused on determinants. The knowledge of determinants is useful for the definition of policies to tackle inequities. The aim of this paper is to analyse the social distribution of cancer incidence, fatality and mortality in the city of Turin during the 80's and to estimate the amount of inequality produced within the health system.

SOURCES OF DATA

The social distribution of the risk of death in Turin during 1981-1989, estimated from the Turin Longitudinal Study, is compared with incidence and fatality during approximately the same time period.

RESULTS

Among men, the relative risks for all cancer sites, among social classes, appear to confirm the hypothesis of a multiplicative model of incidence and fatality. In particular, colo-rectal, prostatic, bladder cancers and lymphoma and leukaemia show relative risks similar to the expected ones. Cancers of larynx, lung and stomach seem to be less coherent. Among women, colon-rectum, lung, breast and lymphoma and leukaemia show coherent results, whereas relative risks for uterus are far from the expected.

DISCUSSION

The coherence with the expected values of the social distribution of mortality suggests the adequacy of the multiplicative model for the provision of mortality from incidence and fatality. Therefore it is possible to state that the portion of inequality in health originated within the health system is big enough to suggest the need to put the equity in the access to health services in the agenda of interventions.

[Social differences and indicators of perceived health, chronic diseases, disability and life style in the 1994. ISTAT national health interview survey]

In this paper social differences in health, analysed by different dimensions (perceived health, chronic diseases, functional deficits and disability) and social differences in lifestyle, in particular smoking habit and use of health services for the prevention of some female tumours, are described. The study is based on the data collected in the National Interview Survey on Health Status and Use of Health Care Services, conducted by ISTAT in the 1994. The analysis has been performed separately for males and females, computing Prevalence Rate Ratios (PRR) standardized by age. Educational level and social class, based on Schizzerotto's classification, have been used as determinants of differences in health and lifestyle. Unfavourable perception of health status and most of chronic diseases, referred as diagnosed by a doctor, show an increasing prevalence with decreasing educational level. Less striking differences are observed in the occurrence of injuries and in the restriction of daily life activities caused by diseases. A lower educational level corresponds to a regular increase in the proportion of disabled subjects. Females show higher differences than males in overweight and underweight prevalences in favour of more educated. Smoking habit shows an inverse correlation with education in males and a direct correlation in females, while attempts to quit smoking are more common among more educated individuals. Among women, the tendency to use screening tests for the prevention of some tumours is directly proportional to the educational level. Similar findings were obtained using the social class, with small bourgeoisie and working class showing similar excess risks, compared to bourgeoisie. This study found significant social inequalities in health status and in lifestyle in Italian population in 1994. The discussion argues that in absence of preventive interventions on disadvantaged groups of the population an increase of social differences in health is predictable.

[Social inequalities in the mortality due to cardiovascular diseases in Italy]

Social inequalities in cardiovascular disease mortality are described in this paper focusing on the results of the Studio Longitudinale Torinese (SLT), an investigation that links census data with the statistical data that are currently available. The overall results confirm that cardiovascular disease mortality is higher in less-advantaged socioeconomic groups, irrespectively of the social indicator used: education, social class, housing quality, job security. Stratified data shows less important inequalities among ischemic heart disease as compared to cerebrovascular mortality. The differences are even more complex when the age groups in the two genders are analyzed, revealing cohort effects. Overall, the results agree with the previous survey carried out by ISTAT on 1981 Italian mortality, which confirmed the variations in inequalities according to geographical areas, gender and age. Differences in access to the health system are likely to be related to the differences detected for geographical areas, while differences in personal history and attitude towards health-associated behavior should explain age and gender variations in inequalities. Equity must be included in the evaluation of preventive programs and health-care models. Epidemiological and social research should be encouraged to better understand the factors that influence inequalities in cardiovascular disease mortality and in the health status of the population at large.

Occupational class and ischemic heart disease mortality in the United States and 11 European countries

OBJECTIVES

Twelve countries were compared with respect to occupational class differences in ischemic heart disease mortality in order to identify factors that are associated with smaller or larger mortality differences.

METHODS

Data on mortality by occupational class among men aged 30 to 64 years were obtained from national longitudinal or cross-sectional studies for the 1980s. A common occupational class scheme was applied to most countries. Potential effects of the main data problems were evaluated quantitatively.

