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Background: Breast, cervical, and colorectal cancer screening are evidence-based interventions recommended by most governmental agencies and scientific societies. The aim of this review is to assess the quality of guidelines on screening and to describe differences according to the context in which they were produced.Methods: A literature search of the main databases, websites on health care, and guidelines, as well as the websites of several scientific societies was carried out in order to identify the most recent guidelines (since 2000) on cervical, breast, and colorectal cancer screening. Only documents written in Italian or English were included. Two investigators independently assessed quality by using the AGREE (Appraisal of Guidelines, Research and Evaluation in Europe) instrument.Results: Thirty-three, 32, and 18 relevant documents for cervical, breast, and colorectal cancer, respectively, were identified. Only some documents (19, 12 and 13 for cervical, breast, and colorectal cancer, respectively) could be evaluated with AGREE. Items included in the domain “scope and purpose” obtained the highest scores, followed by “clarity of presentation” domain, while “applicability”, “patient involvement,” and “conflict of interest disclosure” domains obtained the lowest scores. The quality did not improve in more recent documents. Documents produced by governmental agencies, on average, had higher scores than documents by scientific societies, particularly for “stakeholder involvement” and “applicability”.Conclusions: Documents from different countries and health systems differ in terms of the main recommendations given and in the quality of the documents. Those produced by governmental agencies have a more multidisciplinary authorship and pay more attention to applicability than do those produced by scientific societies. societies.

Background Despite recommendations by Health Authorities, influenza immunization coverage remains low in children with chronic diseases. Different medical providers involved in the management of children with chronic conditions may affect the pattern of influenza vaccine recommendations and coverage. The likelihood of vaccination by type of provider in children with chronic conditions is poorly understood. Therefore, the objectives of this study were to analyze the pattern and the effect of recommendations for seasonal influenza immunization provided by different physician profiles to families of children with chronic diseases and to measure the frequency of immunization in the study population. Methods We recruited children with chronic diseases aged 6 months–18 years who subsequently presented to specialty clinics for routine follow-up visits, during spring 2009, in three Italian Regions Families of children with chronic diseases were interviewed during routine visits at reference centers through a face-to-face interview. We analyzed the following immunization predictors: having received a recommendation toward influenza immunization by a health provider; child’s sex and age; mothers and fathers’ age; parental education and employment; underlying child’s disease; number of contacts with health providers in the previous year. Influenza immunization coverage was calculated as the proportion of children who received at least one dose of seasonal influenza vaccine in the previous season. We calculated prevalence ratios and we used a generalized linear model with Poisson family, log link and robust error variance to assess the effect of socio-demographic variables, underlying diseases, and recommendations provided by physicians on influenza immunization. Results We enrolled 275 families of children with chronic diseases. Overall influenza coverage was 57.5%, with a low of 25% in children with neurological diseases and a high of 91.2% in those with cystic fibrosis. While 10.6% of children who did not receive any recommendation toward influenza immunization were immunized, among those who received a recommendation 87.5-94.7% did, depending on the health professional providing the recommendation. Receiving a recommendation by any provider is a strong predictor of immunization (PR = 8.5 95% CI 4.6;15.6) Most children received an immunization recommendation by a specialty (25.8%) or a family pediatrician (23.3%) and were immunized by a family pediatrician (58.7%) or a community vaccinator (55.2%). Conclusions Receiving a specific recommendation by a physician is a strong determinant of being immunized against seasonal influenza in children with chronic diseases independently of other factors. Heterogeneity exists among children with different chronic diseases regarding influenza recommendation despite international guidelines. Increasing the frequency of appropriate recommendations toward influenza immunization by physicians is a single powerful intervention that may increase coverage in children with chronic conditions.

