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An extensive survey of helminth parasites in fish and shellfish species from Santa Gilla, a brackish water lagoon in southern Sardinia (western Mediterranean), resulted in the identification of 69 helminth parasite taxa and/or species from 13 fish species (n= 515) and seven bivalve species (n= 2322) examined between September 2001 and July 2011. The list summarizes information on the helminth parasites harboured by fish and molluscs contained in the available literature. Digenea species (37), both adults and larvae, dominated the parasite fauna, whereas Cestoda were the least represented class (three species). Monogenea, Nematoda and Acanthocephala were present with 17, 6 and 6 species, respectively, which were mainly adults. The most widespread parasite species was the generalist Contracaecum rudolphii A (Nematoda). Other species, such as the Haploporidae and Ascocotyle (Phagicola) spp. 1 and 2 (Digenea), showed a high family specificity in Mugilidae. Importantly, the study recorded the occurrence of potential zoonotic agents, such as Heterophyes heterophyes, Ascocotyle (Phagicola) spp. and C. rudolphii A, the latter two reaching the highest indices of infection in the highly marketed fish grey mullet and sea bass, respectively. The highest parasite richness was detected in Dicentrarchus labrax, which harboured 17 helminth species, whereas the lowest value was observed in Atherina boyeri, infected by only three species. The list includes the first geographical record in Italian coastal waters of Robinia aurata and Stictodora sawakinensis, and 30 reports of new host–parasite complexes, including the larval stages of Ascocotyle (Ascocotyle) sp. and Southwellina hispida in D. labrax. [ABSTRACT FROM AUTHOR]

Background: reducing air emissions is the fundamental action necessary to mitigate the negative health effects caused by air pollution. However, increased public awareness has highlighted the need to identify protective measures that can mitigate the personal health risks associated with air pollution., Objectives: examine the evidence regarding personal protection strategies capable of mitigating the health effects caused by air pollution, with a focus on healthy individuals and at-risk categories.  Design: narrative review., Setting and Participants: this study examines the most effective personal protection strategies for healthy and at-risk individuals, considering children, the elderly, and individuals with cardiovascular and respiratory diseases; the examined strategies include the use of air purifiers, respiratory masks, exposure limitation, physical activity, alternative means of transportation, and environmental monitoring systems., Main Outcomes Measures: reduction of individual exposure to air pollution, respiratory and cardiovascular outcomes, total and all-cause mortality., Results: the evidence indicates that these measures can reduce exposure and promote well-being. For at-risk individuals, it is crucial to limit exposure during periods and in locations with high pollution levels, with an emphasis on physical activity. The use of high-efficiency air purifiers can reduce the negative effect of air pollution on individuals with respiratory and cardiovascular conditions, especially those with asthma. In healthy individuals, multiple mitigation actions have been identified, with evidence suggesting that the benefits of physical activity persist even in environments with high levels of air pollution., Conclusions: this narrative review provides an overview of personal strategies capable of reducing air pollution exposure and consequently mitigating its negative impact on health. These findings can support the development of recommendations and communication and prevention interventions, promoting risk reduction policies and increased awareness and engagement from both healthcare and non-healthcare networks at the local level. Although more robust systematic approaches are needed, this review serves as a useful tool for stakeholders and citizens, while also providing a simple instrument with significant communicative potential, applicable on a large scale.

Background: according to the International Agency for Cancer Research on Cancer, in 2022, breast cancer is the most common cancer in the Italian population, followed by colorectal cancer. Oncological screenings represent an effective secondary prevention strategy to counteract colorectal and breast cancers, significantly reducing mortality. In Lombardy Region (Northern Italy), screening programmes have been active since 2007, but adherence, especially in specific population subgroups, remains lower than expected., Objectives: to analyse potential predictors of non-adherence to colorectal and breast cancer screening in the Lombardy Region during the pre-pandemic period of 2018-2019., Design: a retrospective cohort study aimed at investigating the role of sociodemographic variables, health status, and access to the healthcare system on non-adherence to colorectal and breast cancer screening. Statistical analyses were conducted separately by each Agency for Health Protection (ATS). The results of the models were synthesized across the Lombardy region through random-effects meta-analysis., Setting and Participants: residents within the territory of each ATS in Lombardy as of 01.01.2018 and aged between 49 and 69 years at the beginning of the follow-up., Main Outcomes Measures: adherence to colorectal and breast cancer screenings., Results: during the study period, across the Lombardy Region, 2,820,138 individuals were eligible to participate in colorectal cancer screening, and 1,357,344 women were eligible to participate in breast cancer screening, with an invitation coverage of 87% and 86%, respectively.For breast cancer screening, older age, cardiopathy, chronic obstructive pulmonary disease (COPD), inflammatory bowel diseases (IBD), autoimmune diseases, and presence of a rare disease are associated with a reduced risk of non-adherence. Conversely, foreign citizenship, oncological diagnosis, transplant, chronic kidney disease/dialysis, diabetes, heart failure, arterial or cerebral vasculopathy, and presence of a neurological diagnosis are associated with significant excess risks of non-participation. For colorectal cancer screening, factors favouring adherence include female gender, older age, cardiopathy, COPD, autoimmune diseases, and having access/utilization of primary care. Non-adherence is associated with foreign citizenship, transplant, chronic kidney disease/dialysis, diabetes, heart failure, arterial or cerebral vasculopathy, IBD, neurological diseases, residence in assisted living facilities, use of integrated home care, and presence of disability., Conclusions: this is the first study conducted in the Lombardy Region which explores the theme of equity of access to organized screenings. This analysis highlights how sociodemographic determinants, chronic conditions, and access to the healthcare and social healthcare system constitute significant risk factors for non-adherence to screening programmes. Based on the results of this analysis, communication and/or organizational change interventions will be developed to counteract inequalities in access to effective prevention procedures.

