Diagnostic Route Research Articles

The pathway to diagnosis and treatment for surgically managed lung cancer patients.

Most lung cancer is diagnosed at an advanced stage, resulting in poor survival. This study examined diagnostic pathways for patients with operable lung cancer to identify factors contributing to early diagnosis. Surgically treated lung cancer patients (aged ≥40, within 6 months of diagnosis), approached via the population-based Cancer Registry, with their primary care physicians (PCPs) and specialists completed cross-sectional surveys assessing symptoms, diagnostic route (symptomatic or 'investigation' of other problem), tests, key event dates and treatment. Time intervals to diagnosis and treatment were determined, and quantile regression examined differences between the two diagnostic routes. Cox proportional hazard regression analyses examined associations between survival and diagnostic route adjusting for stage, sex and age. One hundred and ninety-two patients (36% response rate), 107 PCPs and 55 specialists participated. Fifty-eight per cent of patients had a symptomatic diagnostic route reporting an average of 1.6 symptoms, most commonly cough, fatigue or haemoptysis. Symptomatic patients had longer median primary care interval than 'investigation' patients (12 versus 9 days, P < 0.05) and were more likely to report their PCP first-ordered imaging tests. Secondary care interval was shorter for symptomatic (median = 43 days) than investigation (median = 62 days, P < 0.05) patients. However, 56% of all patients waited longer than national recommendations (6 weeks). While survival estimates were better for investigation than symptomatic patients, these differences were not significant. Many operable lung cancer patients are diagnosed incidentally, highlighting the difficulty of symptom-based approaches to diagnosing early stage disease. Longer than recommended secondary care interval suggests the need for improvements in care pathways.

Diagnostic route of cervicogenic dizziness: usefulness of posturography, objective and subjective testing implementation and their correlation

Purpose To evaluate posturography measurements, and their association with other clinical tests used for cervicogenic dizziness diagnosis, in a cohort of subjects suffering from cervicogenic dizziness, compared with healthy subjects. Materials and methods Ninety-three cervicogenic dizziness patients and 98 age- and gender-matched healthy subjects underwent video-Head impulse test, posturography testing, evaluation of cervical spine movements by means of cervical range of motion goniometer and self-report and performance measures, including Dizziness Handicap Inventory, Neck Disability Index, Neck Pain Intensity, Tampa Scale for Kinesiophobia and Hospital Anxiety and Depression Scale. Results Cervicogenic dizziness patients demonstrated significant increases in classical posturography parameters (i.e., surface and length) and in power spectra values within middle and high-frequency interval depicting balance control alterations especially due to proprioceptive integration changes. Furthermore, decreases in degrees of cervical range of motion and increases of self-report and performance measures – highlighting significant complaints of subjective feeling of dizziness – were found in these patients when compared with healthy subjects. Multiple correlations were found between posturography testing and cervical range of motion and Dizziness Handicap Inventory as well as between different self-report and performance measures in cervicogenic dizziness patients. Conclusions The implementation of posturography – including power spectra analysis - coupled with appropriate exclusion of other disorders, may represent a useful tool in improving cervicogenic dizziness assessment in terms of cost, time consumption and correlation with other measurements. Implications for rehabilitation Uncertainties in diagnostic assessment of cervicogenic dizziness reflect doubts regarding the causes underpinning the symptoms of imbalance, unsteadiness, and disorientation. Posturography measurement is a low-cost, time-sparing technique and its implementations have proven to be useful in detecting significant alterations in body sway during perturbating situations. Implementation of power spectra analysis on posturography testing may represent a useful tool in improving cervicogenic dizziness assessment also in terms of rehabilitative treatment follow-up.

Potential for Reducing Time to Referral for Colorectal Cancer Patients in Primary Care.

An optimal diagnostic process in primary care is pivotal for reducing cancer-related disease burden. This study aims to explore reasons for long times to referral for Dutch colorectal cancer (CRC) patients in primary care. A retrospective cohort study of anonymized free-text primary care records from the Julius General Practitioners' Network database, linked to the Netherlands Cancer Registry. Patients with a confirmed CRC diagnosis from 2007 through 2011 that symptomatically presented in primary care were included. Median time and interquartile ranges from presentation in primary care to referral were calculated for multiple patient and presentation characteristics. Associations of these characteristics with long time to referral (75th percentile was ≥59 days) were examined with log-binomial regression analyses. Routes to referral of patients with the longest times to referral were explored using thematic free-text analyses (90th percentile at ≥219 days). Among the 309 people with CRC, patients who were female, did not have a registered family history, had a history of malignancy, lacked alarm symptoms at presentation, or had hemorrhoids at physical examination were at risk for longer time to referral in univariable analyses (longer median durations and/or univariable association with the 75th percentile). Only presentation without alarm symptoms showed a statistically significant association with long duration (75th percentile) in multivariable analysis (relative risk = 1.7; 95% CI, 1.1-2.6). Thematic exploration of the diagnostic routes to referral of patients with the longest durations (90th percentile) showed 2 dominating themes: "alternative working diagnosis" and "suboptimal diagnostic strategies," and included the sub-themes "omitting to reconsider an initial diagnosis" and "lacking follow-up." Long time to referral for CRC in primary care is mainly related to low cancer suspicion. There is potential for reducing the longest times to referral for patients with CRC in primary care, with earlier reconsideration of the initial hypothesis and implementation of strict follow-up consultations.

