The current status of decision-making procedures and quality assurance in Europe: an overview

The 2005 Report on Social Responsibility and Health of the UNESCO International Bioethics Committee (Ibc) proposes a new approach to implementing the right to healthcare and suggests a number of Courses of Action to be followed in various fields. Based on the latest available data, we intend to present an overview of the current state of European health systems in two of those fields-decision-making procedures and quality assurance in health care-and to attempt a comparison of the situation with the Report's provisions, in order to pave the way for the identification of what still has to be done to bridge international recommendations and the reality of policy and practice in Europe's health care

A Systematic Review of Meta-Analyses on Gene Polymorphisms and Gastric Cancer Risk

BACKGROUND: Individual variations in gastric cancer risk have been associated in the last decade with specific variant alleles of different genes that are present in a significant proportion of the population. Polymorphisms may modify the effects of environmental exposures, and these gene-environment interactions could partly explain the high variation of gastric cancer incidence around the world. The aim of this report is to carry out a systematic review of the published meta-analyses of studies investigating the association between gene polymorphisms and gastric cancer risk, and describe their impact at population level. Priorities on the design of further primary studies are then provided. METHODS: A structured bibliographic search on Medline and EMBASE databases has been performed to identify meta-analyses on genetic susceptibility to gastric cancer, without restriction criteria. We report the main results of the meta-analyses and we describe the subgroup analyses performed, focusing on the detection of statistical heterogeneity. We investigated publication bias by pooling the primary studies included in the meta-analyses, and we computed the population attributable risk (PAR) for each polymorphism. RESULTS: Twelve meta-analyses and one pooled-analysis of community based genetic association studies were included, focusing on nine genes involved in inflammation (IL-1beta, IL-1RN, IL-8), detoxification of carcinogens (GSTs, CYP2E1), folate metabolism (MTHFR), intercellular adhesion (E-cadherin) and cell cycle regulation (p53). According to their random-Odds Ratios, individuals carrying one of the IL-1RN *2, IL-1beta -511T variant alleles or homozygotes for MTHFR 677T are significantly at higher risk of gastric cancer than those with the wild type homozygote genotypes, showing high PARs. The main sources of heterogeneity in the meta-analyses were ethnicity, quality of the primary study, and selected environmental co-exposures. Effect modification by Helicobacter pylori infection for subjects carrying the unfavourable variant of IL-1 polymorphisms and by low folate intake for individuals homozygotes for MTHFR 677T allele has been reported, while genes involved in the detoxification of carcinogens show synergistic interactions. Publication bias was observed (Egger test, p = 0.03). DISCUSSION: The published meta-analyses included in our systematic review focused on polymorphisms having a small effect in increasing gastric cancer risk per se. Nevertheless, the risk increase by interacting with environmental exposures and in combination with additional unfavourable polymorphisms. Unfortunately meta-analyses are underpowered for many subgroup analyses, so additional primary studies performed on larger population and collecting data on environmental and genetic co-exposures are demanded

10 Statements on the Future of Public Health in Europe

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23-valent pneumococcal polysaccharide vaccine (PPV23) for the prevention of invasive pneumococcal diseases (IPDs) in the elderly: is it really effective?

Introduction. Incidence of invasive pneumococcal diseases (IPDs) in Italy is constantly increasing and that is particularly true among the elderly. 23-valent polysaccharide pneumococcal vac- cine (PPV23) is recommended to this age group and offered in all Italian regions. However, efficacy of PPV23 on preventing IPDs is debated. We therefore performed a review of the most recent avail- able meta-analyses in order to assess the efficacy of PPVs. Methods. The literature search was conducted using PubMed and Scopus search engines. We used the following keywords: ?pneu- mococcal?, ?polysaccharide?, ?vaccine?, ?efficacy?, ?elderly?, ?meta analysis?. Only meta-analyses published in the last 7 years were selected. We examined the results of the selected meta-anal- yses and assessed their quality according to the PRISMA recom- mendations. Results. The search returned 16 results in PubMed and 12 in Scopus: among them we selected 3 meta-analyses. According to our quality assessment, all meta-analyses showed generally posi- tive results and almost all items of the PRISMA checklist were respected. However, the research protocol and the registration number were absent in all the 3 revisions and the flow-chart was not shown in Moberley?s and Melegaro?s works. In the study by Huss et al. the relative risk of developing IPDs among vaccinated subjects was 0.90 (95%CI: 0.46-1.77, I2 4.9%), indicating a very slight benefit after vaccination. This contrasts with the results of the Cochrane Review by Moberley et al., in which the PPVs showed a protective efficacy in reducing the risk of IPDs of 74% (OR 0.26, 95%CI: 0.15-0.46) with no statistical heterogeneity (I2 0%). Melegaro et al. found a reduction not statistically signifi- cant of the incidence of IPD of 65% (OR 0.35; 95%CI 0.08-1.49) among healthy elderly, while the global estimate of vaccine efficacy among high risk elderly was minimal (OR 0.80; 95%CI 0.22-2.88). Conclusions. Most of the studies suggest that the PPVs confer low protection against IPDs. Anyhow, their methodological het- erogeneity does not allow definitive conclusions. While waiting to see the results of new trials about the efficacy of PPVs, in particular of PPV23, and the extension of the use of conjugate vaccine among the population over 65, stakeholders should be aware of the results of the meta-analyses discussed in this paper during the implementation of the vaccination programs for the elderly in Public Health. The full article is free available on www.jpmh.or