RESULTS

A north-south contrast existed within Europe. In England and Wales, Ireland, and Nordic countries, manual classes had higher mortality rates than nonmanual classes. In France, Switzerland, and Mediterranean countries, manual classes had mortality rates as low as, or lower than, those among nonmanual classes. Compared with Northern Europe, mortality differences in the United States were smaller (among men aged 30-44 years) or about as large (among men aged 45-64 years).

CONCLUSIONS

The results underline the highly variable nature of socioeconomic inequalities in ischemic heart disease mortality. These inequalities appear to be highly sensitive to social gradients in behavioral risk factors. These risk factor gradients are determined by cultural as well as socioeconomic developments.

Socio-economic inequalities in mortality. Methodological problems illustrated with three examples from Europe

BACKGROUND

Studies from most European countries have been able to demonstrate that lower socioeconomic groups have higher risks of disease, disability and premature death. Uncertain is, however, whether these studies have also been able to estimate the precise magnitude of these inequalities, their patterns and their trends over time. The purpose of this paper is to illustrate the extent to which results of descriptive studies can be biased due to problems with the data that are commonly available to European countries.

METHODS

Three illustrations are presented from a project on socio-economic inequalities in premature morbidity and mortality in Europe. These illustrations concern three problems often encountered in data on social class differences in mortality among middle aged men: the numerator/denominator bias in cross-sectional studies (illustrated for France), the exclusion of economically inactive men (illustrated for 4 countries), and the use of approximate social class schemes (illustrated for Sweden).

RESULTS

In each illustration, inequalities in mortality among middle aged men could be demonstrated, but data problems appeared to bias estimates of the precise magnitude of inequalities in mortality, their patterns by social class and cause of death, and their trends over time. The bias was substantial in most cases. Usually, it was difficult to predict in which ways and to what extent inequality estimates would have been biased.

CONCLUSIONS

When the aim of a study is to determine the precise magnitude, patterns or time trends of health inequalities, the results should be evaluated carefully against a number of potential data problems. Investments are needed, e.g. in data sources and in the measurement of socio-economic status, to secure that future studies can describe socio-economic inequalities in health in Europe in more detail and with more reliability.

Socioeconomic differences in cancer incidence and mortality

This chapter summarizes accumulated data on the presence, magnitude and consistency of socioeconomic differentials in mortality and incidence of all malignant neoplasms and 24 individual types of neoplasms in 37 populations in 21 countries. More or less consistent excess risks in men in lower social strata were observed for all respiratory cancers (nose, larynx and lung) and cancers of the oral cavity and pharynx, oesophagus, stomach, and, with a number of exceptions, liver, as well as for all malignancies taken together. For women, low-class excesses were consistently encountered for cancers of the oesophagus, stomach, cervix uteri and, less consistently, liver. Men in higher social strata displayed excesses of colon and brain cancers and skin melanoma. In the two Latin American populations for which data were available, lung cancer was more frequent in higher social strata. Excesses in high female socioeconomic strata were seen in most populations for cancers of the colon, breast and ovary and for skin melanoma. Longitudinal data from England and Wales suggested widening over time of social class differences in men for all cancers combined and for cancers of the lung, larynx and stomach, and in women for all cancers combined and for cervical cancer.

Accuracy of routine ultrasonography in screening heart disease prenatally. Gruppo Piemontese for Prenatal Screening of Congenital Heart Disease

The aim of the present study was to assess the accuracy of the four-chamber view as a screening test for detection of congenital heart disease (CHD) prenatally in a low-risk population. A prospective observational study was conducted in 17 ultrasound units of the Piemonte Region, Italy, in pregnancies with no risk factors for CHD. At each routine scan, from 18 weeks of gestational age, the four-chamber view of the heart was looked for. When an anomaly was suspected, the patients were referred to a specialized unit. Follow-up of the babies until discharge from the hospital was obtained. 11,232 sonograms were performed on 8299 pregnancies. Cardiac malformations were diagnosed in 40 newborns (4.8/1000). Six of them (15 per cent) had been recognized in utero. The sensitivity, specificity, and positive and negative predictive values were 15, 99.9, 50, and 99.6 per cent, respectively. When malformations that are not associated with an abnormal four-chamber view were excluded from the analysis, the sensitivity increased to 35.3 per cent. The sensitivity found in this study is low, but it is probably realistic since it is comparable to that reported in other multicentric studies. This type of study should reflect the state of the art of the method applied in the field. Although the sensitivity is low, it would be nil if the test were not performed. Moreover, it will probably increase with better training of the operators and by extending the examination to the ventriculo-arterial connections.

