An heart team stroke prevention decision-making process comparing percutaneous endocardial and thoracoscopic epicardial left atrial appendage occlusion

Introduction

Left atrial appendage occlusion (LAAO) is a validated therapeutic option in patients with atrial fibrillation (AF) at high thrombo-embolic risk and contraindication to oral anticoagulation. Large clinical trials have demonstrated excellent efficacy of percutaneous LAAO, but also stand-alone thoracoscopic LAAO has shown promising results with the advantage of absence of antiplatelet therapy. No direct comparison of both strategies has been published yet.

Purpose

To evaluate an Atrial Fibrillation Heart Team guided approach to percutaneous or thoracoscopic left appendage exclusion in patients with non valvular atrial fibrillation (NVAF).

Methods

Forty patients with a contraindication to oral anticoagulation (OAC) were evaluated in the AF Heart Team for LAA exclusion. Contraindication for OAC was based upon a history of cerebral hemorrhages (n=17), non-cerebral life-threatening hemorrhages (n=9), repetitive bleeding (n=8) and having underlying diseases associated to high bleeding risk (n=6). The 20 patients included in the LAAO-Percutaneous group (LAAO-P) were on low molecular weight heparin pre-procedure, whereas in the LAAO-thoracoscopic group (LAAO-TT) none were on low molecular weight heparin nor antiplatelet therapy since the bleeding risk was estimated too high. The LAAO-P group were 70% male, with a mean age of 72.3±7.5 (range 57–82), mean CHA2DS2VASc 4.2 (range 1–6) and a mean HASBLED 3.5 (range 1–5) with an expected risk of bleeding between 3.7–8.7% per year. The LAAO-TT were 72.5% male, with a mean age of 74.9±8 (range 53–87 years), mean CHA2DS2-VASc 6.05 (range 4–8), HASBLED mean 5.4 (range3–8) expected risk of bleeding >12.5% per year. Variables considered were CHA2DS2VASc, HASBLED, documented blood transfusions, comorbidities related risk of bleeding, anatomy of the LAA, lung function, patient quality of life. LAAO-P patients were on dual antiplatelet therapy (DAT) at discharge for the first three months and aspirine 100mg/day thereafter, whereas the LAAO-TT patients were not. Follow up included TEE at 1 months and CT scan at 3 months.

Results

Mean duration of procedures for LAAO-P was 54.4 minutes, for LAAO-TT 52.01 minutes, mean post procedural ventilation time was respectively 11.2±6.4 and 15.8±16.4 minutes. No major complications occurred in both groups. One patient in the LAAO-P crossed over because of an unsuitable anatomy which became apparent intra-operatively. Mean hospital stay were comparable in both groups, 3.4±0.7 and 3.8±0.9 days respectively. At mean follow up of 24.3±10.1 months (range 5–36) all patients had complete exclusion of the appendage, no neurological events were reported.

Conclusions

The Heart Team can improve decision making in complex stroke prevention where LAAO is a therapeutic option, percutaneous and thoracoscopic occlusion seem to be comparably safe and effective. An epicardial LAAO could be advised in patients were the bleeding risk is estimated too high for AP therapy.

Funding Acknowledgement

Type of funding sources: None. Appendage closure: CT scan viewAppendage closure: surgical view

Trends in thyroid function testing, neck ultrasound, thyroid fine needle aspiration, and thyroidectomies in North-eastern Italy

PURPOSE

Evidence of an increased diagnostic pressure on thyroid has emerged over the past decades. This study aimed to provide estimates of a wide spectrum of surveillance indicators for thyroid dysfunctions and diseases in Italy.

METHODS

A population-based study was conducted in North-eastern Italy, including 11.7 million residents (20% of the total Italian population). Prescriptions for TSH testing, neck ultrasound or thyroid fine needle aspiration (FNA), surgical procedures, and drugs for hypo- or hyperthyroidism were extracted from regional health databases. Proportions and rates of selected examinations were calculated from 2010 to 2017, overall and by sex, calendar years, age, and region.

