OBJECTIVES: to update the health profile of the residents in the national priority contaminated sites (SIN) in Sicily Region (Southern Italy), through a description of mortality and hospitalisation by causes, as implemen...OBJECTIVES: to update the health profile of the residents in the national priority contaminated sites (SIN) in Sicily Region (Southern Italy), through a description of mortality and hospitalisation by causes, as implementation of the epidemiological surveillance included in the Programme of health intervention in these populations and in the new Regional Prevention Plan. DESIGN: ecological study which uses two levels of comparison for each SIN: a local level including the populations of SIN neighbouring areas and a regional level including people residing in Sicily. SETTING AND PARTICIPANTS: the population in the study is residents in the municipalities included in the following SIN: Augusta-Priolo (presence of industrial areas); Gela (presence of industrial areas); Milazzo (presence of industrial areas); Biancavilla (presence of natural asbestos-like material). MAIN OUTCOME MEASURES: using the information from the mortality registry for the mortality index, the hospital discharge data for the morbidity index, the standardised mortality ratio (SMR), and the standardised hospitalisation ratio (SHR) with the corresponding 95% confidence intervals were calculated. RESULTS: in the local comparison, an excess of hospitalisation in both sexes is reported in Augusta-Priolo for liver cirrhosis, mental disorders, and digestive tract disease, and an excess of mortality for leukaemia in women and prostate cancer in men. In the SIN of Gela, there is an excess of hospitalisation in both sexes for blood and haematopoietic diseases, circulatory and nervous system diseases, sustained by the same excess of mortality. There are also excesses of hospitalisation and mortality of stomach tumours in men and hospitalisation of lung cancer in women. The area of Milazzo is characterised by an excess of hospitalisation and mortality for melanoma in men. In the municipality of Biancavilla, there is evidence of an excess of hospitalisation for respiratory diseases and endocrine glands diseases in both sexes, while a mortality excess for circulatory system diseases. CONCLUSIONS: the data derived from the new surveillance system help to define the health profile in the SINs of Sicily. Even by using the local level of comparison that was added to the traditional approach in geographic studies in the national priority contaminated sites for the reclamation available until today, the particular impact of some chronic diseases in these populations has also been confirmed in recent years.
OBJECTIVES: to describe the frequency of prostate biopsy and its determinants, as well as the incidence of prostate cancer, in a cohort of asymptomatic residents of the Agency for Health Protection of the Metropolitan Ar...OBJECTIVES: to describe the frequency of prostate biopsy and its determinants, as well as the incidence of prostate cancer, in a cohort of asymptomatic residents of the Agency for Health Protection of the Metropolitan Area of Milan (ATS Milano) who underwent total prostate-specific antigen (PSA) testing. DESIGN: cohort study of resident men aged 30-84 years who underwent at least one PSA test (index test) in 2018-2019 and 2021-2023, with follow-up until December 2024. SETTING AND PARTICIPANTS: from the administrative and healthcare databases of ATS Milano, 414,731 residents who underwent at least one PSA test during the study period, presumably for screening purposes, were identified. MAIN OUTCOME MEASURES: frequency of specific follow-up procedures (repeat PSA testing, urological consultation, ultrasound, magnetic resonance imaging), with particular focus on prostate biopsy, and cumulative incidence at 3, 6, and 12 months after the index test. Logistic regression analysis of the probability of undergoing prostate biopsy within 6 months of the index test. RESULTS: overall, 1.6% of subjects underwent a prostate biopsy within one year (N. 6,598). This proportion increased markedly with higher initial PSA values (13.8% among those with PSA >=6 ng/mL). On average, 11.7% of biopsies were the first procedure after the index test, 22.4% followed one of the procedures considered, 33.7% followed two procedures, 24.9% followed after three procedures, and 7.3% followed four procedures. Prostate cancers diagnosed were 1,157 at 3 months and 3,219 at 1 year, compared by means of the observed-to-expected ratio, to the incidence of the general population. The biopsy-to-cancer ratio was approximately 2. At 6 months, prostate biopsy was positively associated with age (up to 70-79 years), strongly associated with PSA level (>=6 ng/mL, OR: 28.7) and with Italian citizenship, while a lower risk was observed in the presence of comorbidities. The observed-to-expected ratio was greater than 1 for initial PSA values >=3 ng/mL and increased progressively with higher PSA levels. CONCLUSIONS: among residents of the ATS Milano area, a PSA level equal to or greater than 3 ng/mL identifies an early increased risk of prostate carcinoma. To ensure the timely identification of all clinically significant cases, biopsy should be integrated into a multimodal diagnostic pathway including advanced imaging, which was not always available in the analysed cohort.