Background: the peer-review process, which is the foundation of modern scientific production, represents one of its essential elements. However, despite numerous benefits, it presents several critical issues., Objectives: to collect the opinions of a group of researchers from the epidemiological scientific community on peer-review processes., Design: cross-sectional study using a questionnaire evaluation., Setting and Participants: a 29-question survey was administered to 516 healthcare professionals through the SurveyMonkey platform. The questions focused on the individual characteristics of the respondents and their perceived satisfaction with some characteristics of the review process as well as their propensity of changing some aspects of it. In addition, three open-ended questions were included, allowing respondents to provide comments on the role that reviewers and the review process should play. Descriptive statistics were produced in terms of absolute frequencies and percentages for the information collected through the questionnaire. Secondly, a multiple logistic regression analysis was conducted to assess the willingness to change certain aspects of peer review, adjusting for covariates such as age, sex, being the author of at least one scientific work, being a reviewer of at least one scientific work, and belonging to a specific discipline. The results are expressed as odds ratios (ORs) and their 95% confidence intervals (95%CI). Text analysis and representation using word cloud were also used for an open-ended question., Main Outcomes Measures: level of satisfaction regarding some characteristics of the peer-review process., Results: a total of 516 participants completed the questionnaire. Specifically, 87.2% (N. 450) of the participants were the authors of at least one scientific publication, 78.7% were first authors at least once (N. 406), and 71.5% acted as reviewers within the peer-review process (N. 369). The results obtained from the multiple logistic regression models did not highlight any significant differences in terms of propensity to change for age and sex categories, except for a lower propensity of the under 35 age group towards unmasking, defined as the presence of reviewers and editorial boards names on the publish article (OR <35 years vs 45-54 years: 0.51; 95%CI 0.29-0.89) and a higher propensity for post-formatting proposals, defined as the possibility of formatting the article following journal guidelines after the acceptance, among those under 45 (OR <35 years vs 45-54 years: 1.73; 95%CI 0.90-3.31; OR 35-44 years vs 45-54 years: 2.02; 95%CI 1.10-3.72). Finally, approximately 50% of respondents found it appropriate to receive credits for the revision work performed, while approximately 30% found it appropriate to receive a discount on publication fees for the same journal in which they acted as reviewers., Conclusions: the peer-review process is considered essential, but imperfect, by the professionals who participated in the questionnaire, thus providing a clear picture of the value that peer-review adds rigorously to each scientific work and the need to continue constructive dialogue on this topic within the scientific community.

Introduction: Epidemiology is increasingly involved on a wide variety of topics and to engage different professionals and disciplines in an increasingly active way. A fundamental role is played by young researchers active in Italian epidemiology who create opportunities for meeting and discussion, in the name of multidisciplinarity and integration of different skills., Objective: The aim of this paper is to provide a detailed description of the topics most frequently studied in epidemiology by young people and to highlight any changes in these topics in the pre- and post-Covid-19 workplaces., Methods: All abstracts submitted in the years 2019 and 2022 by young participants in the Maccacaro Prize, an annual award aimed at Italian association of epidemiology (Aie) conference addressed to people under 35 years of age, were considered. In addition to the comparison of the topics, a comparison of the related work structures and their geographical location was carried out by grouping the research centres into three Italian geographical regions: north, centre and south/islands., Results: Between 2019 and 2022, the number of abstracts participating in the Maccacaro Prize increased. The interest in topics related to infectious diseases, vaccines, and pharmaco-epidemiology has sharply increased, while in environmental and maternal and child epidemiology it has moderately increased. Social epidemiology, health promotion and prevention, as well as clinical and evaluative epidemiology, have experienced a decrease in interest. Finally, after analysing the geographical distribution of reference centres, it was discovered that certain regions, such as Piedmont, Lombardy, Veneto, Emilia-Romagna, Tuscany and Latium, have a strong and consistent presence of young people in the field of epidemiology. Conversely, there is a small number of young professionals working in this field in other Italian regions, especially in Southern regions., Conclusions: The pandemic has changed our personal and working habits, but it has also played a fundamental role in making epidemiology known. The increase in young people joining an association such as the Aie is a clear sign of the growing interest in this discipline.