RESULTS

Between 2010 and 2017 in North-eastern Italy, 24.5% of women and 9.8% of men received at least one TSH test yearly. In 2017, 7.1% of women and 1.5% of men were prescribed drugs for thyroid dysfunction, 94.6% of whom for hypothyroidism. Neck ultrasound examinations were performed yearly in 6.9% of women and 4.6% of men, with a nearly two-fold variation between areas. Thyroid FNA and thyroidectomies were three-fold more frequent in women (394 and 85 per 100,000) than in men (128 and 29 per 100,000) with a marked variation between areas. Both procedures decreased consistently after 2013.

CONCLUSIONS

The results of this population-based study describe recent variations over time and between surrounding areas of indicators of 'diagnostic pressure' on thyroid in North-eastern Italy. These results emphasize the need to harmonize practices and to reduce some procedures (e.g., neck ultrasound and total thyroidectomies) in certain areas.

Home accidents in the province of Trento. Ten years of observations regarding admissions to the emergency and first aid department

BACKGROUND

Home accidents, or domestic accidents, are accidents that occur inside a home or the adjacent areas (stairways, courtyards, gardens, attics, cellars, garages, etc.). In Italy, they are monitored through a number of surveillance systems including the PASSI system and the ISTAT (Italian Institute of Statistics) Multipurpose Survey on Households. Only the SINIACA system (Italian National Information Service on Domestic Accidents), managed by the Istituto Superiore di Sanità (National Institute for Health), provides health-related information regarding such events and their circumstances and consequences, based primarily on Accident & Emergency Departments' data.

STUDY DESIGN

This is an observational study on the domestic accidents trends in the province of Trento, using data on Accident & Emergency Departments admissions, between 2009 and 2018, combined with mortality and hospital discharge data.

METHODS

The authors extrapolated records regarding admissions for domestic accidents from the digital annual Accident & Emergency admissions archive. For the 2009-2018 period, they analysed: the trend over time, both overall and classified according to gender and age group; and the inflow rate/10,000 inhabitants, broken down according to gender, nationality (Italians and foreign nationals) and age group. The coverage of the additional SINIACA variables regarding the accident dynamic, contingent activity and place of the accident were also analysed. With regard to the case load for 2018, the authors analysed the site and type of the injuries, the level of severity, outcome and the services provided, comparing the 0-14 years and >65 years age groups. Trend significance was analysed using the Cochran-Armitage test for trend and the significance of the differences between the proportions was analysed using the Chi-squared test. We have also calculated the costs of the services provided, overall and by age group.

RESULTS

During the study period, a total of 99,386 A&E admissions for domestic accidents were recorded, with an annual average of 9,938 admissions. Between 2009 and 2018, there was a statistically significant increase of 41%, which was due in part to better event recognition and recording. Females prevail over males, especially over the age of 75 years. Over time there is an increase in cases over the age of 65, due to the progressive ageing of the population. Considering the resident population alone, the A&E inflow rate rises from 147 admissions/10,000 inhabitants in 2009 to 197 admissions/10,000 inhabitants in 2018, with a 39.0% increase. Inflow is greater in the two extreme age groups: in 2018, in the 0-4 years age group, the inflow rate is 319 admissions/10,000 inhabitants and in the over 75 years class it rises to 481 admission/10,000 inhabitants, 1.6 and 2.4 times the mean inflow for home accidents in the province of Trento, respectively. Admissions are less amongst foreign nationals than amongst Italians. Generally speaking, the events were of a mild severity, with white triage codes accounting for 16% of cases and green triage codes for 73%. The degree of severity is higher amongst subjects aged over 65, as well as in women and Italian citizens.The level of recording of SINIACA variables increases over time, to reach 100% coverage in 2018. Falls are the most common dynamic in all age ranges; household chores, activities of daily living and DIY are the three most commonly observed activities. Home accidents most commonly occur in the areas adjacent to the home and the kitchen. In over 2/3 of cases, the injuries sustained were to the limbs and the head/face. Head/face injuries prevail in the youngest age group. Wounds, burns and head injuries are the most common types of injury sustained by children in the 0-14 years age group, whereas fractures and dislocations are typical of the older age groups. Diagnostic and care resource consumption is far higher amongst the elderly, which absorb 61% of the total costs of the cases treated in the year 2018.