OBJECTIVES: to evaluate follow-up patterns after a total prostate-specific antigen (PSA) test performed in the absence of clinical indications among residents of the Agency for Health Protection of the Metropolitan Area...OBJECTIVES: to evaluate follow-up patterns after a total prostate-specific antigen (PSA) test performed in the absence of clinical indications among residents of the Agency for Health Protection of the Metropolitan Area of Milan (ATS Milano). DESIGN: a cohort of men aged 30-84 years residing in the ATS Milano area who underwent at least one PSA test between 2018-2019 and 2021-2023, followed for subsequent investigations through December 2024. SETTING AND PARTICIPANTS: from the administrative and healthcare databases of the ATS Milano, 414,731 individuals who had at least one PSA test during the study period, presumably for screening purposes, were identified. MAIN OUTCOME MEASURES: individual procedures and cumulative follow-up activities within 3, 6, and 12 months from the index PSA test, classified as passive or active, and as conservative (repeat PSA test, ultrasound, or urological visit) or aggressive/therapeutic (CT/MRI imaging, prostate biopsy, or prostate-related hospitalization). Logistic regression was used to estimate the probability of active and aggressive follow-up. RESULTS: overall, 58% of men had no follow-up procedures within the first year, particularly among those with low PSA values, while the proportion remained above 30% among men with PSA >=4 ng/mL. Among those who underwent follow-up, 84% followed a conservative pathway. At one year, among men aged 50-69 years (55.7% of the total population) with PSA >=3 ng/mL, 38.8% had no follow-up, while 18.7% underwent an aggressive procedure, compared with about 5% among those with PSA <3 ng/mL. Within three months, the most frequent procedures were urological consultation (10.0%) and ultrasound (9.3%). The probability of active follow-up increased with age (including advanced age), index PSA value, >=3 comorbidities, and socioeconomic deprivation. Older age, PSA >= 4ng/mL, and Italian citizenship were associated with a higher likelihood of an aggressive approach. CONCLUSIONS: the high rate of active follow-up among older adults (70-84 years) with multiple comorbidities, even with a lower use of aggressive procedures, indicates the value of an organised programme aimed at concentrating interventions on individuals who are most likely to benefit.
BACKGROUND: in environmental epidemiology, critical appraisal of evidence across studies and quantitative synthesis is crucial to inform public health, but it is challenged by the heterogeneity in exposure assessment met...BACKGROUND: in environmental epidemiology, critical appraisal of evidence across studies and quantitative synthesis is crucial to inform public health, but it is challenged by the heterogeneity in exposure assessment methods. Even when assessing the same exposure, different studies frequently report risk estimates using varying categorical exposure intervals, making it difficult to compare and synthetize findings quantitatively. Advanced meta-analytical methodologies capable of harmonizing different exposure categorizations and effect estimates are crucial for generating flexible, policy-relevant, and locally applicable evidence that can be used in Health Impact Assessments of the disease burden related to environmental exposures and of the potential impact of mitigation measures. OBJECTIVES: to present a transparent and reproducible approach for harmonizing diverse categorical risk estimates (based on differently defined categories) into a per-unit continuous effect estimate, thereby including them in meta-analyses. The method is exemplified through a practical application. METHODS: the method involves three steps: 1. estimating the midpoint of each exposure category and calculating category-specific per-unit continuous beta coefficients from categorical effect estimates; 2. deriving a study-specific continuous effect estimate as a weighted average of these beta coefficients; 3. calculating the uncertainty (i.e., confidence intervals) of the resulting estimate. This approach assumes linearity of risk within categories and independence of category-specific estimates. The method was illustrated through a practical application to the dataset reported by Mataloni et al. (2016), with the aim of deriving a continuous hazard risk associated with a 1 ng/m³ increase in H2S exposure. Method robustness was assessed by comparing results with the true continuous effect and with those deriving from previously published pooling methods that overcome some limitations, including the absence of risk modelling across categories and covariance estimation. The effect of different definitions of central category exposures was also examined. RESULTS: the proposed method was applied in cases where the same exposure (e.g., H2S) was examined across studies for a given health outcome, but varying exposure intervals. A sample calculation is provided, along with an R script and corresponding Excel formulas. The method appears