Performance of cytology and colposcopy in diagnosis of cervical intraepithelial neoplasia (CIN) in HIV-positive and HIV-negative women.

As part of an extensive multi-institutional DIANAIDS-HIV-HPV-SIL project run in Italy (co-ordinated by ISS), the present study compares the performance (sensitivity, specificity, agreement) of routine cervical smear cytology with that of colposcopy in the detection of histologically-confirmed CIN lesions in 37 HIV-positive and 21 HIV-negative women, belonging to the DIANAIDS cohort of 459 women. All women were subjected to a cervical smear, colposcopy and biopsy, making possible the pairwise comparison of these techniques. In the whole series of HIV-positive and HIV-negative women, cytology had a sensitivity of 86.9% and specificity of 83.3%, the sensitivity of grade 2 abnormality on colposcopy against histology being 82.6% and specificity, 33.3%. No statistically significant difference was observed in the performance of Pap smears between the HIV-positive and HIV-negative women. The sensitivity of cytology was 89.7% vs 82.4% and the specificity, 75% vs 100%. For colposcopy, the sensitivity was 79.3% vs 88.2% and the specificity, 75% vs 50%. These data suggest that cervical Pap smear cytology is a highly sensitive and specific diagnostic tool in the clinical monitoring of lower genital tract pathology in HIV-positive women. Colposcopy, on the other hand, proved to be a somewhat less accurate diagnostic tool in these women.

[The STF Project: Female Tumor Screening]. / Il progetto STF--Screening Tumori Femminili.

A pilot study has been carried out to evaluate women's compliance to a screening program for cervical cancer. The study, initiated in 1994, was performed in conjunction with the ACRO project of the CNR by the Italian National Health Institute, in collaboration with La Sapienza University of Rome and the National Institute for Cancer Research in Genoa. A preliminary telephone survey was carried out on a sample of 400 women (200 in Rome and 200 in Genoa) to assess, among other factors, their attitude towards the screening program. Afterwards, an ad hoc advertising campaign was launched and 21,827 women, randomly chosen from the register office's lists, were sent a personal invitation to participate in the screening. Most women showed interest in attending the screening program at the interview, but the percentages of participation were low (25.7% in Genoa and 27.3% in Rome). On the other hand, a high percentage of women who participated in the screening had already had a Pap test in the previous three years (Genoa, 73%; Rome, 76%). The recruiting techniques that were used in this study, and that are commonly used, do not seem to reach the core of the target population for cervical screening, i.e. women who have never had a Pap test or who had a Pap test more than 5 years earlier. New methods of recruiting aimed at categories at risk and based more on direct contacts need to be developed.

Variation in the assessment of adequacy in cervical smears.

OBJECTIVE: To assess the interobserver reproducibility of the diagnosis of 'adequacy' of cervical smears according to the Bethesda System criteria in cervical smears. STUDY DESIGN: 358 cervical smears were obtained from three Italian cytopathological centres in 1998-99. All centres provided consecutively collected smears. The cervical smears were independently and blindly assessed by four cytologists. The screening was performed using a 10x objective and an additional evaluation of the percentage of cellularity was performed using a 4x objective. RESULTS: The proportion of smears assessed by the four cytologists as 'adequate' ranged from 60% to 70%, the proportion of 'satisfactory for evaluation but limited by' ranged from 27% to 38%, and the proportion of 'inadequate smears' ranged from 2% to 4%. Full agreement in the assessment of smear adequacy was observed in 311 slides and disagreement was observed only in 47. The category 'inadequate smear' was less reliable than the other two; however, the kappa value observed was acceptable. CONCLUSION: The present study shows that it is possible to achieve a high reproducibility in the assessment of smear adequacy, at least among expert cytologists who follow the Bethesda System criteria strictly.

Using the number of koilocytes to predict HIV serostatus in women with HPV-associated SIL.