Background: currently, individuals at risk of adverse outcomes for COVID-19 can access to vaccination and pharmacological interventions. But, during the first epidemic wave, there were no treatments or therapeutic strategies available to reduce adverse outcomes in patients at risk., Objectives: to assess the impact of an intervention at 15-month follow-up developed by the Agency for Health Protection of the Metropolitan Area of Milan (ATS Milan) based on telephone triage and consultation by the General Practitioners (GPs) for patient with high-risk for adverse outcomes., Design: intervention on population., Setting and Participants: a total of 127,292 patients in the ATS aged ≥70 years and with comorbidities associated with an increased risk of dying from COVID-19 infection were identified. Using a specific information system, patients were assigned to their GPs for telephone triage and consultation. GPs inform them about the risks of the disease, non-pharmacological prevention measures, and precautions in contacts with family members and other persons. No specific clinical intervention was carried out, only an information/training intervention was performed., Main Outcome Measures: by the end of May 2020, 48.613 patients had been contacted and 78.679 had not been contacted. Hazard Ratios (HRs) of infection hospitalisation and death at 3 and 15 months were estimated using Cox regression models adjusted by confounder., Results: no differences in gender, age class distribution, prevalence of specific diseases, and Charlson Index were found between the two groups (treated such as called patients and not called). Called patients had a higher propensity for influenza and antipneumococcal vaccination and have more comorbidities and greater access to pharmacological therapies. Non-called patients have a greater risk for COVID-19 infection: HR was 3.88 (95%CI 3.48-4.33) at 3 months and 1.28 (95%CI 1.23-1.33) at 15 months; for COVID-19 hospitalization HR was 2.66 (95%CI 2.39-2,95) at 3 months and 1.31 (95%CI 1.25-1.37) at 15 months; for overall mortality HR was 2,52 (95%CI 2.35-2:72) at 3 months and 1.23 (95%CI 1.19-1.27) at 15 months., Conclusions: the results of this study show a reduction in hospitalization and deaths and support, in case of pandemic events, the implementation of new care strategies based on adapted stratification systems in order to protect the population's health. This study presents some limits: it is not randomized; a selection bias is present (called patients were those most in contact with the GPs); the intervention is indication-based (on march 2020, the actual benefit of protection and distancing for high-risk groups was unclear), and the adjustment is not able to fully control for confounding. However, this study points out the importance to develop information systems and improve methods to best protect the health of the population in setting of territorial epidemiology.

Background: the influenza and SARS-CoV-2 viruses share a common respiratory symptomatology and transmission mode. COVID-19 and influenza R0 overlapped in the first epidemic wave. In autumn 2021-winter 2022, the influenza epidemic had a delayed onset compared to pre-COVID-19 years and lower incidence rates than in the pre-pandemic period. The SARS-CoV-2 and influenza vaccination campaign overlapped in 2021-2022., Objectives: to evaluate in the SARS-CoV-2 vaccinated cohort the effect of different timing of influenza vaccination on hospitalisations for COVID-19 and overall mortality., Design: prospective cohort study., Setting and Participants: subjects aged 65 years or older who were administered the first booster dose of SARS-COV-2 vaccine between 01.10.2021 and 01.03.2022. Based on the date of influenza vaccination, subjects were divided into the following 4 different mutually exclusive groups: 1. two vaccinations in the same vaccination session; 2. influenza vaccination following SARS-CoV-2 vaccination; 3. influenza vaccination preceding SARS-CoV-2 vaccination; 4. no influenza vaccination. Using Cox regression models, hazard ratio (HR) and corresponding 95% confidence intervals (95% CI) of hospitalisation and death were estimated for the influenza-vaccinated subjects compared to influenza-unvaccinated subjects., Main Outcome Measures: ordinary hospital admissions for COVID-19 and general mortality., Results: the cohort included 618,964 subjects: 16.3% received two vaccinations in the same vaccination session, 8.5% received the influenza vaccination after SARS-CoV-2 vaccination, 33.9% received it before and 41.1% did not receive an influenza vaccination. Those vaccinated against both SARS-CoV-2 and influenza had a combined HR of 0.73 (0.62-0.86) of hospitalisation for COVID-19 and 0.55 (0.49-0.62) of overall mortality compared to those vaccinated against SARS-CoV-2 only., Conclusions: influenza vaccination combined with SARS-CoV-2 vaccination increases the protective effect against hospitalisations and overall mortality compared to SARS-CoV-2 vaccination alone. Both organisational and communication actions aimed to promote and encourage vaccination are required.