A critical appraisal of epidemiological studies comes from basic knowledge: a reader's guide to assess potential for biases

Scientific literature may be biased because of the internal validity of studies being compromised by different forms of measurement error, and/or because of the selective reporting of positive and 'statistically significant' results. While the first source of bias might be prevented, and in some cases corrected to a degree, the second represents a pervasive problem afflicting the medical literature; a situation that can only be 'corrected' by a change in the mindset of authors, reviewers, and editors. This review focuses on the concepts of confounding, selection bias and information bias, utilising explanatory examples and simple rules to recognise and, when possible, to correct for them. Confounding is a mixing of effects resulting from an imbalance of some of the causes of disease across the compared groups. It can be prevented by randomization and restriction, and controlled by stratification, standardization or by using multivariable techniques. Selection bias stems from an absence of comparability among the groups being studied, while information bias arises from distorted information collection techniques. Publication bias of medical research results can invalidate evidence-based medicine, when a researcher attempting to collect all the published studies on a specific topic actually gathers only a proportion of them, usually the ones reporting 'positive' results. The selective publication of 'statistically significant' results represents a problem that researchers and readers have to be aware of in order to face the entire body of published medical evidence with a degree of scepticism

Surveillance and control of antibiotic resistance in the mediterranean region

Antibiotic resistance is one of the most relevant problems in the healthcare: the growth of resistant microorganisms in healthcare settings is a worrisome threat, raising length to stay (LOS), morbidity and mortality in those patients. The importance of the antibiotic resistance and its spread around the world, gave rise to the activation of several surveillance systems, based especially on the collection of laboratory data to local or national level. The objective of this work is to carry out a review of the scientific literature existing on the topic and scientific activities related to surveillance of antibiotic resistance in the countries bordering the Mediterranean Sea. Recent Data from European Centre for Disease Prevention and Control (November 2015) show, for different combinations bacterium-drug, an increase of resistance from North to South and from West to East of Europe. It is of particular concern the phenomenon of resistance carried out by some gram-negative, specifically Klebsiella pneumoniae and Escherichia coli to third-generation cephalosporin, often combined in opposition to fluoroquinolones and aminoglycosides. Is particularly high the incidence of resistance to carbapenems by strains of Enterobacteriaceae (Klebsiella included). The resistance exerted by MRSA (Methicillin-resistant Staphylococcus aureus) continues to be relevant, albeit showing some decline in recent years. The incidence of resistance carried on by Streptococcus pneumoniae is stable and is mainly relevant to macrolides. Finally, a significant increase in recording relatively exercised by Enterococcus faecium to Vancomycin. Detecting, preventing, and controlling antibiotic resistance requires strategic, coordinated, and sustained efforts. It also depends on the engagement of governments, academia, industry, healthcare providers, the general public, and the agricultural community, as well as international partners. Committing to combating antibiotic-resistant microbes does support patient care, economic growth, agriculture, and economic and national security

Epidemiology and direct medical costs of human Leishmaniasis in Italy

INTRODUCTION: Osteoarthrosis is the most prevalent joints disorder and it is also the most frequent cause of physical disability in the elderly. When surgery is not indicated, symptomatic drugs are generally used. These treatments are frequently associated to balneotherapy. In fact, balneotherapy or spa therapy has been widely used in classical medicine as a cure for such diseases. The aim and significance of this study is to evaluate the impact of thermalism in subjects suffering from osteoarthrosis. METHODS: We randomly selected 220 osteoarthrosic subjects (STs = spa treatment subjects), aged from 40 to 90, that usually undergone mud pack therapy and balneotherapy at least once a year. They were enrolled in thermal establishments in the Euganean Basin. We also recruited, as control group, 172 osteoarthrosic subjects (NCs = normal care subjects) that never underwent any spa therapy. A questionnaire, comprehensive of a disability score, was administered by physicians to each subject. RESULTS: STs reported to suffer from osteoarthrosis for more years than NCs. Furthermore STs significantly suffered more than NCs from pain in several joints, and they also showed a more elevated average number of painful joints. In spite of that, STs used less drugs than NCs, and showed a higher degree of disability due to osteoarthrosis (p inf.0.001). CONCLUSION: The regular use of mudpack and balneotherapy seem to improve the wellness, and the spa treatment seems to help the achievement of this goal. In this regard it might be important to encourage new investigations in order to assess in which measure thermal therapy contribute to the wellness improvemen

