Francesco Gilardi

Influenza vaccination coverage among medical residents: an Italian multicenter survey

Although influenza vaccination is recognized to be safe and effective, recent studies have confirmed that immunization coverage among health care workers remain generally low, especially among medical residents (MRs). Aim of the present multicenter study was to investigate attitudes and determinants associated with acceptance of influenza vaccination among Italian MRs. A survey was performed in 2012 on MRs attending post-graduate schools of 18 Italian Universities. Each participant was interviewed via an anonymous, self-administered, web-based questionnaire including questions on attitudes regarding influenza vaccination. A total of 2506 MRs were recruited in the survey and 299 (11.9%) of these stated they had accepted influenza vaccination in 2011–2012 season. Vaccinated MRs were older (P = 0.006), working in clinical settings (P = 0.048), and vaccinated in the 2 previous seasons (P < 0.001 in both seasons). Moreover, MRs who had recommended influenza vaccination to their patients were significantly more compliant with influenza vaccination uptake in 2011–2012 season (P < 0.001). “To avoid spreading influenza among patients” was recognized as the main reason for accepting vaccination by less than 15% of vaccinated MRs. Italian MRs seem to have a very low compliance with influenza vaccination and they seem to accept influenza vaccination as a habit that is unrelated to professional and ethical responsibility. Otherwise, residents who refuse vaccination in the previous seasons usually maintain their behaviors. Promoting correct attitudes and good practice in order to improve the influenza immunization rates of MRs could represent a decisive goal for increasing immunization coverage among health care workers of the future.

Frequent use of emergency departments by the elderly population when continuing care is not well established

Introduction The elderly, who suffer from multiple chronic diseases, represent a substantial proportion of Emergency Department (ED) frequent users, thus contributing to ED overcrowding, although they could benefit from other health care facilities, if those were available. The aim of this study was to evaluate and characterize hospital visits of older patients (age 65 or greater) to the ED of a university teaching hospital in Rome from the 1st of January to the 31st of December 2014, in order to identify clinical and social characteristics potentially associated with “elderly frequent users”. Material and Methods A retrospective study was performed during the calendar year 2014 (1st January 2014 – 31st December 2014) analyzing all ED admissions to the University Hospital of Rome Tor Vergata. Variables collected included age, triage code, arrival data, discharge diagnosis, and visit outcome. We performed a risk analysis using univariate binary logistic regression models. Results A total number of 38,016 patients accessed the ED, generating 46,820 accesses during the study period, with an average of 1.23 accesses for patient. The elderly population represented a quarter of the total ED population and had an increased risk of frequent use (OR 1.5: CI 1.4–1.7) and hospitalization (OR 3.8: CI 3.7–4). Moreover, they showed a greater diagnostic complexity, as demonstrated by the higher incidence of yellow and red priority codes compared to other ED populations (OR 3.1: CI 2.9–3.2). Discussion Older patients presented clinical and social characteristics related to the definition of “elderly frail frequent users”. The fact that a larger number of hospitalizations occurred in such patients is indirect evidence of frailty in this specific population, suggesting that hospital admissions may be an inappropriate response to frailty, especially when continued care is not established. Conclusion Enhancement of continuity of care, establishment of a tracking system for those who are at greater risk of visiting the ED and evaluating fragile individuals should be the highest priority in addressing ED frequent usage by the elderly.

Conflict of interest between professional medical societies and industry: a cross- sectional study of Italian medical societies' websites

Objective To describe how Italian medical societies interact with pharmaceutical and medical device industries through an analysis of the information available on their websites. Design Cross sectional study. Setting Italy. Participants 154 medical societies registered with the Italian Federation of Medical-Scientific Societies. Main outcome measures Indicators of industry sponsorship (presence of industry sponsorship in the programme of the last medical societies’ annual conference; presence of manufacturers’ logos on the homepage; presence of industry sponsorship of satellite symposia during the last annual conference). Results 131 Italian medical societies were considered. Of these, 4.6% had an ethical code covering relationships with industry on their websites, while 45.6% had a statute that mentioned the issue of conflict of interest and 6.1% published the annual financial report. With regard to industry sponsorship, 64.9% received private sponsorship for their last conference, 29.0% had manufacturers’ logos on their webpage, while 35.9% had industry-sponsored satellite symposia at their last conference. The presence of an ethical code on the societies’ websites was associated with both an increased risk of industry sponsorship of the last conference (relative risk (RR) 1.22, 95% CIs 1.01 to 1.48 after adjustment) and of conferences and/or satellite symposia (RR 1.22, 95% CIs 1.02 to 1.48 after adjustment) but not with the presence of manufacturers’ logos on the websites (RR 1.79, 95% CIs 0.66 to 4.82 after adjustment). No association was observed with the other indicators of governance and transparency. Conclusions This survey shows that industry sponsorship of Italian medical societies’ conferences is common, while the presence of a structured regulatory system is not. Disclosure of the amount of industry funding to medical societies is scarce. The level of transparency therefore needs to be improved and the whole relationship between medical societies and industry should be further disciplined in order to avoid any potential for conflict of interest.