CONCLUSION

Accident & Emergency facilities provide a privileged observatory for the monitoring of domestic accidents in the population. By comparing our data with the ISTAT data, it can be estimated that 1 in 2 home accidents in the population resulted in an A&E admission. Admissions increase over time, particularly amongst the elderly and they are not higher amongst foreign nationals than amongst Italians. The inflow rate is higher in the extreme age ranges: 0-4 and >75 years; however, there are differences between the two in terms of type of injury, level of severity and outcome. It is essential for A&E admission data to be fully digitalised, and facility and staff sensitisation is also important in order to guarantee the availability of good-quality data. The completeness of A&E data and the possibility of obtaining case stratification based on social and demographic characteristics could make it possible, through a virtuous integration of services, to use these data for the implementation of prevention initiatives. These, if carried out effectively, could also contribute to contain healthcare costs.

Post-abortion check-ups at Trento Family Planning Centre. Characteristics of those users who attended the check-up appointments and trends between 2003 and 2017

BACKGROUND

The purpose of the study was to analyse the trend for post-abortion check-ups among users requesting the abortion certification from Trento Family Planning Center between 2003 and 2017.

STUDY DESIGN

Retrospective case-control study.

METHODS

During the study period, the Trento Family Planning Center issued a total of 3,870 abortion certificates (46% regarding foreign nationals). The social and demographic characteristics of those users who attended the post-abortion check-up appointments, and of those who did not, were compared.

RESULTS

The proportion of resident users who returned for a post-abortion check-up increases significantly during the study period. The multiple logistic regression analysis model indicates that the factors associated with the likelihood of a return for a post-abortion check-up are: possession of medium to high academic qualifications (> 8 years) versus low qualifications, being a non-EU or Asian citizen, being a minor and being nulliparous or multiparous versus primiparous.

CONCLUSIONS

According to Family Planning Centers' philosophy, post-abortion check-ups are a good opportunity for promoting responsible procreation. The strategy for the management of the Trento Family Planning Center's users requesting an abortion led to an increase of the proportion of users who returned for the post-abortion check-up greater than is the case for other territorial Family Planning Centers.

Estimates of cancer burden in Italy

Aims and background

This paper presents updated estimates of the incidence, prevalence and mortality of stomach, colorectal, lung, breast, uterine cervix and prostate cancer and skin melanoma in the Italian population. In particular, point estimates for 2012 and time trends from 1970 to 2015 will be provided.

Methods

The presented figures were obtained by summing up the regional epidemiological indicator estimates presented in the other papers of this monographic issue, which were derived by applying the MIAMOD statistical back-calculation method to cancer registries survival data and official mortality rates.

Results

Our findings indicate that breast, colon-rectum and prostate will be the cancer sites with the highest incidence rates in the forthcoming years. The incidence rates still tend to increase for breast, male colorectal cancer and female lung cancer as well as for skin melanoma. By contrast, the incidence of stomach cancer, cervical cancer and male lung cancer, by far the most common tumor sites up to the early 1990s, will continue to decrease. The mortality estimates showed a decreasing trend for all considered cancers with the only exception of lung cancer in women.

Conclusion

These results point to the need to reinforce prevention activities by developing more effective preventive measures for population groups at risk. There is also a need to support timely and continuous cancer surveillance in the Italian population through cancer registries in order to monitor the spread of the cancer risk and to evaluate the impact of prevention policies and therapeutic advances.

A Nutritional Approach to the Prevention of Cancer: from Assessment to Personalized Intervention

Among lifestyle factors, nutrition is one of the most important determinants of health, and represents a pivotal element of cancer risk. Nonetheless, epidemiological evidences of the relationship between several cancers and specific foods and nutrients is still inadequate, and solid conclusions are missing. Indeed, caloric restriction without malnutrition is associated to cancer prevention. Food may be also the primary route of exposure to contaminants such as metals, persistent organic pollutants, and pesticides. Exposuredisease associations and the interplay with genetic susceptibility requires further studies on genetic variation, environment, lifestyle, and chronic disease in order to eliminate and reduce associated health risks, thus contributing to improve health outcomes for the population. A primary nutritional approach for Active and Healthy Ageing (AHA) has been developed by the Nutrition group of the European Innovation Partnership (EIP) on AHA. The working group on lifestyles of the Italian Ministry of Health has developed a comprehensive approach to adequate nutrition using a consensus methodology to collect and integrate the available evidences from the literature and from the Italian experiences at the regional level, to raise the interest of other experts and relevant stakeholders to outline and scale-up joint strategies for a primary nutritional approach to cancer prevention.