to provide an unbiased estimation of the 'true' continuous effect and obtained results comparable with other more complex methods both in terms of point and interval estimates pooled across categories and was robust to different central category exposures definitions. CONCLUSIONS: the proposed method provides a practical and replicable approach for converting categorical risk estimates into continuous effect estimates, enabling the harmonization of heterogeneous exposure categories across studies. This allows comparability and enables to carry out meta-analyses even in settings with a limited evidence base, where the addition of a single study can meaningfully contribute to the pooled estimate. The method helps overcome a frequent source of heterogeneity in environmental epidemiology, enhancing the robustness, precision, and interpretability of meta-analytical results. Applying methods such as the one here presented to systematic reviews and meta-analyses in the field of environmental epidemiology - where commonly potential effects of exposures are highly uncertain, as in the case of municipal solid waste disposal sites - more valid and robust estimates of the effects of specific environmental exposures can be obtained, therefore providing a stronger evidence base to inform public health decision-making.
The experience of the COVID-19 pandemic highlighted the need for a radical rethink of pandemic preparedness in Italy. The new National Pandemic Plan, currently under discussion at the interregional level, represents a cr...The experience of the COVID-19 pandemic highlighted the need for a radical rethink of pandemic preparedness in Italy. The new National Pandemic Plan, currently under discussion at the interregional level, represents a crucial opportunity to translate lessons learned into operational tools. In emphasizing the centrality of epidemiology in prevention, early surveillance, and timely response to health emergencies, structural and organizational criticalities of the current system are highlighted. Among the main recommendations: overcoming regional fragmentation, ensuring interoperable information infrastructures, strengthening local epidemiological surveillance, adopting advanced and shared systems for contact tracing, and defining common indicators to evaluate the strategies adopted. Special attention is given to enhance local epidemiological skills and the essential role of institutional communication. The document advocates for strong national coordination and shared strategies that turn past experience into the ability for concrete and timely responses to future challenges.
BACKGROUND: the association between air pollution and human health has been extensivelyinvestigated in the epidemiological literature. However, evidence in non-urban areasaffected by industrial activities is still limite...BACKGROUND: the association between air pollution and human health has been extensivelyinvestigated in the epidemiological literature. However, evidence in non-urban areasaffected by industrial activities is still limited. OBJECTIVES: to assess the association between daily exposure to PM10 and cause-specific mortality in municipalities affected by emissions from industrial plants during the period 2006-2015. DESIGN: two-stage time-series design was applied to assess the relationship between lagged PM10 and the outcomes. In the first stage, the association at the municipal level was analyzed with Poisson regression models adjusted for space-time confounders (trend and temperature). In the second stage, a mixed effects metanalysis of municipal estimates was applied to obtain a pooled estimate. Effect modification for individual variables (sex, age) and type of industrial site (chemical, steel, energy, or mining plant) was assessed. SETTING AND PARTICIPANTS: using the European Pollutant Release and Transfer Register, industrial plants entailing a combustion process were selected. 4x4 km² buffer around the plant was constructed to select the municipalities to be included in the analysis. Daily PM10 was estimated using machine-learning models based on satellite data. MAIN OUTCOMES MEASURES: daily counts of natural, cardiovascular, and respiratory deaths. RESULTS: the average exposure to PM10 was 28.4 μg/m³ (±SD 16.9). During the period under study, 568,804 deaths from natural causes were observed in the 100 municipalities near the 61 industrial sites identified. Percentage risk variations for 10-units increments of lagged 0-1 PM10 were 1.04% (95%CI 0.67;1.41), 1.04% (95%CI -1.21;3.34), and 7.89% (95%CI 0.16;16.23) for natural, cardiovascular, and respiratory mortality, respectively. Higher risk estimates were observed in municipalities near steel plants, especially for respiratory mortality (8.13%; 95%CI -2.85;20.35). No differences were observed in estimates between different age and sex classes. CONCLUSIONS: although not fully able to capture the industrial component of pollution, the results indicate excess risk of mortality in residents of the municipalities under study, especially when considering the presence of steel plants.