Background: during 2020, Italy was one of the first nation hit by SARS-CoV-2, but it was not the hardest-hit country in terms of deaths. In absence of the death certificate, the burden of COVID-19 on mortality is usually calculated from overall deaths or from deaths of patients tested positive for COVID-19. However, these measures do not express the real burden of the disease on the population., Objectives: identify deaths due to or involving COVID-19 in absence of the death certificates., Design: deaths for all causes, cause-specific deaths, COVID-19 hospitalization and COVID-19 confirmed cases between 01.01.2020 and 31.12.2021 observed in subjects residing in the territory of the ATS of Milan. Potential deaths due to or involving COVID-19 as those occurring in an optimal time period between the date of death and the date of positive swab and/or COVID-19 hospitalization, were identified. Optimal time period was defined maximizing sensitivity and specificity, comparing potential COVID-19 deaths with 2020 cause-specific mortality as gold standard, stratifying results by time of deaths, age, and number of comorbidities. Then, this method was further validated using a time-series approach to estimate the excess mortality during the COVID-19 outbreak in comparison with the pre-outbreak period 2015-2019. Accuracy of predictions was evaluated with the Root Mean Square Error (RMSE) between observed and predicted values., Setting and Participants: 78,202 deaths for all causes, of which 8,815 due to or involving COVID-19 as classified by the Milan Register of Death Causes for 2020., Main Outcome Measures: all-cause mortality, cause-specific mortality., Results: from the beginning of the epidemic, 30% (23,495) died in the first semester of 2020, 26% (19,988) in the second semester of 2020, 23% (18,189) in the first semester of 2021, and 21% (16,530) in the second semester of 2021. COVID-19 hospitalizations were 13.826 (17%), while confirmed COVID-19 cases were 17,548 (22%). The optimal time intervals capable to identify a potential death due to or involving COVID-19 were 0-61 between the date of death and the date of positive swab and 0-11 between the date of death and the date of COVID-19 hospitalization, with an overall sensitivity of 90%, a specificity of 95%, and a RMSE of 3.6. Comparing the method proposed with the time-series approach, a RMSE in 2021 of 15.8 was found. Results showed different optimal time intervals for 2021 vs 2020 and by years of age and comorbidities., Conclusions: this study found that deaths due to or involving COVID-19 could be sensitively identified from the date of positive swab and/or COVID-19 hospitalization. This method can be used for public health interventions which provided so far measures in terms of total deaths instead of real numbers of COVID-19 death, in particular those involving the effective reproduction number usually calculated from overall mortality.

Background: In the context of the fourth wave of the COVID-19 pandemic in Italy, which occurred in correspondence with the outbreak of the Omicron variant, it became fundamental to assess differences in the risk of severe disease between the Omicron variant and the earlier SARS-CoV-2 variants that were still in circulation despite Omicron becoming prevalent., Methods: We collected data on 2,267 genotyped PCR-positive swab tests and assessed whether the presence of symptoms, risk of hospitalization, and recovery times were significantly different between Omicron and the earlier variants. Multivariable models adjusted for sex, age class, citizenship, comorbidities, and symptomatology allowed assessing the difference in outcomes between Omicron and the earlier variants according to vaccination status and timing of administration., Results: Compared to the earlier variants in the same period, Omicron was less symptomatic, resulted in fewer hospital admissions for those who were unvaccinated and for those who were already immunized after the booster dose, and was associated with quicker recovery, yet not in subjects with three vaccination doses., Conclusion: Despite being milder, Omicron's higher transmissibility and vaccine resistance should not lead to underrating its damage potential, especially with regard to hospital and health service saturation., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Consolazio, Murtas, Tunesi, Lamberti, Senatore, Faccini and Russo.)

Objectives: The emergency department (ED) is one of the most critical areas in any hospital. Recently, many countries have seen a rise in the number of ED visits, with an increase in length of stay and a detrimental effect on quality of care. Being able to forecast future demands would be a valuable support for hospitals to prevent high demand, particularly in a system with limited resources where use of ED services for non-urgent visits is an important issue., Design: Time-series cohort study., Setting: We collected all ED visits between January 2014 and December 2019 in the five larger hospitals in Milan. To predict daily volumes, we used a regression model with autoregressive integrated moving average errors. Predictors included were day of the week and year-round seasonality, meteorological and environmental variables, information on influenza epidemics and festivities. Accuracy of prediction was evaluated with the mean absolute percentage error (MAPE)., Primary Outcome Measures: Daily all-cause EDs visits., Results: In the study period, we observed 2 223 479 visits. ED visits were most likely to occur on weekends for children and on Mondays for adults and seniors. Results confirmed the role of meteorological and environmental variables and the presence of day of the week and year-round seasonality effects. We found high correlation between observed and predicted values with a MAPE globally smaller than 8.1%., Conclusions: Results were used to establish an ED warning system based on past observations and indicators of high demand. This is important in any health system that regularly faces scarcity of resources, and it is crucial in a system where use of ED services for non-urgent visits is still high., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: the levels of anti-SARS-CoV-2 antibodies after the second vaccine dose decline in the following months; the administration of an additional vaccine dose (booster) is able to restore the immune system in the short period significantly reducing the risk of a severe disease. In the winter of 2021, a new particularly infectious variant caused the urgent need to increase the coverage of the booster dose., Objectives: to present, using real data, an evaluation of the efficacy of the booster dose in reducing the severe disease of SARS-CoV-2 infection in terms of hospital admissions, intensive care and death from all causes., Design: descriptive study of vaccine adherence; associative study of the factors linked with adherence of vaccination and COVID-19 symptoms; associative study of vaccine effectiveness against hospital admission and mortality., Setting and Participants: population-based study in the Milan and Lodi provinces (Lombardy Region, Northern Italy) with subjects aged >=19 years alive at 01.10.2021, not residing in a nursery home, followed up to 31.12.2021., Main Outcome Measures: COVID-19 symptoms, hospitalization for COVID-19, intensive care hospitalization, and all-cause mortality in the period 01.10.2021-31.12.2021., Results: the cohort included 2,936,193 patients at 01.10.2021: at the end of the follow-up period (31.12.2021), 378,616 (12.9%) had no vaccine, 128,879 (4.3%) had only 1 dose, 412,227 (14.0%) had a 2nd dose given since less than 4 months, 725. 806 (25%) had a 2nd dose given since 4-7 months, 74,152 (2.5%) had a 2nd dose given since 7+ months, 62,614 (2.1%) had a 2nd dose and have had the disease, and 1,153,899 (39.3%) received the booster. In the study period (01.10.2021-31.12.2021), characterized by a very high prevalence of the omicron variant, 121,620 cases (antigenic/molecular buffer positive), 3,661 hospitalizations for COVID-19, 162 ICU hospitalizations, and 7,508 deaths from all causes were identified. Compared to unvaccinated people, subjects who had the booster dose had half the risk of being symptomatic, in particular for asthenia, muscle pain, and dyspnoea which are the most commons COVID-19 symptoms. In comparison with the subjects who had the booster dose, the unvaccinated had a 10-fold risk of hospitalization for COVID-19, a 9-fold risk of intensive care, and a 3-fold risk of dying., Conclusions: this work highlights the vaccination efficacy in reducing serious adverse events for those who undergo the booster and the need to implement specific engagement policies to bring to a booster those who had taken the second dose since the longest time.