Survival in patients with primary liver cancer, gallbladder and extrahepatic biliary tract cancer and pancreatic cancer in Europe 1999-2007: Results of EUROCARE-5

BACKGROUND

The EUROCARE study collects and analyses survival data from population-based cancer registries (CRs) in Europe in order to provide data on between-country differences in survival and time trends in survival.

METHODS

This study analyses data on liver cancer, gallbladder and extrahepatic biliary tract cancers ("biliary tract cancers"), and pancreatic cancer diagnosed in 2000-2007 from 88 CRs in 29 countries. Relative survival (RS) was estimated overall, by region, sex, age and period of diagnosis using the complete approach. Time trends in 5-year RS over 1999-2007 were also analysed using the period approach.

RESULTS

The prognosis of the studied cancers was poor. Age-standardised 5-year RS was 12% for liver cancer, 17% for biliary tract cancers and 7% for pancreatic cancer. There were some between-country differences in survival. In general, RS was low in Eastern Europe and high in Central and Southern Europe. For all sites, 5-year RS was similar in men and women and decreased with advancing age. No substantial changes in survival were reported for pancreatic cancer over the period 1999-2007. On average, there was a crude increase in 5-year RS of 3 percentage points between the periods 1999-2001 and 2005-2007 for liver cancer and biliary tract cancers.

CONCLUSIONS

The major changes in imaging techniques over the study period for the diagnosis of the three studied cancers did not result in an improvement in the prognosis of these cancers. In the near future, new innovative treatments might be the best way to improve the prognosis in these cancers.

Clinical, morphological and genetic studies in a cohort of 21 patients with myofibrillar myopathy

The term myofibrillar myopathies (MFM) refers to uncommon neuromuscular disorders that pathologically are characterized by myofibrillar degeneration and ectopic expression of several proteins. MFM are partly caused by mutations in genes that encode mainly Z-disk-related proteins (desmin, alphaB-crystallin, myotilin, ZASP, filamin C and BAG3). We reviewed clinical, light and electron microscopy, immunohistochemistry, immunoblotting and genetic findings of 21 patients with MFM (15 unrelated patients and three pairs of brothers) investigated at our neuromuscular center. MFM patients begin to show symptoms at any age, from juvenile to late adult life and present a different distribution of muscle weakness. Cardiac involvement and peripheral neuropathy are common. Typical histological features include focal areas with reduction/loss of ATPase and oxidative enzyme activity, and amorphous material (eosinophilic on hematoxylin and eosin and dark blue on Engel-Gomori trichrome) in these abnormal fiber areas. Electron microscopy shows disintegration of myofibrils starting from the Z-disk and accumulation of granular and filamentous material among the myofilaments. Immunohistochemical studies demonstrate focal accumulation of desmin, alphaB-crystallin and myotilin in abnormal muscle fibers while immunoblot analysis does not highlight differences in the expression of these proteins also including ZASP protein. Therefore, unlike immunoblot, immunohistochemistry together with light and electron microscopy is a useful diagnostic tool in MFM. Finally three of our 21 patients have missense mutations in the desmin gene, two brothers carry missense mutations in the gene encoding myotilin, one has a missense mutation in alphaB-crystallin, and none harbour pathogenic variations in the genes encoding ZASP and BAG3.

[General practitioners and colorectal cancer screening: experience in the Trentino region]

The aims of this longitudinal study are to investigate general practitioners' opinions and knowledge about colorectal cancer screening in Trentino region, to identify their role and level of participation within the screening program and to find out their formative needs. 174 general practitioners answered the postal self-filled questionnaire: 82% of them asserted their main role in colorectal screening is patient counselling, but many physicians also showed availability to collaborate with the Centre for Health Services of Trento in organizing patients recruitment list and in recovering patients who didn't accept screening invitation. 78% thinks the Health Services of Trento should allocate incentives, especially push money, to promote physicians participation in screening program. Moreover 68% needs a basic formative course about screening programme. Female general practitioners are more prepared to collaborate in organizing patients recruitment list and in handing over the kit for fecal occult blood test than their male colleagues. Instead men prefer to take an active role in counselling and are more interested in economic incentives. The study has found considerable general practitioners support for the introduction of the new screening programme. The info-formative line to improve in Trentino could create a better interface between general practitioners and Centre for Health Services, keeping into account the organizing features of physicians. It seems to be important the definition of shared procedures for the counselling and the requirement of formative courses by general practitioners; the Centre for Health Services of Trento has already undertaken these courses disguised as seminars addressed all health operators.