Establishing population-based surveillance of diagnostic timeliness using linked cancer registry and administrative data for patients with colorectal and lung cancer

BackgroundDiagnostic timeliness in cancer patients is important for clinical outcomes and patient satisfaction but, to-date, continuous monitoring of diagnostic intervals in nationwide incident cohorts has been impossible in England. MethodsWe developed a new methodology for measuring the secondary care diagnostic interval (SCDI - first relevant secondary care contact to diagnosis) using linked cancer registration and healthcare utilisation data. Using this method, we subsequently examined diagnostic timeliness in colorectal and lung cancer patients (2014–15) by socio-demographic characteristics, diagnostic route and stage at diagnosis. ResultsThe approach assigned SCDIs to 94.4% of all incident colorectal cancer cases [median length (90th centile) of 25 (104) days] and 95.3% of lung cancer cases [36 (144) days]. Advanced stage patients had shorter intervals (median, colorectal: stage 1 vs 4 - 34 vs 19 days; lung stage 1&2 vs 3B&4 - 70 vs 27 days). Routinely referred patients had the longest (colorectal: 61, lung: 69 days) and emergency presenters the shortest intervals (colorectal: 3, lung: 14 days). Comorbidities and additional diagnostic tests were also associated with longer intervals. ConclusionThis new method can enable repeatable nationwide measurement of cancer diagnostic timeliness in England and identifies actionable variation to inform early diagnosis interventions and target future research.

Diagnostic route is associated with care satisfaction independently of tumour stage: Evidence from linked English Cancer Patient Experience Survey and cancer registration data

BackgroundWhether diagnostic route (e.g. emergency presentation) is associated with cancer care experience independently of tumour stage is unknown. MethodsWe analysed data on 18 590 patients with breast, prostate, colon, lung, and rectal cancers who responded to the 2014 English Cancer Patient Experience Survey, linked to cancer registration data on diagnostic route and tumour stage at diagnosis. We estimated odds ratios (OR) of reporting a negative experience of overall cancer care by tumour stage and diagnostic route (crude and adjusted for patient characteristic and cancer site variables) and examined their interactions with cancer site. ResultsAfter adjustment, the likelihood of reporting a negative experience was highest for emergency presenters and lowest for screening-detected patients with breast, colon, and rectal cancers (OR versus two-week-wait 1.51, 95% confidence interval [CI] 1.24–1.83; 0.88, 95% CI 0.75–1.03, respectively). Patients with the most advanced stage were more likely to report a negative experience (OR stage IV versus I 1.37, 95% CI 1.15–1.62) with little confounding between stage and route, and no evidence for cancer-stage or cancer-route interactions. ConclusionsThough the extent of disease is strongly associated with ratings of overall cancer care, diagnostic route (particularly emergency presentation or screening detection) exerts important independent effects.

Ovarian cancer suspicion, urgent referral and time to diagnosis in Danish general practice: a population-based study.

Ovarian cancer (OC) survival rates are lower in Denmark than in countries with similar health care. Prolonged time to diagnosis could be a contributing factor. The Danish cancer patient pathway (CPP) for OC was introduced in 2009. It provides GPs with fast access to diagnostic work-up. To investigate cancer suspicion and pathway use among GPs and to explore the association between these factors and the diagnostic intervals (DIs). We conducted a national population-based cohort study using questionnaires and national registers. Of the 313 women with participating GPs, 91% presented with symptoms within 1 year of diagnosis, 61% presented vague non-specific symptoms and 62% were diagnosed with late-stage disease. Cancer was suspected in 39%, and 36% were referred to a CPP. Comorbidity [prevalence ratio (PR): 0.53, 95% confidence interval (CI): 0.29-0.98] and no cancer suspicion (PR: 0.35, 95% CI: 0.20-0.60) were associated with no referral to a CPP. The median DI was 36 days. Long DIs were associated with no cancer suspicion (median DI: 59 versus 20 days) and no referral to a CPP (median DI: 42 versus 23 days). Nine in ten patients attended general practice with symptoms before diagnosis. Two-thirds initially presented with vague non-specific symptoms were less likely to be referred to a CPP and had longer DIs than women suspected of cancer. These findings underline the importance of supplementing the CPP with additional accelerated diagnostic routes.