Background: The COVID-19 pandemic has placed a huge strain on the health care system globally. The metropolitan area of Milan, Italy, was one of the regions most impacted by the COVID-19 pandemic worldwide. Risk prediction models developed by combining administrative databases and basic clinical data are needed to stratify individual patient risk for public health purposes., Objective: This study aims to develop a stratification tool aimed at improving COVID-19 patient management and health care organization., Methods: A predictive algorithm was developed and applied to 36,834 patients with COVID-19 in Italy between March 8 and the October 9, 2020, in order to foresee their risk of hospitalization. Exposures considered were age, sex, comorbidities, and symptoms associated with COVID-19 (eg, vomiting, cough, fever, diarrhea, myalgia, asthenia, headache, anosmia, ageusia, and dyspnea). The outcome was hospitalizations and emergency department admissions for COVID-19. Discrimination and calibration of the model were also assessed., Results: The predictive model showed a good fit for predicting COVID-19 hospitalization (C-index 0.79) and a good overall prediction accuracy (Brier score 0.14). The model was well calibrated (intercept -0.0028, slope 0.9970). Based on these results, 118,804 patients diagnosed with COVID-19 from October 25 to December 11, 2020, were stratified into low, medium, and high risk for COVID-19 severity. Among the overall study population, 67,030 (56.42%) were classified as low-risk patients; 43,886 (36.94%), as medium-risk patients; and 7888 (6.64%), as high-risk patients. In all, 89.37% (106,179/118,804) of the overall study population was being assisted at home, 9% (10,695/118,804) was hospitalized, and 1.62% (1930/118,804) died. Among those assisted at home, most people (63,983/106,179, 60.26%) were classified as low risk, whereas only 3.63% (3858/106,179) were classified at high risk. According to ordinal logistic regression, the odds ratio (OR) of being hospitalized or dead was 5.0 (95% CI 4.6-5.4) among high-risk patients and 2.7 (95% CI 2.6-2.9) among medium-risk patients, as compared to low-risk patients., Conclusions: A simple monitoring system, based on primary care data sets linked to COVID-19 testing results, hospital admissions data, and death records may assist in the proper planning and allocation of patients and resources during the ongoing COVID-19 pandemic., (©Rossella Murtas, Nuccia Morici, Chiara Cogliati, Massimo Puoti, Barbara Omazzi, Walter Bergamaschi, Antonio Voza, Patrizia Rovere Querini, Giulio Stefanini, Maria Grazia Manfredi, Maria Teresa Zocchi, Andrea Mangiagalli, Carla Vittoria Brambilla, Marco Bosio, Matteo Corradin, Francesca Cortellaro, Marco Trivelli, Stefano Savonitto, Antonio Giampiero Russo. Originally published in JMIR Public Health and Surveillance (https://publichealth.jmir.org), 15.11.2021.)

Background: Long-term exposure to traffic-borne noise and air pollution has been variably associated with incidence of acute vascular events, namely acute myocardial infarction, ischaemic stroke and haemorrhagic stroke. This study aims at exploring this association within a highly urbanized city., Methods: This is a population-based retrospective dynamic cohort study including all residents aged ≥ 35 years in the municipality of Milan over the years 2011-18 (1 087 110 inhabitants). Residential exposure to road traffic noise (day-evening-night levels) and nitrogen dioxide was estimated using a noise predictive model and a land use regression model, respectively. Cox proportional hazards regression analyses were performed to assess the incidence of acute vascular events and specific outcomes in single-exposure and two-exposure models including adjustment for sociodemographic confounders, fine particulate matter and surrounding greenness., Results: A total of 27 282 subjects (2.5%) had an acute vascular event. Models using nitrogen dioxide produced inconsistent results. The strongest effect was observed for noise, with an optimal cut-off for dichotomization set at 70 dBA (hazard ratio 1.025, 95% confidence interval 1.000-1.050). This association was observed specifically for ischaemic and haemorrhagic stroke. When stratifying by age group and sex, a remarkable effect was found for haemorrhagic stroke in men aged <60 years (hazard ratio 1.439, 95% confidence interval 1.156-1.792)., Conclusions: Living by roads with a day-evening-night noise level above 70 dBA exerts a small but tangible independent effect on the risks of both ischaemic and haemorrhagic stroke. It is urgent to propose mitigation measures against pollution and noise originating from vehicular traffic in order to reduce their impact, especially in the population younger than 60 years., (© The Author(s) 2021. Published by Oxford University Press on behalf of the International Epidemiological Association.)