Prevalence of respiratory symptoms in migrant children to Italy: the results of SIDRIA-2 study

BACKGROUND

Epidemiological studies have documented large international variations in the prevalence of asthma, and 'westernization' seems to play an important role in the development of the disease. The aims of this study were to compare the prevalence of respiratory symptoms in migrant and nonmigrant children resident in Italy, and to examine the effect of length of time living in Italy.

METHODS

Data were collected in a large cross-sectional study (SIDRIA-2) performed in 12 Italian centres, using standardized parental questionnaires. For the 29 305 subjects included in the analysis (6-7 and 13-14 years old), information about place of birth and parental nationality was available.

RESULTS

There were 1012 children (3%) born outside of Italy, mainly in East Europe. Lifetime asthma and current wheeze were generally significantly less common among children born abroad than among children born in Italy (lifetime asthma: 5.4% and 9.7% respectively, P < 0.001; current wheeze: 5.2% and 6.9%, respectively, P = 0.04). Lower risks for lifetime asthma (prevalence odds ratio, POR = 0.39; 95% CI: 0.23-0.66) and current wheeze (POR = 0.72; 95% CI: 0.47-1.10) were found for children who had lived in Italy <5 years, while migrant children who had lived in Italy for 5 years or more had risks very similar to Italian children.

CONCLUSIONS

Migrant children have a lower prevalence of asthma symptoms than children born in Italy. Prevalence increased with the number of years of living in Italy, suggesting that exposure to environmental factors may play an important role in the development of asthma in childhood.

Mould/dampness exposure at home is associated with respiratory disorders in Italian children and adolescents: the SIDRIA-2 Study

AIMS

To report on the relation between home mould and/or dampness exposure and respiratory disorders in a large sample of children and adolescents in Italy, accounting for age at time of exposure.

METHODS

20,016 children (mean age 7 years) and 13,266 adolescents (mean age 13 years) completed questionnaires on indoor exposures and respiratory symptoms/diseases. Statistical analyses were adjusted for sex, age, questionnaire's compiler, area of residence, season of interview, parental educational status, family history of asthma, rhinitis, eczema, chronic obstructive pulmonary disease, presence of gas water heaters, passive smoking, pets, and active smoking (only for adolescents). Population attributable risk % (PAR) was also computed.

RESULTS

Asthma was more strongly related to only early than to only current exposure, both in children (OR 1.80, 95% CI 1.41 to 2.30) and adolescents (OR 1.89, 95% CI 1.38 to 2.59). The same result was found for rhino-conjunctivitis (OR 1.46, 95% CI 1.17 to 1.82), in children, and for wheeze among adolescents (OR 1.56, 95% CI 1.15 to 2.11). In children, wheeze (OR 1.98, 95% CI 1.47 to 2.66) and eczema (OR 1.44, 95% CI 1.09 to 1.91) were more strongly related to mould/dampness when exposed both early and currently; the same occurred in adolescents for rhino-conjunctivitis (1.78, 95% CI 1.30 to 2.45). Although persistent cough/phlegm was significantly related to mould/dampness exposure in children, regardless of exposure timing, no significant association between mould/dampness exposure and eczema or cough/phlegm was found among adolescents. PAR estimates were higher for only early than only current exposures. Avoiding early only exposure would abate wheeze by 6%, asthma or cough/phlegm by 7%, rhino-conjunctivitis in children by 4%, and in adolescents, asthma by 6%, and wheeze by 4%.

CONCLUSIONS

Respiratory disorders such as wheeze and asthma can often be explained by exposure to home mould/dampness, especially early in life. The association seems more evident in children than in adolescents. These findings may suggest the need for environmental prevention strategies.