OBJECTIVE: To investigate the relationship between specific cytopathologic changes, koilocyte counts and human papillomavirus (HPV) types in HIV-positive and -negative women. STUDY DESIGN: A cohort of 459 women (266 HIV+ and 193 HIV-), were examined in a multicentric study (Early Diagnosis of Neoplasia in AIDS) involving 14 gynecologic centers. Altogether, 97 women had cervical smears consistent with squamous intraepithelial lesions (SIL). Koilocytes were found in 60/97 SIL slides, subjected to quantitative counting in 30 predetermined fields. HPV genotype was determined by polymerase chain reaction (PCR) and restriction fragment length polymorphism (RFLP) analysis. RESULTS: SIL lesions were four times more frequent (29%) in HIV-positive women than in HIV-negative women (10%) (odds ratio = 3.80). HPV DNA was equally frequent in both groups. There was a strong association between the number of koilocytes and HIV serostatus in both high grade and low grade SIL diagnoses. The presence of eight or more koilocytes had a specificity of 93% and sensitivity of 76% toward the diagnosis of HIV-positive status. No HIV-negative woman had a count > 8 koilocytes. No association was shown between koilocyte count and HPV genotype. CONCLUSION: An elevated number of koilocytes could suggest the possibility of HIV infection. Pap smear examination might give the first clue to HIV positivity in otherwise-unsuspected cases.

[The impact on the international literature of the scientific production of Italian researchers in the disciplines "psychiatry" and "psychology". A bibliometric evaluation]. / L'impatto sulla letteratura internazionale della produzione scientifica dei ricercatori italiani, nelle discipline "psichiatria" e "psicologia". Una valutazione bibliometrica.

OBJECTIVE: The aim of the study was to present the results of a citation analysis concerned with the impact of Italian researchers and institutions in psychiatry and psychology upon the international scientific community. METHOD: The analysis has been performed using a database of the Institute for Scientific Information (ISI): All scientific papers which were published between 1981 and 1998 in psychiatric and psychological journals included in the Science Citation Index (SCI) and the Social Sciences Citation Index (SSCI) were considered. The most cited Italian papers, authors and institutions are reported, as well the most frequently utilised journals. RESULTS: Publications concerned with neuropsychology, psychopharmacology and biological psychiatry were the most cited. This prevalence also affected the ranking of the most cited authors, even though, in this case, research groups in disciplines such as clinical psychology and epidemiological psychiatry appeared to be strong. The four most productive Italian Universities were characterized by the presence of both a School of Medicine and a School of Psychology. The Journal of Neurology, Neurosurgery and Psychiatry and Psychopharmacology were the most frequent vehicles of scientific communication. CONCLUSIONS: The results entail important implications for Italian research in psychology and psychiatry. On a general level, these analyses appear to be helpful for monitoring scientific production by granting agencies and for comparing different individual researchers. On a more specific level the analysis has identified the leading trends in research of Italian psychiatry and psychology.

Development, reliability and acceptability of a new version of the DSM-IV Social and Occupational Functioning Assessment Scale (SOFAS) to assess routine social functioning.

OBJECTIVE: Development of a scale to assess patients' social functioning, the Personal and Social Performance scale (PSP). METHOD: PSP has been developed through focus groups and reliability studies on the basis of the social functioning component of the DSM-IV Social and Occupational Functioning Assessment Scale (SOFAS). The last reliability study was carried out by 39 workers with different professional roles on a sample of 61 psychiatric patients admitted to the rehabilitation unit. Each patient was rated independently on the scale by the two workers who knew them best. RESULTS: The PSP is a 100-point single-item rating scale, subdivided into 10 equal intervals. The ratings are based mainly on the assessment of patient's functioning in four main areas: 1) socially useful activities; 2) personal and social relationships; 3) self-care; and 4) disturbing and aggressive behaviours. Operational criteria to rate the levels of disabilities have been defined for the above-mentioned areas. Excellent inter-rater reliability was also obtained in less educated workers. CONCLUSION: Compared to SOFAS, PSP has better face validity and psychometric properties. It was found to be an acceptable, quick and valid measure of patients' personal and social functioning.