Hematocolpus in two bitches with a history of GnRH treatment to postpone puberty

Two mixed-breed bitches (18 and 19 months), 1 year before treated with deslorelin acetate implant to postpone puberty, were hospitalized and monitored during their first heat. The heat was visible to the owners for the vulvar swelling but in both cases no vulvar bloody discharge was observed. The following diagnostic procedures were employed: physical genital tract examination, vaginoscopy, vaginal cytology, endocrine assay, ultrasound and X ray using vaginal infusion of iodum and pneumobladder as positive and negative contrasts. In bitch 1, vaginal cytology and progesterone levels confirmed the presence of an ovulatory “dry” oestrus. Ultrasound showed preovulatory follicles and, in the following days, transition to corpora lutea. The caudal abdomen presented a large ovoid cystic structure filled with echoic fluid, next to the bladder. Radiographic scans demonstrated a normal bladder profile, while the contrast medium failed to enter into the cranial vagina. On the basis of these findings, the bitch 1 was submitted to laparotomy 10 days after the end of oestrus. A vaginal dilatation (10x5 cm), from which brown fluid was aspirated, was found and resected together with uterus and ovaries. Bitch 2 had the same diagnostic route and findings but was laparotomized 3 months after the heat. During this period no spontaneous regression of the lesion was observed. At laparotomy, the vaginal dilatation (8x4 cm) was only aspirated and the bitch regularly neutered. In both cases, cytology of the fluid taken from the vaginal sac revealed superficial epithelial cells and abundant degenerate red blood cells. Histology (bitch 1) confirmed the vaginal origin of the dilatation and revealed a Gartner duct cyst. The abnormality (hematocolpus) probably originated by an inadequate drainage of proestrous bloody discharge for a vaginal obstruction. A congenital origin of the lesion was unlikely; it was strongly suspected that the treatment of the prepubertal bitches interfered, by an irreversible way, with the normal development of the vagina.

Hypertrophic cardiomyopathy – symptomatic atrial fibrillation in a patient at high risk of sudden cardiac death (RCD code: V-2A.2)

We present the case of a young patient with significant left ventricular hypertrophy as a common representation of the hypertrophic cardiomyopathy (HCM) phenotype. The clinical presentation and diagnostic route of the disease (despite negative genotype), which can be found in everyday cardiology practice, are shown. Despite the presence of guidelines on this topic, each clinical case is demanding, especially during qualification for invasive procedures. Limited data about the periprocedural risk of catheter ablation and success rate in HCM makes physician decisions for this type of patient challenging. The importance of informed consent and how the patient’s decisions affet further progress are also shown. JRCD 2018; 4 (1): 18-21.

Circulating microRNAs combined with PSA for accurate and non-invasive prostate cancer detection.

The dosage of prostate-specific antigen (PSA), an easily evaluable and non-invasive biomarker, has made early detection of prostate cancer (PCa) possible. However, it leads to high percentages of unnecessary biopsies and may miss aggressive tumors in men with PSA levels below 4 ng/ml. Therefore, we propose to combine circulating microRNAs (miRs) with PSA, to improve the diagnostic route for PCa. Plasma miR profiling identified candidate diagnostic miRs in a discovery cohort of 60 tumors and 60 controls (men with benign prostatic hyperplasia or healthy donors). Linear models with an empirical Bayesian approach and multivariate penalized logistic regression were applied to select tumor-associated miRs and/or clinical variables. A classifier was developed and tested on a validation cohort of 68 tumors and 174 controls consecutively collected, where miRs were evaluated by quantitative real-time polymerase chain reaction. A classifier based on miR-103a-3p, let-7a-5p and PSA could detect both overall and clinically significant tumors better than PSA alone, even in 50-69 years aged men with PSA ≤ 4 ng/ml. Even in the validation cohort, the classifier performed better than PSA alone in terms of specificity and positive predictive value, allowing to correctly identify eight out of nine tumors undetected by PSA, including three high-risk and three tumors in 50-69 years old men. Of carriers of non-malignant lesions with PSA in the 4-16 ng/ml interval, who may avoid unnecessary biopsies, 34% were correctly identified. Coupling two circulating miRs with PSA could be a useful strategy to diagnose clinically significant PCa and avoid an important fraction of unnecessary biopsies.