[Customer satisfaction analysis in women attending an organized mammographic screening. Pilot study at Trento]

Present paper reports on the results of a pilot customer satisfaction study carried out on 1.720 consecutive women (18.7 with spontaneous access) attended senology department (Trento and Borgo) in the context of a organized mammography screening programme, started in October 2000. Data were collected by a questionnarie filled by the women after mammography. 4.3% of the invited women reported the receiving the letter late, 0.9% considered it inaccurate, 7.2% had some problems for getting a new date for test, 1.8% of the whole sample reported some problems for external access and 2.2% for internal access to health facilities; 1.9% perceived waiting room as not friendly. The welcoming by the personnel is judged quite well, only 0.6% complained about it. Trento centre, is more efficient than Borgo. In 21.7% of the cases the mammography has been performed within next 30 minutes of the fixed time and in 7.9% besides that. 36.8% of the whole sample perceived mammography as tiresome and 4.1% as painful. The percentage of women reporting mammography disconforting increase, in Trento sample, according the education level as previously reported. The data about perceived quality are satisfactory, on the whole. Anyway it would be opportune to contain the waiting time.

Classic Kaposi's sarcoma in Italy, 1985-1998

To evaluate incidence rates (IRs) of classic Kaposi's sarcoma (CKS) in Italy after the spread of AIDS, we distinguished CKS from AIDS-related KS (AKS) using an 'ad hoc' record linkage procedure between 15 Cancer Registries (CRs) (21% of the Italian population) and the national AIDS Registry. Between 1985 and 1998, 874 cases of CKS and 634 cases of AKS were diagnosed in the study areas. CKS accounted for 16 and 27% of KS cases below 55 years of age in men and women, respectively, but for 91 and 100% of those above age 55. The IRs for CKS were 1.0/ in men and 0.4/100,000 in women, but they varied between 0.3 in Umbria and 4.7 in Sassari in men, and between 0.1 in Parma and 1.7 in Sassari in women. IRs of CKS in both genders were stable between 1985-1987 and 1993-1998. In Northern and Central CRs the IR (adjusted for age and gender) for CKS was 0.5 in individuals born in the same area, but 1.6 in individuals born in Southern Italy or in the Islands (rate ratio = 3.2) suggesting that KS-associated herpesvirus, the cause of KS, is acquired early in life.

[Dietary habits in primary school children. Role of school meals and parents's social class]

Present paper reports the results of a survey on dietary habits of 1,398 children attending first class of primary school in Trento Province (northern Italy). The following items were investigated: frequency of breakfast and foods intake; frequency of foods at school. The consumption of tracer foods as vegetables, fruit and sweets was also investigated. The results were analyzed according gender, area of residence, teaching method (full time or not) and educational level of parents. The data about nutritional style are satisfactory even if they are strongly associated to education level of parents, above all of the mother. The adequacy of nutritional style is increasing with the increasing of education level. School meal, offering selected foods to all children attending full time teaching section, can re-equilibrate nutritional style, decreasing the differences associated to education level of the parents. Present data can be used for implementing and improving health promotion action on correct dietary habits in childhood, keeping count of the role of education level of the parents.

[7-valent conjugate Pneumococcal vaccine and nasopharyngeal cavity]

7-valent conjugate pneumococcal vaccine is effective for preventing invasive pneumococcal diseases in childhood. The present serotype formulation of the conjugate Pneumococcal Vaccine is effective for preventing 75-90% of the invasive pneumococcal disease cases, depending of the vaccine-serotypes distribution in the several countries. Recent studies, carried out in the north-american context, show that mass vaccination campaign by 7-valent conjugate Pneumococcal Vaccine in childhood, reduce, in vaccinated subjects, the nasopharyngeal colonization by vaccine-serotypes, that are much more joined to antibacterial resistance. This implies non only an active and specific protection for vaccinated, but also for family and community contacts, children and adults. This interesting results, need to be confirmed also in european countries, open a new view for a wider pharmacoeconomic evaluation of the 7-valent conjugate Pneumococcal Vaccine in childhood.