Introduction: Syndromic surveillance arose from the need for rapid identification of unexpected clusters of a disease. The emergecy department is considered one of the most sensitive and timely sources of information for syndromic surveillance.Methods: This paper reports the results of the pilot phase (4 months) of an Emergency-based syndromic surveillance system in the Lazio region (5.5 million inhabitants), which aimed to monitor in real time the occurrence of clusters of 13 different syndromes. It collected information online from 34 of the 61 emergency departments in the region. Diagnoses and chief complaints of individual emergency visits were automatically screened daily, the occurrence of clusters were measured comparing the number of visits for the same syndrome with those from the same calendar week from the previous five years; an epidemiology team checks the clusters manually before determining if an alarm should be called.Results: 500.000 ER visits occurred in the study period, and 15.343 fulfilled one of the case criteria. The most frequent syndrome was gastroenterisis (5051 cases), the least frequent was hemorrhagic diarrhoea (2 cases). There were 253 automatically generated alarms and 17 were confirmed manually as suspected outbreaks. In the same period, the infectious disease surveillance identified 55 outbreaks of infectious diseases; only two clusters were reported by both surveillance systems.Conclusions: the predicted increase in workload is one more outbreak to be investigated every four months per local health unit. The next step will be to test protocols for the activation of the public health services following an alarm.

IntroductionIn western countries the transmission of hepatitis B virus (HBV) transmission through multi-patients lancing devices has been inferred since early '90s, however no study has ever provided biological evidence which directly link these device with HBV cross-infection. Here we present results of an outbreak investigation which could associate, by molecular techniques, the use of lancing device on multiple patients with HBV transmission in an Italian oncohematology unit.MethodsThe outbreak investigation was designed as a retrospective cohort study to identify all potential cases. All cases identified were eventually confirmed through molecular epidemiology techniques. Audit of personnel including extensive review of infection control measures and reviewing personnel's tests for HBV was done identify transmission route.ResultsBetween 4 May 2006 and 21 February 2007, six incident cases of HBV infection were reported among 162 patients admitted in the oncohematology. The subsequent molecular instigation proved that 3 out 6 incident cases and one prevalent cases (already infected with HBV at the admission) represented a monophyletic cluster of infection. The eventual environmental investigation found that an identical HBV viral strain was present on a multi-patients lancing device in use in the unit and the inferential analysis showed a statistically significant association between undergoing lancing procedures and the infection.DiscussionThis investigation provide molecular evidence to link a HBV infection cluster to multi-patients lancing device and highlights that patients undergoing capillary blood sampling by non-disposable lancing device may face an unacceptable increased risk of HBV infection. Therefore we believe that multi-patients lancing devices should be banned from healthcare settings and replace with disposable safety lancets that permanently retract to prevent the use of the same device on multiple patients. The use of non-disposable lancing devices should be restricted to individual use at patients' home.

Since children with chronic diseases represent a primary target for immunization strategies, it is important that their immunization coverage and timeliness of vaccines is optimal. We performed a study to measure immunization coverage and timeliness of vaccines in children with type 1 diabetes, HIV infection, Down syndrome, cystic fibrosis, and neurological diseases. A total of 275 children aged 6 months–18 years were included in the study. Coverage for diphtheria–tetanus–pertussis (DTP), polio (Pol), and hepatitis B (HBV) vaccines approximated 85% at 24 months, while measles–mumps–rubella (MMR) coverage was 62%. Immunization coverage for seasonal influenza was 59%. The analysis of timeliness revealed that there was heterogeneity among children with different chronic diseases. A proportional hazard model showed that children with HIV infection had the longest time to complete three doses of DTP, Pol, and HBV, and those with neurological diseases received the first dose of MMR later than the other categories. Causes of missing or delayed vaccination mostly included a concurrent acute disease. Children with chronic diseases should be strictly monitored for routine and recommended vaccinations, and health care providers and families should be properly informed to avoid false contraindications.