Prognostic factors and survival of laryngeal cancer patients from Turin, Italy. A population-based study

Little information is available on the role of risk factors for cancer of the larynx in survival. This study analyzed survival through the end of 1994 for 355 cases of laryngeal cancer diagnosed among residents of Turin, Italy, during 1979-1982. Relative survival at 5 years was 75% in women and 67% in men. The role of clinical and etiologic factors was analyzed in detail among 222 male cases. The role of nodal involvement as a strong predictor of poor survival was confirmed. Patients of low socioeconomic status experienced poorer survival than other patients, as did heavy smokers. Alcohol drinking and diet did not seem to strongly influence survival. Survival in this series of laryngeal cancer cases closely parallels that observed in other case series from Europe. While the results regarding socioeconomic status, tobacco smoking, and alcohol drinking parallel those of the few previous studies available, this investigation did not confirm a role for diet in the survival of laryngeal cancer patients, a finding that was recently seen in another study from northern Italy.

Social class and cancer survival in Turin, Italy

STUDY OBJECTIVE

This study aimed to investigate social differences in cancer survival in residents of Turin, Italy.

DESIGN

Incident cases from the Piedmont cancer registry were linked to municipality files and 1981 census data, and followed up from 1985-92. The census provided data on education and housing tenure, which were used as indicators of social class. The case fatality ratio (CFR) was estimated through a proportional hazard model, with socioeconomic indicators as risk factors.

MAIN RESULTS

Educated people of both sexes showed better survival for all malignant neoplasms together and, particularly among men, for tumours which show a better prognosis such as cancer of colon-rectum, larynx, prostate, and bladder. The relative risk of dying, compared with people who had only primary school education, decreased from 0.91 for those with middle school education to 0.67 for those who held a university degree.

CONCLUSION

There were major differences in cancer survival showing a poorer outcome for those from the lower social stratum, particularly in sites for which effective treatments are available. Since is unlikely that the observed differences could be totally explained by extraneous factors, such as competing mortality, it is concluded that even in a country where the health system offers universal coverage, non-financial barriers act by creating differences in opportunities for better care.

Relative validity and reproducibility of a food frequency dietary questionnaire for use in the Italian EPIC centres

A pilot questionnaire was developed for the EPIC centres of northern Italy, and validated in the feasibility part of the cohort project. The questionnaire was self-administered and of the food frequency type with portion size estimated by means of pictures. It was structured by courses within a meal characteristic of Italian dietary habits. Dietary intake estimated by the questionnaire was compared to the corresponding estimates obtained from 8-14 24-hour recall interviews administered over a 1-year period. The reference method was validated by means of urinary nitrogen in 4-6 repeated 24-hour urine collections. One hundred and ninety-seven volunteers (47 men and 150 women) were enrolled and completed the study lasting 1 year. They filled out two questionnaires at the beginning and at the end of the study, and had a 24-hour recall interview once a month. Twenty-four-hour urine samples were collected at regular intervals. Usual intake of energy, the major nutrients and some vitamins were estimated for the questionnaires and the reference method by means of food composition tables compiled for this study. The agreement between the questionnaire and the 24-hour recalls was only good for alcohol consumption: Pearson's correlation was 0.73 and 0.77 in men and women respectively. Otherwise the relative validity of the questionnaire ranged between 0.28 for fat to 0.52 for carbohydrates in men and 0.25 and 0.50 in women for the same nutrients. The validity of the two interview methods in estimating protein intake, compared to mean urinary nitrogen was 0.24 (M) and 0.18 (W) for the questionnaire and 0.63 (M) and 0.48 (W) for 24-hour recalls. The main causes of low performance of the questionnaire were identified to be the estimated intake of dressing and cooking fats, vegetables and meat. Remedies were devised and introduced in the final version of the questionnaire currently in use in the EPIC project.