Diagnostic routes and time intervals for patients with colorectal cancer in 10 international jurisdictions; findings from a cross-sectional study from the International Cancer Benchmarking Partnership (ICBP)

ObjectiveInternational differences in colorectal cancer (CRC) survival and stage at diagnosis have been reported previously. They may be linked to differences in time intervals and routes to diagnosis. The International...

Breast cancer detection method, diagnostic interval and use of specialized diagnostic assessment units across Ontario, Canada

Breast cancer is detected through screening or through signs and symptoms. In Canada, mammograms for breast cancer screening are offered in organized programs or independently (opportunistic screening). Province of Ontario breast Diagnostic Assessment Units (DAUs) are facility-based programs that provide coordinated breast cancer diagnostic services, as opposed to usual care, in which the primary care provider arranges the tests and consultations. This study describes breast cancer detection method, diagnostic interval and DAU use across Ontario. The study cohort consisted of 6898 women with invasive breast cancer diagnosed in 2011. We used the Ontario Cancer Registry linked to administrative health care databases. We determined the detection method using the Ontario Breast Screening Program (OBSP) data and physician claims. The diagnostic interval was the time between the initial screen, specialist referral or first diagnostic test and the cancer diagnosis. The diagnostic route (whether through DAU or usual care) was determined based on the OBSP records and biopsy or surgery location. We mapped the diagnostic interval and DAU coverage geographically by women's residence. In 2011, 36% of Ontario breast cancer patients were screen-detected, with a 48% rate among those aged 50 to 69. The provincial median diagnostic interval was 32 days, with county medians ranging from 15 to 65 days. Provincially, 48.4% were diagnosed at a DAU, and this ranged from zero to 100% across counties. The screening detection rate in age-eligible breast cancer patients was lower than published population-wide screening rates. Geographic mapping of the diagnostic interval and DAU use reveals regional variations in cancer diagnostic care that need to be addressed.

Factors associated with the breast cancer diagnostic interval across five Canadian provinces: a CanIMPACT study

IntroductionA long breast cancer diagnostic process can affect patient anxiety and survival. Variations in the length of the diagnostic interval for similar patient presentations can indicate health system inequities and/or inefficiencies.&#x0D; Objectives and ApproachWe describe the breast cancer diagnostic interval across Canada and factors associated with its length.&#x0D; We studied breast cancer patients diagnosed from 2004/7 to 2010/11/12 in the Canadian provinces: British Columbia, Alberta, Manitoba, Ontario, and Nova Scotia. Using administrative data, we created parallel population-based, provincial-level datasets and ran common analyses. The diagnostic interval was defined from the screening mammogram to the diagnosis for screen-led and from the first referral/test ordering date to the diagnosis for diagnostic-led patients. Stratified by these two diagnostic routes, we describe the variation in the interval across provinces and report on the province-specific associations between the diagnostic interval and: patient age, comorbid disease burden, socioeconomic status combined with rural residence, and continuity of primary care while controlling for cancer stage.&#x0D; ResultsThe median diagnostic interval varied by 6 days (29 to 35 days) across provinces. Screen-led patients were diagnosed more quickly (median 2-12 days quicker). The 90th percentile diagnostic interval was 84-126 days longer in diagnostic-led patients. In the diagnostic-led group, increasing comorbid burden was consistently associated with longer diagnostic intervals and being &gt;70 was associated with a shorter interval at the 90th percentile in Manitoba and Ontario. There was no evidence of a clear rural or low socioeconomic status effect and patients without a primary care physician had shorter intervals. In the screen-led group, patients age 40-49 and those in the medium or low income rural areas waited longer for a diagnosis.&#x0D; Conclusion/ImplicationsDiagnostic wait times differ across Canada and are variably associated with comorbidity, age, area-level socioeconomic status and rural residence. These results point to practice and system-level effects that warrant further study.

LESIÓN CENTRAL DE CELULAS GIGANTES EN MANDÍBULA, REPORTE DE CASO

La lesión central de células gigantes multinucleadas (LCCGM), también llamada granuloma central de células gigantes, es&#x0D; de una neoplasia benigna, de evolución lenta y de carácter no odontogénico, que puede presentarse en los huesos maxilares,&#x0D; especialmente la mandibula y se caracteriza por ser asintomático y comúnmente es un hallazgo radiográfico. Este artículo&#x0D; presenta el caso de una paciente de 18 años sin antecedentes médicos de relevancia a quien se le encuentra un defecto&#x0D; radiolúcido a nivel del primer molar inferior izquierdo, el cual se extirpa mediante cirugía bajo anestesia local y se envía&#x0D; a análisis histopatológico resultando compatible con lesión central de células gigantes. El objetivo de este artículo es presentar&#x0D; esta lesión central de células gigantes multinucleadas en mandíbula para ampliar los conocimientos clínicos, radiográficos&#x0D; e histopatológicos para colaborar con nuestros estudiantes y colegas odontólogos, en el buen direccionamiento de lesiones&#x0D; intraóseas de carácter no odontogénico.