Testing the accuracy ratio of the Spatio-Temporal Epidemiological Modeler (STEM) through Ebola haemorrhagic fever outbreaks

Mathematical modelling is an important tool for understanding the dynamics of the spread of infectious diseases, which could be the result of a natural outbreak or of the intentional release of pathogenic biological agents. Decision makers and policymakers responsible for strategies to contain disease, prevent epidemics and fight possible bioterrorism attacks, need accurate computational tools, based on mathematical modelling, for preventing or even managing these complex situations. In this article, we tested the validity, and demonstrate the reliability, of an open-source software, the Spatio-Temporal Epidemiological Modeler (STEM), designed to help scientists and public health officials to evaluate and create models of emerging infectious diseases, analysing three real cases of Ebola haemorrhagic fever (EHF) outbreaks: Uganda (2000), Gabon (2001) and Guinea (2014). We discuss the cases analysed through the simulation results obtained with STEM in order to demonstrate the capability of this software in helping decision makers plan interventions in case of biological emergencies.

Minimalist video-assisted thoracic surgery biopsy of mediastinal tumors

BACKGROUND Mediastinal tumors often require surgical biopsy to achieve a precise and rapid diagnosis. However, subjects with mediastinal tumors may be unfit for general anesthesia, particularly when compression of major vessels or airways does occur. We tested the applicability in this setting of a minimalist (M) uniportal, video-assisted thoracic surgery (VATS) strategy carried out under locoregional anesthesia in awake patients (MVATS). METHODS We analyzed in a comparative fashion including propensity score matching, data from a prospectively collected database of patients who were offered surgical biopsy for mediastinal tumors through either MVATS or standard VATS. Tested outcome measures included feasibility, diagnostic yield, and morbidity. RESULTS A total of 24 procedures were performed through MVATS. Diagnostic yield was 100%. Median hospital stay and time interval to oncologic treatment were 2 days (IQR, 2-3 days) and 7 days (IQR, 5.5-11.5 days), respectively. At overall comparison (MVATS, N=24 vs. VATS, N=23), there was a significant difference in both frequency and severity of postoperative complication as measured by Clavien-Dindo classification (P<0.006). In a propensity score matched comparison (8 patients per group), grade 3 or 4 complications requiring aggressive management were found only in the general anesthesia group. Global time spent in the operating room was shorter in the MVATS group (P=0.05). Time interval to oncological treatment was the same between groups. Other differences were also found in SIRS score (P=0.05) and PaO2/FiO2 (P=0.04) thus suggesting better adaption to perioperative stress. CONCLUSIONS MVATS biopsy appears to be a reliable tool to optimize diagnostic assessment in patients with mediastinal tumors. It can offer high diagnostic accuracy due to large tissue samples, while reducing morbidity rate compared to the same operation under general anesthesia. More robust evaluation is needed to define the appropriateness of MVATS in this specific clinical setting.

Frailty as a predictor of mortality and hospital services use in older adults: a cluster analysis in a cohort study

Abstract Background Lowering mortality and hospitalization of older adults is one of the main goals of public health to improve both health systems’ sustainability and older adults’ quality of life. The aim of this study is to identify the determinants associated with mortality and the use of hospital services in the population older than 64 years of age. Methods A randomized sample from the population of the Lazio region (Italy) above the age of 64 was enrolled in 2014 by the administration of a questionnaire to assess frailty; the rates of use of hospital services and mortality in the year following the enrolment have been retrieved by the regional database. Univariable and multivariable analyses addressed the association of health status, social and economic variables with health outcomes. Results One thousand two hundred and eighty persons were recruited; 52 deaths were reported at 1 year of follow-up (robust 1.8%, frail 10.1% and very frail 19.1%, P < 0.001). The mean rate of use of hospital services was 692.2 per 1000 observation/year (robust 589.5, frail 1191.1 and very frail 848.4, P < 0.001). In the multivariate analysis, the higher rate of use of hospital services was independently associated with functional status, social support, psychological/psychiatric discomfort, availability of home care services and physical health. Conclusions Frailty, as a multidimensional issue, is also a strong predictor of survival in the short term. The use of the hospital services by older adults is associated mainly with functional status, social resources, psycho-physical status and health service organization factors.