Reliability of an Italian standardized and expanded Brief Psychiatric Rating Scale (BPRS 4.0) in raters with high vs. low clinical experience.

OBJECTIVE: The aims of this study were (i) to assess the inter-rater reliability of the latest Italian expanded 24-item version of the Brief Psychiatric Rating Scale, BPRS version 4.0 and (ii) to assess the feasibility of obtaining reliable BPRS 4.0 ratings by reliability training of clinically less experienced trainees (medical and rehabilitation students). METHOD: A videotape-training procedure was used, and the inter-rater agreement scores of three different groups of raters, namely psychiatrists and psychologists (n=28), psychosocial rehabilitation students (n=27) and medical students (n=54) were calculated and compared. RESULTS: The results indicated that both experienced raters (psychiatrists and psychologists) and inexperienced raters (medical and psychosocial rehabilitation students) were able to achieve high levels of inter-rater reliability. CONCLUSION: Our results are of particular interest in view of the increasing need to draw upon professionals, other than psychiatrists and psychologists, for cost-effective and standardized evaluation of rehabilitation interventions.

[Reproducibility and accuracy of the diagnosis of cervical intraepithelial neoplasia (CIN) in 15 Italian laboratories: a national pilot project. Development of new indices of diagnostic variability. National Work Group for the expert quality control in cervico-vaginal cytopathology]. / Riproducibilità ed accuratezza nelle diagnosi di CIN in 15 laboratori italiani: progetto pilota nazionale. Messa a punto di nuovi indici clinici di variabilità diagnostica. Gruppo Nazionale di lavoro per il controllo di qualità esterno in Citopatologia cervico-vaginale.

OBJECTIVES: To assess reliability and accuracy of cervical smear diagnoses, to evaluate the effectiveness of the participation in a programme of slide exchange in increasing reliability and to re-examine the agreement in discriminating between CIN 2 and CIN 3 (merged in High grade SIL in the Bethesda System). SETTING: 15 laboratories participating on a voluntary basis throughout Italy, for a period of 1 year. METHOD: Phase one: circulation of 40 slides including all main diagnostic categories; discussion of results by representatives of participating centres. Phase two: circulation of another 40 similar slides. For each slide, not only a diagnosis but also recommendations for further examinations and a judgment on diagnostic difficulty were asked. Common measures of reliability and accuracy and (the latter only for slides on which a consensus diagnosis was reached corresponding to the histological diagnosis) were calculated; three new indices of diagnostic variability were also computed. RESULTS: Consensus diagnosis among representatives of participating laboratories on about 90% of the slides was reached both in the first and in the second phase. On 3 slides it was impossible to reach a consensus diagnosis even among external referees. In both phases, the study showed a marked variability among diagnoses, recommendations and judgment on diagnostic difficulty and, on some slides, a worrying lack of reliability in the determination of precancerous lesions. The agreement on discrimination between CIN 1 and CIN 2 was low, but it was slightly better between CIN 2 and CIN 3. No significant relationship between accuracy and workload was found. External quality control or better said, continuous quality improvement activities are essential but should be conducted in a more systematic way with greater involvement of cytotechnicians.

A new questionnaire assessing coping strategies in relatives of patients with schizophrenia: development and factor analysis.

This paper describes the development and validation of a questionnaire assessing the coping strategies adopted by relatives of patients with schizophrenia. The final version of the questionnaire includes 27 items, grouped into seven subscales (information, positive communication, social interests, coercion, avoidance, resignation and patient's social involvement), the intra-rater reliability of which ranges from 0.46 to 0.76. Cronbach's alpha coefficient, which tests the content validity of the subscales, ranges from 0.68 to 0.83. Factor analysis identifies three factors (problem-oriented coping strategies, emotionally focused strategies, and maintenance of social interests in association with patient's avoidance), accounting for 70.9% of the total variance. This questionnaire may be particularly useful for targeting and monitoring psychoeducational interventions in the families of patients with schizophrenia.