The impact of parental smoking on asthma and wheezing. SIDRIA Collaborative Group. Studi Italiani sui Disturbi Respiratori nell'Infanzia e l'Ambiente

To evaluate the impact of parental smoking on childhood asthma and wheezing, we studied two random samples of subjects ages 6-7 and 13-14 years in ten areas of northern and central Italy. Standardized questionnaires were completed by parents of 18,737 children and 21,068 adolescents (response rates, 92.8% and 96.3%, respectively) about their smoking habits and the respiratory health of their children. Adolescents were asked about their respiratory health and personal smoking. We compared two groups of cases with healthy subjects: (1) "current asthma" (children, 5.2%; adolescents, 6.2%) and (2) "current wheezing" not labeled as asthma (children = 4.5%, adolescents = 8.5%). Exposure to smoke of at least one parent increased the relative risk of current asthma among children [odds ratio (OR) = 1.34; 95% confidence interval (CI) = 1.11-1.62] and of current wheezing among adolescents (OR = 1.24; 95% CI = 1.07-1.44). Maternal smoking had a stronger effect than paternal smoking. Maternal smoking during pregnancy was associated with current asthma (OR = 1.62; 95% CI = 1.34-1.96) and current wheezing in children (OR = 1.31; 95% CI = 1.06-1.62); the effects were lower among adolescents. Among subjects with a negative history of parental asthma, maternal smoking was associated with current wheezing in both age groups, whereas among those with a positive history of parental asthma it was associated with current asthma in children, but not in adolescents. We estimated that 15% (95% CI = 12-19) of the current asthma cases among children and 11% (95% CI = 8.3-14) of the current wheezing cases among adolescents are attributable to parental smoking in Italy.

Road traffic and adverse respiratory effects in children. SIDRIA Collaborative Group

OBJECTIVES

To investigate the relation between traffic indicators in the area of residence and the occurrence of chronic respiratory disorders in children.

METHODS

A population based survey was conducted in 10 areas of northern and central Italy (autumn 1994 to winter 1995) in two age groups (6-7 and 13-14 years). Information on several respiratory disorders and on traffic near residences was collected with a questionnaire given to children and to their parents. The sample analysed included 39,275 subjects (response rate 94.4%). Outcomes were: (a) early (first 2 years of life) respiratory diseases, and (b) current respiratory disorders (asthma, wheeze, cough, or phlegm in the past year). Odds ratios (ORs) and 95% confidence intervals (95% CIs), adjusted for several potential confounders, were estimated from logistic regression models. Main results were stratified by level of urbanisation (metropolitan areas, other centres).

RESULTS

In the metropolitan areas, high frequency of lorry traffic in the street of residence was associated with significantly increased risks for many adverse respiratory outcomes. Among early respiratory diseases, the strongest associations were found for recurrent bronchitis (OR 1.69, 95% CI 1.24 to 2.30), bronchiolitis (1.74, 1.09 to 2.77) and pneumonia (1.84, 1.27 to 2.65), although no association was detected for episodes of wheezing bronchitis. All the current respiratory disorders were positively and consistently associated with frequency of lorry traffic, particularly the most severe bronchitic and wheezing symptoms: persistent phelgm for > 2 months (1.68; 1.14 to 2.48), and severe wheeze limiting speech (1.86; 1.26 to 2.73). No or weaker associations with heavy vehicular traffic were detected in urban and rural areas and no increased risks were found in the whole sample with the reported traffic density in the zone of residence. After extensive evaluations, the potential of reporting bias seems unlikely.

CONCLUSION

Exposure to exhausts from heavy vehicular traffic may have several adverse effects on respiratory health of children living in metropolitan areas, increasing the occurrence of lower respiratory tract infections early in life and of wheezing and bronchitic symptoms at school age.

[Nursing aspects in men with urinary catheters at the Nursing Service of the District of Trento]

The whole male population with indwelling catheter of the Trento health district has been included in a survey of the quality of the home nursing services. The epidemiological and in depth analysis of the characteristics and motivation of the high degree of heterogeneity of medical prescribing behaviors and of the nursing practices suggest that an important effort of rationalization (on the basis of pre adopted protocols) is both needed and possible.