Background Monitoring the incidence of bacterial meningitis is important to plan and evaluate preventive polices. The study's aim was to estimate the incidence of bacterial meningitis by aetiological agent in the period 2001–2005, in Lazio Italy (5.3 mln inhabitants). Methods Data collected from four sources – hospital surveillance of bacterial meningitis, laboratory information system, the mandatory infectious diseases notifications, and hospital information system – were combined into a single archive. Results 944 cases were reported, 89% were classified as community acquired. S. pneumoniae was the most frequent aetiological agent in Lazio, followed by N. meningitis. Incidence of H. influenzae decreased during the period. 17% of the cases had an unknown aetiology and 13% unspecified bacteria. The overall incidence was 3.7/100,000. Children under 1 year were most affected (50.3/100.000), followed by 1–4 year olds (12.5/100,000). The percentage of meningitis due to aetiological agents included in the vaccine targets, not considering age, is 31%. Streptococcus spp. was the primary cause of meningitis in the first three months of life. The capture-recapture model estimated underreporting at 17.2% of the overall incidence. Conclusion Vaccine policies should be planned and monitored based on these results. The integrated surveillance system allowed us to observe a drop in H. influenzae b meningitis incidence consequent to the implementation of a mass vaccination of newborns.

Pancreatic endocrine tumors (PETs) are heterogeneous tumors with increasing prevalence. Little is known about the molecular pathogenesis and risk factors for the occurrence of sporadic PETs. The aim of this study was to identify the risk factors associated with the occurrence of sporadic PETs.A case-control study comprising 162 sporadic PETs and 648 controls was undertaken. Subjects were interviewed using a specific questionnaire on demographics and potential risk factors, including smoking, alcohol, height, weight, medical history, and family history of cancer. A multiple hierarchical logistic regression analysis was performed with a stepwise variable- selection procedure.A first-degree family history of any cancer was a significant risk factor (odds ratio (OR) 2.2; 95% confidence interval (CI): 1.5-3.2). Among the different cancer sites, first-degree family history of pancreatic adenocarcinoma was more frequent in PETs than in controls (4.3 vs. 1.2%; P=0.01). A high alcohol intake (OR 4.8; 95% CI: 2.4-9.5), history of chronic pancreatitis (CP) (OR 8.6; 95% CI: 1.4-51), and recent-onset diabetes (OR 40.1; 95% CI: 4.8-328.9) were all independent risk factors. The history of diabetes was also associated with metastatic disease at the time of diagnosis.This case-control study identified family history of any cancer (and to a less extent of pancreatic adenocarcinoma), CP, high alcohol intake, and recent-onset diabetes as risk factors for PET, thus suggesting a possible partial overlap with risk factors for exocrine pancreatic carcinogenesis.

Background Screening programmes should be organized to translate theoretical efficacy into effectiveness. An evidence-based organizational model of colorectal cancer screening (CRCS) should assure feasibility and high compliance. Methods A multidisciplinary Working Group (WG), reviewed literature and guidelines to define evidence-based recommendations. The WG identified the need for further local studies: physicians' CRCS attitudes, the effect of test type and provider on compliance, and individual reasons for non-compliance. A survey of digestive endoscopy services was conducted. A feasibility study on a target population of 300.000 has begun. Results Based on the results of population trials and on literature review the screening strategy adopted was Faecal Occult Blood Test (FOBT) every two years for 50–74 year olds and, for positives, colonoscopy. The immunochemical test was chosen because it has 20% higher compliance than the Guaiac. GPs were chosen as the preferred provider also for higher compliance. Since we observed that distance is the major determinant of non-compliance, we choose GPs because they are the closest providers, both geographically and emotionally, to the public. The feasibility study showed several barriers: GP participation was low, there were administrative problems to involve GPs; opportunistic testing by the GPs; difficulties in access to Gastroenterology centres; difficulties in gathering colonoscopy results; little time given to screening activity by the gastroenterology centre. Conclusion The feasibility study highlighted several limits of the model. Most of the barriers that emerged were consequences of organisational choices not supported by evidence. The principal limit was a lack of accountability by the participating centres.