Reliability and accuracy of reporting cervical intraepithelial neoplasia (CIN) in 15 laboratories throughout Italy: phase 1 of a national programme of external quality control in cervical screening. The National Working Group for External Quality Control in Cervical Screening.

This paper reports results of a first phase of a pilot study to assess and improve quality of diagnoses in cervical cytological laboratories located throughout Italy. It represents the first phase of an External Quality Assurance programme (EQA). In the first phase, two sets of cervical smears representing a range of diagnoses were circulated among participating laboratories. Responses were recorded on a standardized form. Participants were asked to assess the adequacy of the smear and formulate a diagnosis. They were also asked to recommend management of the patient on the basis of the smear report and judge the degree of diagnostic difficulty of each slide. Crude index of agreement, unweighted and weighted kappas, diagnostic specific kappas, sensitivity and specificity as well as clinical indices of variability were calculated. In the second phase, two additional sets of slides were circulated after discussion of the first phase. There was striking variability between laboratories, both in terms of diagnoses offered and recommendations for management on individual slides. Assessment of the degree of difficulty of each slide was also very variable. Discrimination between CINII and CINIII was poor, confirming the choice of merging these two categories in the Bethesda classification. However, discrimination between CINI and CINII was also unsatisfactory. The results were discussed in workshops and it was possible to reach a consensus diagnosis in 35 of 40 smears. This study confirms the need for external quality control programmes.

Cervical intraepithelial neoplasia and human papillomavirus related lesions of the genital tract in HIV positive and negative women.

Two hundred and twenty one women at high risk for HIV (intravenous drug users and/or those with infected partners) were investigated, through a self-filled questionnaire and gynaecological examination, to define the relationship between genital Human Papilloma Virus (HPV) infections, preneoplastic cervical intraepithelial lesions (CIN) and behavioural risk factors. In the 121 HIV positive women, 58 (47%) had HPV lesions at colposcopic and/or cytologic examination and, out of these 58, 23 (40%) had CIN 1, CIN 2 or CIN 3. Six out of the 16 cases with CIN 1 and CIN 2 (37%) followed-up showed a rapid progression of the lesion to CIN 3; in 3 women the interval was 6 months, in the other 3 about 12 months. Only 5 (7%) of the remaining 66 women without HPV lesions had a CIN lesion, with an obviously significant difference on comparison with HPV positive subjects. Sixty two women out of the 121 (52%) had a previous diagnosis of condylomata. In the 100 HIV negative women, 23 (23%) had HPV lesions and, among these 23, 6 (26%) had CIN 1, CIN 2 or CIN 3; 1 of them had rapid progression from CIN 1 to CIN 3 within a year. Only 5 (3%) without HPV infection showed any kind of CIN. 33 women out of 100 (33%) had a previous clinical history of condylomata. Our findings strongly suggest that HIV infection is associated with HPV lesions and that cervical cytological abnormalities develop in this situation. There is a need for short interval cytological and colposcopic follow-up for women at high risk of HIV infection.

Burden on key relatives of patients with schizophrenia vs neurotic disorders: a pilot study.

The burden perceived by the key relatives of 27 schizophrenics and 19 patients with neurotic disorders, both with at least a minimal degree of personal/social disability and a current exacerbation of symptoms, was assessed by a self-administered questionnaire. Only modest quantitative and qualitative differences between the two samples of key relatives were found. The burden perceived by the relatives of schizophrenics was more closely related to the patients' personal/social disability than that reported by the relatives of neurotic patients. The psychopathological features of schizophrenic patients that were perceived as the most burdensome were "negative" symptoms, whereas the burden reported by the relatives of neurotic patients was predominantly related to obsessive/compulsive and anxiety symptoms.

Severely and persistently mentally ill patients in Italy: an overview of epidemiological and psychosocial findings.