A case-control study on the combined effects of p53 and p73 polymorphisms on head and neck cancer risk in an Italian population

<p>Abstract</p> <p>Background</p> <p>The purpose of this study is to analyze the combined effects of selected <it>p</it>53 and <it>p</it>73 polymorphisms and their interaction with lifestyle habits on squamous cell carcinoma of the head and neck (SCCHN) risk and progression in an Italian population.</p> <p>Methods</p> <p>Two hundred and eighty-three cases and 295 hospital controls were genotyped for <it>p</it>53 polymorphisms on exon 4 (Arg72Pro), intron 3 and 6, and <it>p</it>73 G4C14-to-A4T14. Their association with SCCHN was estimated using a logistic regression analysis, while a multinomial logistic regression approach was applied to calculate the effect of the selected polymorphisms on SCCHN different sites (oral cavity, oropharynx, hypopharynx and larynx). We performed an haplotype analysis of the <it>p</it>53 polymorphisms, and a gene-gene interaction analysis for the combined effects of <it>p</it>73 G4C14-to-A4T14 and <it>p</it>53 polymorphisms.</p> <p>Results</p> <p>We found a significant increased risk of SCCHN among individuals with combined <it>p</it>73 exon 2 G4A and <it>p</it>53 intron 3 variant alleles (OR = 2.22, 95% CI: 1.08–4.56), and a protective effect for those carrying the <it>p</it>53 exon 4-<it>p</it>53 intron 6 diplotype combination (OR = 0.67; 95% CI: 0.47–0.92). From the gene-environment interaction analysis we found that individuals aged < 45 years carrying <it>p</it>73 exon 2 G4A variant allele have a 12.85-increased risk of SCCHN (95% CI: 2.10–78.74) compared with persons of the same age with the homozygous wild type genotype. Improved survival rate was observed among <it>p</it>53 intron 6 variant allele carriers (Hazard Ratio = 0.51 (95% CI: 0.23–1.16).</p> <p>Conclusion</p> <p>Our study provides for the first time evidence that individuals carrying <it>p</it>53 exon 4 and <it>p</it>53 intron 6 variant alleles are significantly protected against SCCHN, and also shows that an additional risk is conferred by the combination of <it>p</it>73 exon 2 G4C14-to-A4T14 and <it>p</it>53 intron 3 variant allele. Larger studies are required to confirm these findings.</p

Alter Ego. Drug and brain ? Information to prevent. Compared analysis of opinions, knowledge and habits among a multicentric sample of secondary school students about drug addiction

Repression and control have been shown to be inadequate for drug addiction issues. Recent history, however, has proved that information is one of the most effective measures against the spread of drugs. The wide range of drug circulation and the need for the spread of correct information on the effects of drugs in man, especially his brain, have led the Center for Scientific Culture Diffusion of Cassino University, to widen the scope of ?Alter Ego. Drugs and the brain?, a touring educational exhibition, which opened in 1994, by dedicating more attention to socially accepted drugs, such as alcohol and tobacco, and to new substances like ecstasy and similar drugs. Concurrently with the Alter Ego touring exhibition, a study was undertaken to obtain information on public awareness of the dangers of psychotropic drug abuse and to assess the effectiveness of the exhibition as an instrument of scientific information about drug addiction among its visitors, during its tour of over 60 Italian towns

The impact of Public Reporting on clinical outcomes: a systematic review and meta-analysis

BACKGROUND: To assess both qualitatively and quantitatively the impact of Public Reporting (PR) on clinical outcomes, we carried out a systematic review of published studies on this topic. METHODS: Pubmed, Web of Science and SCOPUS databases were searched to identify studies published from 1991 to 2014 that investigated the relationship between PR and clinical outcomes. Studies were considered eligible if they investigated the relationship between PR and clinical outcomes and comprehensively described the PR mechanism and the study design adopted. Among the clinical outcomes identified, meta-analysis was performed for overall mortality rate which quantitative data were exhaustively reported in a sufficient number of studies. Two reviewers conducted all data extraction independently and disagreements were resolved through discussion. The same reviewers evaluated also the quality of the studies using a GRADE approach. RESULTS: Twenty-seven studies were included. Mainly, the effect of PR on clinical outcomes was positive. Meta-analysis regarding overall mortality included, in a context of high heterogeneity, 10 studies with a total of 1,840,401 experimental events and 3,670,446 control events and resulted in a RR of 0.85 (95 % CI, 0.79-0.92). CONCLUSIONS: The introduction of PR programs at different levels of the healthcare sector is a challenging but rewarding public health strategy. Existing research covering different clinical outcomes supports the idea that PR could, in fact, stimulate providers to improve healthcare quality