Social inequalities in health are known to be influenced by the socioeconomic status of the territory in which people live. In the context of the ongoing coronavirus disease 2019 (COVID-19) pandemic, this study is aimed at assessing the role of 5 area-level indicators in shaping the risk of contagion in the provinces of Milan and Lodi (Lombardy, Italy), namely: educational disadvantage, unemployment, housing crowding, mobility, and population density. The study area includes the municipalities at the origin of the first Italian epidemic outbreak. Data on COVID-19 patients from the Integrated Datawarehouse for COVID Analysis in Milan were used and matched with aggregate-level data from the National Institute of Statistics Italy (Istat). Multilevel logistic regression models were used to estimate the association between the census block-level predictors and COVID-19 infection, independently of age, sex, country of birth, and preexisting health conditions. All the variables were significantly associated with the outcome, with different effects before and after the lockdown and according to the province of residence. This suggests a pattern of socioeconomic inequalities in the outbreak, which should be taken into account in the eventuality of future epidemics to contain their spread and its related disparities.

Objective: In Italy, the first diagnosis of COVID-19 was confirmed on 20 February 2020 in the Lombardy region. Given the rapid spread of the infection in the population, it was suggested that in Europe, and specifically in Italy, the virus had already been present in the last months of 2019. In this paper, we aim to evaluate the hypothesis on the early presence of the virus in Italy by analysing data on trends of access to emergency departments (EDs) of subjects with a diagnosis of pneumonia during the 2015-2020 period., Design: Time series cohort study., Setting: We collected data on visits due to pneumonia between 1 October 2015 and 31 May 2020 in all EDs of the Agency for Health Protection of Milan (ATS of Milan). Trend in the winter of 2019-2020 was compared with those in the previous 4 years in order to identify unexpected signals potentially associated with the occurrence of the pandemic. Aggregated data were analysed using a Poisson regression model adjusted for seasonality and influenza outbreaks. PRIMARY OUTCOME MEASURES : Daily pneumonia-related visits in EDs. RESULTS : In the studied period, we observed 105 651 pneumonia-related ED visits. Compared with the expected, a lower occurrence was observed in January 2020, while an excess of pneumonia visits started in the province of Lodi on 21 February 2020, and almost 10 days later was observed in the remaining territory of the ATS of Milan. Overall, the peak in excess was found on 17 March 2020 (369 excess visits compared with previous years, 95% CI 353 to 383) and ended in May 2020, the administrative end of the Italian lockdown. CONCLUSIONS : An early warning system based on routinely collected administrative data could be a feasible and low-cost strategy to monitor the actual situation of the virus spread both at local and national levels., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: to develop a risk prediction model for 30-day mortality from COVID‑19 in an Italian cohort aged 40 years or older., Design: a population-based retrospective cohort study on prospectively collected data was conducted., Setting and Participants: the cohort included all swab positive cases aged 40 years older (No. 18,286) among residents in the territory of the Milan's Agency for Health Protection (ATS-MI) up to 27.04.2020. Data on comorbidities were obtained from the ATS administrative database of chronic conditions., Main Outcome Measures: to predict 30-day mortality risk, a multivariable logistic regression model, including age, gender, and the selected conditions, was developed following the TRIPOD guidelines. Discrimination and calibration of the model were assessed., Results: after age and gender, the most important predictors of 30-day mortality were diabetes, tumour in first-line treatment, chronic heart failure, and complicated diabetes. The bootstrap-validated c-index was 0.78, which suggests that this model is useful in predicting death after COVID-19 infection in swab positive cases. The model had good discrimination (Brier score 0.13) and was well calibrated (Index of prediction accuracy of 14.8%)., Conclusions: a risk prediction model for 30-day mortality in a large COVID-19 cohort aged 40 years or older was developed. In a new epidemic wave, it would help to define groups at different risk and to identify high-risk subjects to target for specific prevention and therapeutic strategies., Competing Interests: None declared