Sensitivity and Specificity of a Short Questionnaire to Screen Frailty in the Community-Dwelling Older Population

Introduction. Frailty represents a major risk factor for death and Use of Hospital Services (UHS) among older adults. A simple tool to detect frailty might permit stratification of the community-dwelling older population according to the risk of negative outcomes. The present study aims at determining the sensitivity and specificity in predicting mortality and UHS of the Short Functional Geriatric Evaluation (SFGE), a short questionnaire to screen for frailty in community-dwelling older citizens. Methods. The study is a secondary analysis of all the data collected through an observational longitudinal cohort study carried out in Lazio region (Italy). The SFGE is compared with the Functional Geriatric Evaluation (FGE) questionnaire to define sensitivity and specificity for mortality and for UHS during the first year following its administration. Results. The SFGE classifies 36.3% of the respondents as frail and shows a sensitivity of 90.4% and a specificity of 78.3% compared to the FGE (area under the ROC: 0.928; CL95%: 0.910 - 0.947; p-value < 0.001). Those respondents identified by the SFGE as frail also include some of those classified by the FGE as pre-frail, who also show a high rate of UHS. The results show that the SFGE score predicts the UHS more accurately than it does the mortality rate. Conclusion. The SFGE identifies as frail a larger portion of the enrolled population than the FGE. Those people so identified show a high rate of UHS. Because of its easy and quick administration, it can be considered a useful primary screening tool but it must be followed up with a more extensive assessment of those identified as frail. The small time needed to fill in the tool and the possibility of administering it by telephone makes the SFGE a useful tool to screen for frailty and to plan the provision of care services at both individual and population level.

To assess community care services effectiveness: the use of the Chronic Obstructive Pulmonary Disease in-patient admission rate

Background Assessment of appropriateness is a criteria of increasing relevance for delivering health care services. In Italy elderly h ospital admissions for Chronic Obstructive Pulmonary (COPD) disease is one of the chosen indicators to measure the appropriate use of services. This study describes the characteristics of hospital admissions at a regional level for COPD – DRG 88 and to evaluates their relationship with other indicators linked to the provision of hospital or community care services. Methods Data on hospital admissions for COPD in the years 2006 and 2011 were collected from hospital discharge records. Correlations among acute in-patients admission rates by Italy’s Regions and provision of Long Term Care (LTC) services have been analyzed through univariate and multivariate linear regression models. Results The national rate of hospitalization for COPD decreased from 2006 to 2011 (-35%). The COPD in-patient admission rate showed a weak inverse relation with the provision of LTC that was statistically significant only for 65-74 age-group in 2006. The reduction was greater than 60% for those under the age of 75 and around 14% for those over 74 years. The inclusion in the interpretative model the rate of beds per capita in and the rate of General Practitioners improves the percentage of variability between the regions in the rate of hospitalization for the DRG 88 explained by the model itself. Conclusion The reduction in hospitalizations for COPD in the over-fifty age group is particularly noticeable; it seems mainly related to factors other than to the operation of those services outside the hospital.

The role of the Student’s involvement in GlobalHealth Medical Education: the results of a surveyconducted in four Medical Schools in Rome

2010 as reached universal salt iodization (USI). After this time, researches on iodine deficiency at the national level were not held in Kazakhstan. Objectives: The evaluation of the situation on iodine intake at the national level by urine iodine excretion, revelation of salt iodization quality and the awareness level of the population on iodine deficiency, comparison of indicators overtime in RK. Methods A cross-sectional survey of 2011 included 64 clusters on 22 women in each cluster. The women of reproductive age (15-49 years) were interviewed and 1145 salt samples were collected from their households for quantitative determination of iodine, and 1296 their urine samples were analyzed on content of iodine by ammonium persulfate digestion method, based on the Sandell-Kolthoff reaction. It was conducted a comparative analysis of the results with data from national studies before adopting USI strategy (1999) and MICS (2006). Results The urinary iodine median at women in 2011 was 181.1 mg/l, in 2006 235.9 mg/l, in 1999 93.9 mg/l. The prevalence of iodine deficiency of women was 22.8% in 2011, it was 15.9% in 2006, and 54.2% in 1999. In 2011 the percentages of salt samples with adequately iodized salt (?15 ppm) were 95.9%, in 2006 91.4 %, in 1999 29%. In 2011 among interviewed women 92.7%, n = 1303 knew that salt is iodized, in 2004 these were 93,3%, n = 1 500, and only 58.6% were aware of the need to use iodized salt, n = 4800 in 1999. Conclusions Since the adoption of the Law on mandatory salt iodization consumption percentage of adequately iodized salt has increased, which in turn affected the rising of urinary iodine levels at the population. After 8 years of USI median of urinary iodine excretion decreased slightly comparing with 2006, but remained in the normal range on the Background of adequately iodized salt coverage more than 90%. It indicates the necessity of periodic biological monitoring and continuing communication activity among population on long-term and constantly basis. Key message After 8 years of USI median of urinary iodine excretion decreased slightly comparing with 2006, but remained in the normal range.