OBJECTIVES: to assess the frequency of total prostate-specific antigen (PSA) testing in the absence of clinical conditions in the Agency for Health Protection of the Metropolitan Area of Milan (ATS Milan), prior to the l...OBJECTIVES: to assess the frequency of total prostate-specific antigen (PSA) testing in the absence of clinical conditions in the Agency for Health Protection of the Metropolitan Area of Milan (ATS Milan), prior to the launch of the Lombardy regional prostate cancer screening programme. DESIGN: the study included all men aged 30-84 years residing in the ATS Milan area who underwent at least one PSA test during the years 2018-2019 and 2021-2023. The absence of prostate-related clinical conditions was verified using local health records and the cancer registry of the ATS Milan. SETTING AND PARTICIPANTS: the study used data from administrative and healthcare databases of ATS Milan. Among the 466,616 citizens with at least one PSA tests recorded during the study period, 414,731 had the test presumably conducted for screening purposes. MAIN OUTCOME MEASURES: at least one PSA test in the period. RESULTS: screening tests accounted for approximately 80% of total PSA tests. On average, 35.6% of male residents underwent at least one preventive PSA test, with low uptake among those under 50, 48.9% in those aged 50-69 years, 60.8% among men in their seventies, and 51.8% in the 80-84 age group. The mean number of PSA test per individual over the study period was 2.3. Testing decreased in 2021-2022, but increased again in 2023. A significant and increasing proportion of individuals undergoing PSA testing had three or more comorbidities. Among the 414,731 initial tests, 47.3% had PSA values <1 ng/mL, 35.4% between 1 and 3, 11.0% between 3 and 6 and 6.3% >=6. CONCLUSIONS: the high frequency of testing among the elderly, the frequent repeat testing, and the growing involvement of individuals with multiple comorbidities highlight the need to transition to an organized screening programme capable of balancing benefits and risks.
OBJECTIVES: to investigate pesticide residues in private gardens near crops in the province of Verona (Veneto Region, Northern Italy) and assess potential risks to human and environmental health. DESIGN: cross-sectional...OBJECTIVES: to investigate pesticide residues in private gardens near crops in the province of Verona (Veneto Region, Northern Italy) and assess potential risks to human and environmental health. DESIGN: cross-sectional observational study based on a participatory research approach. SETTING AND PARTICIPANTS: fifty residential gardens located within 40 metres of cultivated fields, selected through community engagement activities. MAIN OUTCOME MEASURES: detection frequency, type, and concentration of pesticides in deciduous leaves; assessment of associated toxicological risk levels. RESULTS: pesticides were found in over 70% of the samples analysed. Folpet-phthalimide was the most frequently detected compound (55.3%). Several hazardous substances were found within distances below those recommended by regional guidelines. CONCLUSIONS: the findings highlight shortcomings in current protection measures against pesticide drift. Participatory environmental monitoring can strengthen prevention strategies and support public health action.