Background: COVID-19 epidemic has paralleled with the so called infodemic, where countless pieces of information have been disseminated on putative risk factors for COVID-19. Among those, emerged the notion that people suffering from autoimmune diseases (AIDs) have a higher risk of SARS-CoV-2 infection., Methods: The cohort included all COVID-19 cases residents in the Agency for Health Protection (AHP) of Milan that, from the beginning of the outbreak, developed a web-based platform that traced positive and negative cases as well as related contacts. AIDs subjects were defined ad having one the following autoimmune disease: rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis, Sjogren disease, ankylosing spondylitis, myasthenia gravis, Hashimoto's disease, acquired autoimmune hemolytic anemia, and psoriatic arthritis. To investigate whether AID subjects are at increased risk of SARS-CoV-2 infection, and whether they have worse prognosis than AIDs-free subjects once infected, we performed a combined analysis of a test-negative design case-control study, a case-control with test-positive as cases, and one with test-negative as cases (CC-NEG)., Results: During the outbreak, the Milan AHP endured, up to April 27th 2020, 20,364 test-positive and 34,697 test-negative subjects. We found no association between AIDs and being positive to COVID-19, but a statistically significant association between AIDs and being negative to COVID-19 in the CC-NEG. If, as likely, test-negative subjects underwent testing because of respiratory infection symptoms, these results imply that autoimmune diseases may be a risk factor for respiratory infections in general (including COVID-19), but they are not a specific risk factor for COVID-19. Furthermore, when infected by SARS-CoV-2, AIDs subjects did not have a worse prognosis compared to non-AIDs subjects. Results highlighted a potential unbalance in the testing campaign, which may be correlated to the characteristics of the tested person, leading specific frail population to be particularly tested., Conclusions: Lack of availability of sound scientific knowledge inevitably lead unreliable news to spread over the population, preventing people to disentangle them form reliable information. Even if additional studies are needed to replicate and strengthen our results, these findings represent initial evidence to derive recommendations based on actual data for subjects with autoimmune diseases.

Objectives: to describe the epidemic trends of COVID-19 over time and by area in the territory covered by Milan's Agency for Health Protection (ATS-MI) from February to May 2020., Design: descriptive study of COVID-19 cases., Setting and Participants: a new information system was developed to record COVID-19 cases with positive nasopharyngeal swab. Patients resident in the area covered by ATS-MI with symptom onset between February and May 2020 were selected. Different epidemic periods were considered based on the timeline of the various regional and national containment measures., Main Outcome Measures: case fatality ratios, incidence rates, and reproduction number by epidemic period and sub-area of ATS-MI., Results: a total of 27,017 swab-positive COVID-19 cases were included. Mean age was 65 years and males were 45%. Incidence in the ATS-MI area was 776 per 100,000 population. The number of deaths was 4,660, the crude case fatality ratio was 17.3%, higher in males (21.2%) than in females (14.0%). The estimated reproduction number registered its peak (3.0) in the early stages of the epidemic and subsequently decreased. Territorial differences were observed in the epidemic spread, with a higher incidence in the Lodi area., Conclusions: estimated incidence and case fatality ratios were higher than national estimates for Italy. Each ATS-MI area had different epidemic spread patterns.

Objectives: to describe the overall mortality increase in the provinces of Milan and Lodi - area covered by the Agency for Health Protection of Milan - during the COVID-19 epidemic in the first four months of 2020, compare it with the same time period in the years 2016-2019, and evaluate to what extent the mortality can be directly attributed to the outbreak., Design: cohort study., Setting and Participants: using a new information system developed during the pandemic, we gathered data on the number of daily deaths in the population residing in the provinces of Milan and Lodi by Local Health Unit (ASST) and age groups. To describe the case fatality of COVID-19, we performed a record linkage with a database specially constructed during the epidemic to identify deaths that occurred in confirmed cases., Main Outcome Measures: mortality and excess mortality were analysed by comparing the number of observed deaths in the first 4 months of 2020 with the average deaths of the years 2016-2019 in the same calendar period and with expected deaths, estimated using a Poisson model. Furthermore, a measure of relative risk was calculated as observed/expected ratio with a 95% confidence interval., Results: the increase in mortality for all causes occurring in the study population in the first 4 months of 2020 was 48.8%, 30.8% for ages between 60 and 69, 43.9% for ages between 70 and 79, and 56.7% for subjects above 80 years of age. Focusing on the epidemic period, from 1 March to 30 April, the excess is quantifiable as more than 2-fold and mainly concerns the population over 60 years of age. The excess mortality was observed in all local health units (ASSTs). The highest increments were in the province of Lodi and the North-East of Milan (ASST Nord). In the ASSTs of Lodi and Melegnano-Martesana the mortality excess was detectable from March 15th, while for the other ASSTs the increase began in the first week of April., Conclusions: evaluation of overall mortality in the provinces of Milan and Lodi during the first wave of the Covid-19 epidemic showed a significant excess compared to the first 4 months of the years 2016-2019, mainly in the population over 60 years of age. However, this excess cannot be completely attributed directly to COVID-19 itself. This phenomenon was more intense in the Lodi ASST, with daily deaths up to 5 times higher than expected.

In July 2018, a large outbreak of Legionnaires' disease (LD) caused by Legionella pneumophila serogroup 1 (Lp1) occurred in Bresso, Italy. Fifty-two cases were diagnosed, including five deaths. We performed an epidemiological investigation and prepared a map of the places cases visited during the incubation period. All sites identified as potential sources were investigated and sampled. Association between heavy rainfall and LD cases was evaluated in a case-crossover study. We also performed a case-control study and an aerosol dispersion investigation model. Lp1 was isolated from 22 of 598 analysed water samples; four clinical isolates were typed using monoclonal antibodies and sequence-based typing. Four Lp1 human strains were ST23, of which two were Philadelphia and two were France-Allentown subgroup. Lp1 ST23 France-Allentown was isolated only from a public fountain. In the case-crossover study, extreme precipitation 5-6 days before symptom onset was associated with increased LD risk. The aerosol dispersion model showed that the fountain matched the case distribution best. The case-control study demonstrated a significant eightfold increase in risk for cases residing near the public fountain. The three studies and the matching of clinical and environmental Lp1 strains identified the fountain as the source responsible for the epidemic.