Objective: To describe the effect of terminal cancer on the patient’s family, finances and daily life. Methods: A cluster sample of 2000 adults (⩾18 years old) who had died from cancer, and who were representative of Italy, was studied. 1900 caregivers were identified and 68% responded to a post-bereavement survey. Caregivers included the patient’s child (46%), his/her spouse (31%), other relatives or friends (20%) or a health professional (3%). The median age of a caregiver was 54 years and 69% were females. During the last 3 months of the patient’s life, 44% of caregivers reported difficulties in their regular employment. Results: Of the 68% of families who had to pay for some of the care, 37% had to pay for drugs, 36% for nursing and assistance and 22% for physicians. Paying for care was more frequent in the south of Italy (OR 2.5; 95% CI 1.0 to 6.3) and when the patient was a housewife (OR for unit increase 2.7; 95% CI 1.6 to 6.1). To cover the costs of patient care, 26% of families used all or most of their savings. Economic difficulties were greater in the south of Italy (OR 3; 95% CI 1.8 to 5.1), for female caregivers (OR 1.4; 95% CI 1.0 to 1.9) and for disadvantaged patients. The duration of time the patient was completely dependent strongly determined the effect caregiving had on their regular employment and on the family’s financial situation. Conclusions: Although in Italy families are responsible for a small percentage of the overall costs of patient care, the effect of cancer on savings and daily life can be substantial. Strong geographical and gender differences emerged from this study.

Background The major limit to colorectal cancer screening effectiveness is often low compliance. We studied the reasons for non compliance and determinants of compliance to faecal occult blood tests in Lazio, Italy. Methods This is a case-control study nested within a trial that tested the effect of type of test and provider on colorectal cancer screening compliance. Non compliant trial subjects were classified as cases, and compliant subjects were classified as controls. We sampled 600 cases and 600 controls matched by their general practitioner, half were invited for screening at the hospital, and the other half directly at their general practitioner's office. Cases and controls answered questions on: distance from test provider, logistical problems, perception of colorectal cancer risk, confidence in screening efficacy, fear of results, presence of colorectal cancer in the family, and gastrointestinal symptoms. Results About 31% of cases never received the letter offering free screening, and 17% of the sampled population had already been screened. The first reported reason for non-compliance was "lack of time" (30%); the major determinant of compliance was the distance from the test provider: odds ratio >30 minutes vs Conclusion To increase compliance, screening programmes must involve test providers who are geographically close to the target population.

Background Administrative data can serve as an easily available source for epidemiological and evaluation studies. The aim of this study is to evaluate the use of hospital administrative data to determine breast cancer severity and the appropriateness of surgical treatment. Methods the study population consisted of 398 patients randomly selected from a cohort of women hospitalized for first-time breast cancer surgery in the Lazio Region, Italy. Tumor severity was defined in three different ways: 1) tumor size; 2) clinical stage (TNM); 3) severity indicator based on HIS data (SI). Sensitivity, specificity, and positive predictive value (PPV) of the severity indicator in evaluating appropriateness of surgery were calculated. The accuracy of HIS data was measured using Kappa statistic. Results Most of 387 cases were classified as T1 and T2 (tumor size), more than 70% were in stage I or II and the SI classified 60% of cases in medium-low category. Variation from guidelines indications identified under and over treatments. The accuracy of the SI to predict under-treatment was relatively good (58% of all procedures classified as under-treatment using pT where also classified as such using SI), and even greater predicting over-treatment (88.2% of all procedures classified as over treatment using pT where also classified as such using SI). Agreement between clinical chart and hospital discharge reports was K = 0.35. Conclusion Our findings suggest that administrative data need to be used with caution when evaluating surgical appropriateness, mainly because of the limited ability of SI to predict tumor size and the questionable quality of HIS data as observed in other studies.