OBJECTIVES: to investigate the care pathway of dialysis patients in the final stages of life and to identify possible predictors of the interruption of dialysis treatment. DESIGN: cohort study. SETTING AND PARTICIPANTS:...OBJECTIVES: to investigate the care pathway of dialysis patients in the final stages of life and to identify possible predictors of the interruption of dialysis treatment. DESIGN: cohort study. SETTING AND PARTICIPANTS: the study used data from the Regional Dialysis and Transplantation Registry of Lazio Region, along with data from the Lazio Health Information Systems. The study included haemodialysis patients who died between 2009 and 2022, residing of Lazio, and on dialysis for at least 6 months. MAIN OUTCOME MEASURES: using descriptive statistical analysis and both unadjusted and adjusted logistic regression models, the interruption of dialysis treatment (defined as suspension for at least 7 days before death), and the possible predictors of this interruption were analysed. RESULTS: the final cohort included 6,247 patients, of whom 1,009 (16.2%) interrupted dialysis treatment. The main causes of death include cardiac diseases, cachexia, and infections. The average age of the patients was 76.1 years (10.1 standard deviation); 65.2% were male. Multiple regression analysis identified the number of hospitalizations in the year prior to death (OR: 2.34; 95%CI 1.84-2.97), dialysis vintage (OR 0.80; 95%CI 0.66-0.96), and the presence of non-uremic anaemia (OR 1.46; 95%CI 1.06-2.00) as potential predictors of treatment interruption. Finally, a North-South gradient appears to exist by province of residence, with a higher likelihood of the final stages of life recognition in the province of Viterbo and a lower one in the province of Frosinone. CONCLUSIONS: this study represents the first attempt in Italy, based oh health infromation sistems, to explore end-of-life care in haemodialysis patients, revealing insufficient recognition of end-of-life stages, leading to the continuation of dialysis treatment close to death. These data suggest an excessive medicalization of the end of life and a risk of inappropriate treatments. The introduction of advanced care planning documents, improved training for nephrologists, and the creation of multidisciplinary teams with palliative care specialists could improve patients' quality of life and optimize the use of healthcare resources.
BACKGROUND: in 2016, based on data 2000-2012, using gender-specific age-cohort models, the number of mesothelioma cases in Lombardy were predicted for the period 2013-2029. OBJECTIVES: to evaluate accuracy forecasts for...BACKGROUND: in 2016, based on data 2000-2012, using gender-specific age-cohort models, the number of mesothelioma cases in Lombardy were predicted for the period 2013-2029. OBJECTIVES: to evaluate accuracy forecasts for the years 2013-2024; to examine the characteristics of affected subjects and to calculate incidence rates for the years 2000-2021. DESIGN: incidence study. SETTING AND PARTICIPANTS: Lombardy Region (Northern Italy); individuals recorded in the Lombardy Mesothelioma Registry. MAIN OUTCOME MEASURES: mesothelioma incidence. METHODS: the number of observed and predicted cases was compared for the years 2013-2024. Moreover, cases observed in 2000-2021 (years in which all registry activities have been completed) were selected from the registry database, their clinical characteristics and asbestos exposure were described, and crude and age-standardized rates (ASR) were calculated by year and Province of residence. RESULTS: in the years 2013-2024, 3,588 cases were observed in men, 435 more than the predicted value; in women, 1,671 cases were recorded, 90 less than the predicted value. The yearly number of cases was constant in men and slightly declining in women. In the period 2000-2021, 8,437 cases (7,922 pleural mesotheliomas) were recorded and evaluated, 5,568 in men and 2,869 in women. Evidence of occupational exposure was found for about two thirds of men and for one third of women. Most men had been exposed to asbestos in metalworking and metallurgy industries (35.4%) and in the construction sector (33.7%). Most women had been exposed in non-asbestos textile (53.3%) or clothing (13.4%) industries. In both genders, rates decreased for ages below 70 years, were stable for ages 70-74 years, and increased for ages 75+ years. In both genders, the highest rates were recorded in Pavia Province, where an asbestos cement factory had been operating for a long time. CONCLUSIONS: a fair agreement between observed mesothelioma cases and forecasts as of 2024 was found. The peak occurred in 2013, but in the following years there was no indication of decrease of yearly cases in men and only a slight decrease in women. The highest disease burden concerns individuals aged 75 years or more. Data from this paper indicates that in 2025-2029 in Lombardy there still will be between 350 and 400 cases per year.