Evidence-based guidelines for the correct management of cancer patients are developed on the idea that timely care can improve health prognoses and quality of life.The aim of this paper is to evaluate the adherence of clinical pathways to clinical guidelines provided at the hospital level, for colorectal cancer care.By using a retrospective observational study, we proposed a method for associating each patient to a healthcare provider and modeling adherence as a latent construct governed by a set of 10 influential indicators. These indicators measure the adherence to specific guidelines for diagnosis, surgical treatment, chemotherapy, and follow-up. The model used was that of the item response theory (IRT). When evaluating providers, the IRT allows for a comparison of indicators in terms of their discriminating ability and difficulty, and in terms of their adherence to guidelines. The IRT results were compared with non-latent methods: numerator-based weight and denominator-based weight.A strong degree of coherence of the indicators in measuring adherence, and a high level of overall agreement between latent and non-latent methods were noted. The IRT approach demonstrated similar providers' evaluations between endoscopy and histological assessment indicators. The greatest discriminating ability among providers could be attributed to all diagnostic exams, while the lowest was associated with follow-up endoscopies. The most difficult indicator to achieve was fecal occult blood test, while follow-up imaging was the easiest.In a decision-making framework, valuable indications can be derived from the use of IRT models rather than weighting methods. Using IRTs, we were able to highlight the principal indicators in terms of strength of discrimination, and to isolate those that merely duplicated information.

Background: The association between the extremely low-frequency magnetic field generated by overhead power lines and neurodegenerative disease is still a matter of debate., Methods: A population-based case-control study was carried out on the residents in the Milan metropolitan area between 2011 and 2016 to evaluate the possible association between exposure to extremely low-frequency magnetic fields generated by high-voltage overhead power lines and Alzheimer's dementia and Parkinson's disease. A statistical analysis was performed on cases and controls matched by sex, year of birth and municipality of residence (with a case to controls ratio of 1 : 4) using conditional logistic regression models adjusted for socio-economic deprivation and distance from the major road network as potential confounders., Results: Odds ratios for residents <50 m from the source of exposure compared with residents at ≥600 m turned out to be 1.11 (95% confidence interval: 0.95-1.30) for Alzheimer's dementia and 1.09 (95% confidence interval: 0.92-1.30) for Parkinson's disease., Conclusions: The finding of a weak association between exposure to the extremely low-frequency magnetic field and neurodegenerative diseases suggests the continuation of research on this topic. Moreover, the low consistency between the results of the already existing studies emphasises the importance of increasingly refined study designs., (© The Author(s) 2019. Published by Oxford University Press on behalf of the International Epidemiological Association.)

Background: In the winter of 2016-2017, the number of deaths recorded in the north-west Europe was significantly higher than that in previous years. This spike in mortality was attributed principally to an influenza epidemic, but the contribution of air pollution and cold temperature has not been investigated. Information on the combined effect of low temperatures, influenza epidemic, and air pollution on mortality is inadequate. The objective of this study was to estimate the excess mortality in the winter of 2016-2017 in the metropolitan area of Milan, and to evaluate the independent short-term effect of 3 risk factors: low temperatures, the influenza epidemic, and air pollution., Methods: We used a case-crossover, time-stratified study design. Mortality data were collected on all people aged > 65 years who died of natural causes, due to respiratory diseases or cardiovascular diseases, between December 1, 2016 and February 15, 2017. Environmental data were extracted from the Regional Environmental Protection Agency. The National Surveillance Network provided data on influenza epidemic., Results: Among the 7590 natural deaths in people aged > 65 years, 965 (13%) were caused by respiratory conditions, and 2688 (35%) were caused by cardiovascular conditions. There were statistically significant associations between the minimum recorded temperature and deaths due to natural causes (OR = 0.966, 95% CI: 0.944-0.989), and cardiovascular conditions (OR = 0.961, 95% CI: 0.925-0.999). There were also statistically significant association between the influenza epidemic and deaths due to natural causes (OR = 1.198, 95% CI: 1.156-1.241), cardiovascular conditions (OR = 1.153, 95% CI: 1.088-1.223), and respiratory conditions (OR = 1.303, 95% CI: 1.166-1.456). High levels of PM10 (60 and 70 μg/m 3 ) were associated with a statistically significant increase in natural and cause-specific mortality. There were statistically significant interactions between PM10 and influenza for cardiovascular-related mortality, and between influenza and temperature for deaths due to natural causes., Conclusions: Excess of mortality in Milan during winter 2016-2017 was associated with influenza epidemic and concomitant environmental exposures, specifically, the combined effect of air pollution and low temperatures. Policies mitigating the effects of environmental risk factors should be implemented to prevent future excess mortality.