Francesco Cipriani

A case-control study of cancers of the gastric cardia in Italy

In a case-control study of gastric cancer (GC) in high-risk and low-risk areas in Italy, 923 GCs were reviewed by one pathologist and classified according to anatomic site. There were 68 (7.4%) cancers occurring in the gastric cardia. Compared to other GCs, cardia cancer tended to occur more often in males (sex ratio 2.8 vs 1.7) and as intestinal or unclassified histologic types. Nutritional factors for cardia tumours resembled those of other GCs, showing inverse associations with the consumption of raw vegetables, citrus and other fresh fruit, and ascorbic acid, and positive associations with the intake of traditional soups and meat, protein and cholesterol, and preference for salty foods. Cigarette smoking and wine consumption were unrelated to cardia cancer risk, and there was only a weak association with total alcohol intake. Cardia tumours showed a greater familial occurrence of GC than did other sites, with a 7-fold increase in risk for those reporting two first-degree relatives with GC. The authors discuss these findings in view of the rising incidence of adenocarcinomas of the cardia and lower oesophagus that has been reported in some western countries.

Reproducibility of histologic classification of gastric cancer.

A panel review of histologic specimens was carried out as part of a multi-centre case-control study of gastric cancer (GC) and diet. Comparisons of diagnoses of 100 GCs by six pathologists revealed agreement in histologic classification for about 70-80% of the cancers. Concordance was somewhat higher when using the Lauren rather than the Ming or World Health Organization classification systems. Histologic types from reading biopsy tissue agreed with those derived from surgical specimens for 65-75% of the 100 tumours. Intra-observer agreement in histologic classification, assessed by repeat readings up to 3 years apart by one pathologist, was 95%. The findings indicate that, although overall concordance was good, it is important to standardise diagnoses in multi-centre epidemiologic studies of GC by histologic type.

Occupational exposures as risk factors for gastric cancer in Italy.

Occupational associations with gastric cancer were investigated in a multicenter case-control study in Italy involving interviews with 640 histologically confirmed male cases and 959 controls, randomly selected from the resident populations of the study areas. From information on the three jobs each person held the longest, risks were evaluated according to employment in 35 occupations (ever or 21+ years) and to estimated exposure (ever or 21+ years) to six chemicals using a job-exposure matrix. All risk estimates were adjusted by personal, demographic, and dietary variables identified as gastric-cancer risk factors in previous analyses. The only significantly increased risk was observed for sailors, seamen, and allied groups (ever employed: odds ratio [OR]=2.9; 95 percent confidence interval [CI]=1.1–8.0; 21+ years: OR=3.1, CI=0.8–13). Nonsignificant increases after 21+ years of employment were observed for forestry workers, miners, and janitors and cleaners. Crude ORs were elevated significantly among farmers, but adjusting for demographic and lifestyle factors largely eliminated the association: a nonsignificant 30 percent excess risk remained for farm laborers, but there was no rise in risk among long-term farm laborers and no excess among farm owners. Application of the job-exposure matrix revealed excess risks of borderline significance associated with potential exposure to mineral dusts and nitrogen oxides. For subjects with 21+ years of potential exposure, nonsignificantly increased risks were related to mineral dusts, asbestos, fertilizers, and nitrosamines. Although possibly incomplete occupational histories and use of broad occupational codes likely resulted in some exposure misclassification, the results of this study indicate that occupation in general is not a strong risk factor for gastric cancer. The findings, however, are consistent with previous reports suggesting that certain occupational exposures may influence gastric cancer risk.