Differences in Cancer Mortality Trends between Four Neighboring North-Eastern Areas and Italy, 1970-1990

Aims and background

The present report combines descriptive statistics (partly never published) on four neighboring areas of north-eastern (NE) Italy [Friuli-Venezia Giulia (1970-89) and Veneto (1970-87) regions and the provinces of Trento (1970-89) and Bolzano (1971-90)], and all Italy (1970-89). The aim was to highlight potential differences in mortality trends and promote a more systematic sharing of data and methodologies.

Methods

Death certificates stratified by cause, sex, age and residence were obtained from official publications of the Italian Central Institute of Statistics. Absolute numbers of deaths from different causes, age-standardized rates (on the basis of the European standard population) and percentage of change over the examined period for both sexes were computed for each geographic area.

Results

Unfavorable trends were seen for neoplasms of the upper aerodigestive tract, lung, breast, colorectum, bladder, kidney and pancreas and cutaneous malignant melanoma. Increases in most of these neoplasms were more marked in the 4 NE areas than in Italy, especially with respect to cancers of the upper aerodigestive tract in both sexes and cancer of the lung and ovary in women. In Bolzano, rates of neoplasms associated with tobacco and alcohol consumption were lower and less steeply increasing than in the other NE areas, most notably Trento, therefore, contributing to produce the lowest overall cancer mortality rates of NE areas. Cancers of the stomach, uterus, and testis and Hodgkin's disease presented consistent downward trends in all examined areas.

Conclusions

The analysis of mortality trends across areas is consistent with elevated and still increasing cancer rates in the 4 NE areas considered, especially for tobacco and alcohol-related neoplasms and skin melanoma. Preventive strategies, based on epidemiologic knowledge, especially against tobacco and heavy alcohol consumption, and intense intermittent sun exposure, seem to be priorities and may benefit from systematic sharing of information, expertise and intervention tools in NE Italy. At least part of the lack of cancer deaths in Bolzano must be attributable to the deaths of Bolzano residents abroad (especially in Austria) and/or to differences in coding practices. This should be elucidated in future studies.

[Diagnosis and prognosis of malignant mesothelioma. A description of 8 clinical cases]

A retrospective study of patients at the Trento S. Chiara Hospital in the period 1982-86 showed up 8 cases of malignant mesothelioma (7 pleural and 1 peritoneal). The histology was re-examined for each case and clinical records was also looked at so as to identify onset symptomatology, diagnostic procedures and treatment. A standard questionnaire given to patients or close relations revealed previous exposure to asbestos in 2 of 3 males and in none of the 5 females. There was also a significant delay in formulation of correct diagnosis, attributable on the hand to the nonspecificity of the symptomatology of onset and on the other to the inadequacy of currently available clinical and radiological procedures. Only histology with the aid of immunocytochemical procedures was able to pinpoint correct diagnosis, in life. The ineffectiveness of conventional therapies and the poor overall prognosis for these patients is confirmed.

Skeletal scintigraphy and physical examination in the staging of early breast cancer

The significance of skeletal scintigraphy in staging of early breast cancer is still controversial. The results of bone scanning with 99Tcm diphosphonate and clinical examination in 204 patients with stage I-II breast cancer are reported. Bone scans were positive in 28 cases. However, only one was true positive as confirmed by x-ray examination and/or biopsy, with a detection rate of 0.5%. Physical examination had a detection rate similar to bone scan, but with superior specificity. In our experience bone scan cannot be recommended as a routine staging test in early breast cancer.

Neoadjuvant Chemotherapy with Vincristine, Bleomycin and Methotrexate Combined with Radiotherapy in Advanced Head and neck Squamous Cell Carcinoma

From September 1980 to August 1981, 25 patients with advanced head and neck squamous cell carcinoma were treated at the Centro Oncologico, Trento, by a chemo-radiotherapeutic combination. The treatment protocol consisted of 4–6 courses of VBM (vincristine, bleomycin and methotrexate) followed by conventional radiotherapy (65 Gy). Only to VBM responders (15 patients) were administered 10 cycles of vincristine-methotrexate. At the end of induction chemotherapy an overall response of 60 % (12 % complete, 48 % partial) was obtained. At the end of radiotherapy the responses were 52.5 % complete and 35.5 % partial, for an overall response of 88 %. The overall survival at 60 months was 8 %. This combined approach, in spite of the satisfactory immediate local response rate, does not offer advantages for survival in comparison to conventional treatment modalities.