The aim of this paper is to provide an overview of epidemiological, clinical and psychosocial characteristics of patients needing long-term treatment. The data concerned the following aspects: prevalence and incidence from the five best-established Italian psychiatric case registers; needs for care; psychosocial and clinical outcome as assessed by means of follow-up studies; social disability and relatives' perceived burden. The one-year prevalence rate of "long-term users" is consistent in Northern Italy, higher in Middle Italy and lower in Southern Italy. The incidence rate was found to be around 4 per 100,000. Even in a community oriented mental health service, users' needs for care are only partially met. A good psychosocial outcome was found associated with the use of social and/or vocational skills training, while the average number of days per year of hospitalization in a psychiatric department was found associated with poor outcome. A moderate degree of social disability was found among patients needing long-term treatment. The resulting family burden presented to a marked or very marked degree in more than 50% of the relatives.

Prevalence of mental disorders in Tuscany: a community study in Lari (Pisa).

A number of population studies of mental disorders has been carried out using standardized diagnostic tools. We performed a study of this type in the small town of Lari (Pisa) with the objectives of estimating the prevalence of mental disorders, including "minor" disorders, and of comparing our estimates with similar studies carried out in UK and Greece using identical methods (PSE-IX and CATEGO). The prevalence of individuals with mental disorders in our study population was 15.4% similar to that observed in Greece (16%) and higher than that observed in London (10%). Prevalence of "obsessive neurosis" was higher in London as compared to Lari and Athens, while the opposite was true for "generalized anxiety".

[Evaluation of work styles using the clinical case method at the departments of mental health in the region of Campania]. / Valutazione degli stili di lavoro mediante il metodo dei casi clinici nei dipartimenti di salute mentale della regione Campania.

In the present study, designed after the Australian "Quality Assurance Project", the same 9 clinical "vignettes" relative to 3 schizophrenia cases, 3 depressives and 3 neurosis were read by 48 psychiatrists of the Campania Region (Italy). For each case, the psychiatrists were requested to give their opinions on best place of treatment, psycoactive drugs, psychotherapy, etc. A remarkable variability among psychiatrists was observed, regarding not only psycotherapy but drug therapy as well.

Prevalence of mental disorders in Sardinia: a community study in an inland mining district.

Using standardized interviews 374 subjects randomly selected among people living in two villages in a mining district in Sardinia (Italy), were studied. Of these, 57 subjects (15.2%) were identified as 'cases'. Ten per cent of the sample was affected by a depressive syndrome and 4% by an anxiety disorder. Females were significantly more at risk for anxiety disorders, while a trend towards a major risk for depression emerged among middle-aged and elderly people. Of the sample 9.8% were taking benzodiazepines, with a significant over representation of females. Depressed subjects took benzodiazepines more frequently than anxious subjects, while the use of antidepressants was negligible.

[Avoidable deaths in the evaluation of the performance of health services. II. European Atlas of avoidable deaths: initial data and several reflections]. / Le morti evitabili nella valutazione dell' attività del servizio sanitario. II. Atlante Europeo sulle morti evitabili: primi dati ed alcune riflessioni.

The second European Atlas of Avoidable deaths, which will be shortly issued, concerns the period 1979-83 for Italy. The causes of deaths included were: tuberculosis, neoplasms of the cervix uteri and those of the uterus with no specified site, Hodgkin's disease, chronic rheumatic heart disease, hypertensive and cerebrovascular disease, childhood respiratory infections, asthma, appendicitis, abdominal hernia, cholecystitis and cholelithiasis, maternal and perinatal deaths. In Italy marked excesses for cholecystitis-cholelithiasis, Hodgkin's disease, hypertensive and cerebrovascular disease and perinatal mortality were observed. A remarkable decrease was observed in comparison with the first Atlas (1974-78); but the European countries generally maintained the differences amongst them and their rank. Proposals to assess the causes of the observed differences are suggested (death certificate quality evaluation studies, case-reference studies, cohort studies) and the role of confidential enquiries is discussed.