The epidemiological changes of HCV and HBV infections in the era of new antiviral therapies and the anti-HBV vaccine

The World Health Organization (WHO) resolution adopted in 2010 recognized viral hepatitis as a global health problem. In April 2014, for the first time, the WHO produced guidelines for the screening, care and treatment of persons with hepatitis C infections. In May 2014, a follow-up resolution urged WHO Member States to develop and implement a national strategy for the prevention, diagnosis and treatment of viral hepatitis based on the local epidemiological context. Although blood donor screening, which began in the early 1990s, has reduced the spread of the virus in the population, the WHO estimates that 150 million people are chronically infected with hepatitis C virus (HCV) and are at an increased risk of developing liver cirrhosis and hepatocellular carcinoma. In addition, 3-4 million people are infected each year. HCV treatment is currently evolving rapidly, and several drugs are in various stages of development. With regard to the hepatitis B virus (HBV), in March 2015, the WHO published the first guidelines for the prevention, care and treatment of persons with chronic hepatitis B infection, which were designed to complement the recent guidelines on HCV. Although the introduction of an effective vaccine against the hepatitis B virus has reduced the prevalence and health and economic impact of hepatitis in industrialized countries, the WHO estimates that more than 2 billion people are HBV-infected and 350 million people are chronic carriers.

Gastric cancer in a high-risk area in Italy: histopathologic patterns according to Lauren's classification

Two thousand five hundred forty cases (1628 males and 912 females) of primary gastric cancer (GC) histologically diagnosed to gastroscopic biopsy or resected specimens, occurring from 1973 to 1982 in a high risk area in Italy (Florence), were reviewed. According to Laurens criteria, 1587 (62.5%) were classified as intestinal type, 624 (24.6%) as diffuse type and 329 (12.9%) as mixed unclassified. The intestinal type is more frequent in males and increases in both sexes with advancing age; conversely for the diffuse type. In the two 5‐year periods (1973–1977 and 1978–1982) the intestinal type shows a reduction over time more evident in females than in males, in contrast to the increasing trend for the diffuse type. In males, the distribution of Laurens histologic types is stable over time for resected specimens, whereas there is a significant reduction of intestinal type for biopsy specimens. In females, both for resected and biopsy specimens there is a reduction of the intestinal type and an increase of the diffuse type from the first to the second period. For a subgroup of 297 subjects two different specimens were available (gastroscopic biopsy and surgical); sensitivity and positive predictive value, for biopsy specimen as compared with the resected one, in the diagnosis for Laurens histologic types were calculated. An excess of diagnoses in the mixed/unclassified category for biopsy material was evident (positive predictive value = 44.3%). However, for the two main histologic types, the biopsy appears a quite reliable indicator of the final diagnosis on surgical material (intestinal: ppv = 88.6%; Diffuse: ppv = 87.0%). The study supports the hypothesis that the reduction in GC mortality in the Province of Florence in recent years may be associated with a moderate reduction in the frequency of the intestinal type.

Methodological issues in a multicentric study of gastric cancer and diet in Italy: Study design, data sources and quality controls

The authors examine the problems of planning and conducting a multicentric case-control study on diet and gastric cancer in Italy. The solutions chosen for the study design, cases and controls identification, dietary interview, production of a common protocol for the field work are discussed. Results on the evaluation of the quality and comparability of collected data are presented. Further, compliance of cases and controls to the interview and to the blood and urine sampling with reasons of non-response are shown. Finally, the phases of the study and the methods for improving and controlling omogeneity among Centers are summarized.

The descriptive epidemiology of suicide in Tuscany, 1988-2002

AIMS To describe the epidemiology of Suicide in Tuscany according to the triad of time, place and person. METHODS The 4,764 cases of suicide, defined according to categories E950-E959 of ICD-9 in Tuscany over the period 1988-2002, were obtained from the Tuscan Mortality Register. Mortality indicators were calculated and analyzed. The spatial analysis was carried out by deriving Empirical Bayes Estimates for the 287 municipalities. RESULTS The crude mortality rate in the 2000-2002 is 7.8 per 100000 population (male: 12.4; female: 3.5). The age-standardized rate in the 2000-2002 is 5.8 per 100,000 population (male: 9.6; female: 2.6). The highest risk for suicide, especially in the case of males, are concentrated in the southern hinterland Tuscany, in a cluster of rural municipalities that represent the old mining district of Tuscany. The SMRs according to residential municipality (population per square kilometre), confirm a greater risk of suicide for males residing in rural communities. CONCLUSIONS The cluster of excessive mortality from suicide in Southern Tuscany could be the consequence of social determinants, related to the urban and social crisis following agriculture decline and mine closure.