BACKGROUND: the malignant mesothelioma is a neoplasm caused by the exposure to asbestos in a wide majority of cases; however, in a significant number of these cases, it is not possible to highlight it and, as a consequen...BACKGROUND: the malignant mesothelioma is a neoplasm caused by the exposure to asbestos in a wide majority of cases; however, in a significant number of these cases, it is not possible to highlight it and, as a consequence, a specific category named 'Asbestos Exposure Unknown' was adopted by the 2003 guidelines of the Italian National Mesothelioma Register (ReNaM). OBJECTIVES: to present a new occurrence of asbestos exposure in a case of mesothelioma diagnosed in a nurse who worked in the operating room, for which the exposure was initially classified as 'Unknown'. DESIGN, SETTING AND PARTICIPANTS: case study. METHODS: in-depth studies were carried out on the tasks performed by the nurse. Samples of anti-heat protective gloves, used in the Eighties in operating rooms, were analysed using the Scanning Electron Microscopy (SEM). RESULTS: pleural mesothelioma was diagnosed at age 56 and caused patient's death at 59 years. It was possible to confirm that the gloves used for the sterilization of surgical instruments during the years and up to 1990 were made of chrysotile asbestos and that they have been the sole sure cause of the nurse's professional exposure, which lasted 4 years. A possible family exposure has been hypothesized in the washing of parents work clothes. The case was re-classified as 'certain professional cause'; the occupational origin of the tumour has not been recognized from the Italian Workers' Compensation Authority (Inail). CONCLUSIONS: this case-report suggests: a. the need to carry out any possible thorough analysis of the circumstances and of the sources of the exposure, every time this exposure is first classified as unknown, according to the ReNaM guidelines; b. to consider at least likely a professional asbestos exposure in case of frequent use of anti-heat protective gloves for surgical instrument sterilization.
BACKGROUND: Outpatient Contracted Specialist (OCS) healthcare, together with General Medicine and Pediatrics, is one of the basic elements of community healthcare granted by the Italian National Health Service (NHS). In...BACKGROUND: Outpatient Contracted Specialist (OCS) healthcare, together with General Medicine and Pediatrics, is one of the basic elements of community healthcare granted by the Italian National Health Service (NHS). In 2022, an important reform of community healthcare (Italian Ministerial Decree No.77) was introduced, strengthening the role played by OCS in Community Homes, home care and nursing homes. However, unlike all other community health workers, no staffing or hours' provision standards have been established for OCS. Besides this, ministerial reports state only few and different data on the amount of OCS care actually provided in community settings. OBJECTIVES: to analyse Italian National Information Systems methods and variables for measuring OCS healthcare provision in community settings. METHODS: starting from the sources used by institutional national reports on healthcare workforce and resources, the national information systems containing health workforce-related variables were selected and their latest regulations and technical documentations were analysed. Data collection methods, variables for OCS and their survey criteria were therefore identified. A comparison among the systems was then made through a common matrix. Similarly, regulations and technical documentations previously adopted by the same systems were also reviewed. RESULTS: the national information systems containing variables on healthcare workforce are: the annual surveys established by the Italian Ministerial Decree of 19.03.1988 and subsequent amendments, the Annual Account survey (AA), the Report attached to the AA, and the Interregional Agency for contracted health professionals survey (SISAC). Only two of these systems were found to collect data on OCS: the SISAC survey and the AA. The OCS variables collected were the total number of OCS medical doctors (collected by SISAC and AA), stratified by gender and specialization (by AA only), and the number of overall hours of care provided (collected by SISAC only), which is not stratified by specialization. Data reported for the single common variable (total number of OCS doctors) were always different in the two systems, with AA data constantly lower to those of SISAC between 29.12% and 41.37% in all surveys performed from 2019 to 2022. The classification system for medical specialty used by AA was however different from that used by SISAC which also includes OCS doctors working in penal institutes and OCS dentists. No variable dedicated to the number of hours provided per specialization was found and none of the systems was able to distinguish between community or hospital setting. CONCLUSIONS: the analysis highlights a major weakness in current national information systems in properly measuring NHS provision of OCS care in all settings. Currently available variables, besides having different data according to the sources, appear to be of little public health use, even for the development of the new community healthcare model as envisaged by Ministerial Decree No. 77. To avoid the risk of a silent erosion in the Italian NHS public provision of community specialist outpatient care and its replacement by the private sector, the following actions seem to be needed: the adoption of variables for monitoring provided OCS hours by specialization at health district level, the introduction of hours' provision standards for community specialist outpatient care and the inclusion of OCS in staffing need plans.