Alcohol and Tobacco Consumption among Albanian Immigrants in Florence

The aim of the present study was to obtain information about both drinking and smoking, as well as about alcohol consumption-related problems, among Albanians who have immigrated to Florence, Italy, after the collapse of the Communist regime in 1990. Between October 2001 and January 2002, an opportunistic sample of 141 Albanians living in the city of Florence were interviewed about their alcohol and tobacco use, as well as about their drinking pattern and health problems Interviewees were mainly (81%) males, of an average age of 28, who had been living in Italy for the last 4 years; 92.9% drank alcoholic beverages, the preferred beverages were wine and liquor, and the average daily consumption was 39.5 grams of pure alcohol—males consumed 48.1 grams per day, which was 3.5 times more than a comparable sample of Florentine males. Also Albanians overtook Florentines in terms of the rate of smokers (49.6% vs. 39.6%) and of contact with the emergency rooms (24.1% vs. 0.37%). Such high amounts of alcohol intake may contribute to the reported high rates of accidents and acts of violence involving Albanians in Florence. Some hypotheses were discussed to explain such a high level of alcohol consumption, including the sociocultural change due to emigration. The studys limitations are noted.

Trends in Consumption of Alcoholic Beverages and Policy Interventions in Europe: An Uncertainty "Associated" Perspective

Having qualitatively investigated, both the temporal curves of alcoholic beverage consumption trends and the introduction of preventive alcohol policy measures in six European countries during the 1960s–2000s, drinking control policy measures often appeared to operate as co-factors of change, while during some periods of time they were not even present even if effective consumption changes were occurring. Study limitations are noted.

Epidemiology of Liver Cirrhosis.

Dear Editor, Liver cirrhosis is a major public health problem and a significant source of morbidity and mortality that is preventable and underestimated. It represents the main indication for liver transplantation in both United States and Europe. Recently in a large secondary care hospital, Hsiang et al, showed that the common primary aetiologies for liver cirrhosis were chronic hepatitis B cirrhosis (37.3%), alcoholic liver disease cirrhosis (24.1%), chronic hepatitis C cirrhosis (22.3%) and non-alcoholic fatty liver disease cirrhosis (16.4%). All chronic liver diseases are characterized by their capacity to progress into cirrhosis. The fibrogenic process goes through various phases where excessive collagen deposition results in qualitative and quantitative changes of the extracellular matrix. Cirrhosis is the structural subversion of the liver with the formation of regenerative nodules and it represents the late-stage liver disease. Advanced cirrhosis is a condition with limited treatment options. Changes in mortality for cirrhosis in different countries reflect differences in the prevalence of risk factors such as alcohol abuse and HBV and HCV infection. In 2010, liver cirrhosis was the 23rd cause of death worldwide (31 million), Disability Adjusted Life Years with roughly equal proportions attributable to HCV, HBV and alcohol consumption. Although cirrhosis is predominantly of viral etiology, with the current encoding system it is not possible to identify cases of cirrhosis of viral etiology. In fact, the International Classification of Diseases (ICD) permits assignment of an ICD code to the underlying cause of death as noted in a death certificate. Depending on information available on the death, a more general code can only be assigned, for example, unspecified cirrhosis of the liver. However, some observations can be made. The use of this code could underestimate the true incidence rate for cirrhotic patients who die. For example, deaths for hepatorenal syndrome or portal hypertension are currently classified with other codes, because the classification is based only on the main cause of death. As previously mentioned, a further issue is the lack of a subcategory that identifies cirrhosis, such as viral etiology. This suggests that the mortality rate tends to underestimate the illnesses that are really incident to cirrhosis.