Associations between diagnostic pathways and care experience in colorectal cancer: evidence from patient-reported data

ObjectiveTo examine how different pathways to diagnosis of colorectal cancer may be associated with the experience of subsequent care.DesignPatient survey linked to information on diagnostic route.English patients with colorectal cancer...

Determination and diagnostic value of CA9 mRNA in peripheral blood of patients with oral leukoplakia

Background: Oral leukoplakia is one of the most common oral premalignant disorder. The classical evaluation through tissue biopsy is not always valid to evaluate the risk of malignization.Material and methods: RT-qPCR was performed on 47 blood samples (21 patients with leukoplakia, 2 with oral squamous cell carcinoma (OSCC), and 24 healthy patients) and on 11 tissue samples (3 leukoplakia, 4 OSCC, and 4 samples of healthy tissue).Results: There are significant differences in expression between the different groups (F = 4.057, p = .006). The Duncan post hoc test shows that the only group that differentiates is the tumour tissue. Using Wilcoxon test, different covariables of patients with leukoplakia were analysed with respect to the group of healthy patients and no significant differences were observed.Conclusions: The diagnostic route through liquid biopsy has not been conclusive in this study, but there are significant differences in the levels analysed in the different tissue samples.

Chronic prostatitis and small intestinal bacterial overgrowth: is there a correlation?

Background: Clinical management of chronic inflammation of prostate and seminal vesicles is very complex. Among the causes of recurrent chronic prostatitis (CP), a possible malabsorption, such as lactose intolerance, in turn related to small intestinal bacterial overgrowth (SIBO), should be considered. Methods: We have performed lactose and lactulose breath test (BT) in 42 patients with CP, in order to evaluate the prevalence of SIBO in this kind of patients and the concordance of the two tests. Results: A positive lactulose BT was present in 33/42 patients and in 73% (24/33) was associated to lactose malabsorption. Five patients had positive response after lactulose, while only 4 had both negative tests. Conclusions: Our data showed an association between lactose and lactulose BT positivity. They also indicated high prevalence of bacterial colonization of small bowel in patients with CP, possibly related to recurrence or chronicity of genitourinary tract inflammation. The research for these phenomena could be relevant in diagnostic route of infertile patients in whom slight gastro-enteric symptoms can be underestimated.

Structural and immunochemical relatedness suggests a conserved pathogenicity motif for secondary cell wall polysaccharides in Bacillus anthracis and infection-associated Bacillus cereus.

Bacillus anthracis (Ba) and human infection-associated Bacillus cereus (Bc) strains Bc G9241 and Bc 03BB87 have secondary cell wall polysaccharides (SCWPs) comprising an aminoglycosyl trisaccharide repeat: →4)-β-d-ManpNAc-(1→4)-β-d-GlcpNAc-(1→6)-α-d-GlcpNAc-(1→, substituted at GlcNAc residues with both α- and β-Galp. In Bc G9241 and Bc 03BB87, an additional α-Galp is attached to O-3 of ManNAc. Using NMR spectroscopy, mass spectrometry and immunochemical methods, we compared these structures to SCWPs from Bc biovar anthracis strains isolated from great apes displaying “anthrax-like” symptoms in Cameroon (Bc CA) and Côte d’Ivoire (Bc CI). The SCWPs of Bc CA/CI contained the identical HexNAc trisaccharide backbone and Gal modifications found in Ba, together with the α-Gal-(1→3) substitution observed previously at ManNAc residues only in Bc G9241/03BB87. Interestingly, the great ape derived strains displayed a unique α-Gal-(1→3)-α-Gal-(1→3) disaccharide substitution at some ManNAc residues, a modification not found in any previously examined Ba or Bc strain. Immuno-analysis with specific polyclonal anti-Ba SCWP antiserum demonstrated a reactivity hierarchy: high reactivity with SCWPs from Ba 7702 and Ba Sterne 34F2, and Bc G9241 and Bc 03BB87; intermediate reactivity with SCWPs from Bc CI/CA; and low reactivity with the SCWPs from structurally distinct Ba CDC684 (a unique strain producing an SCWP lacking all Gal substitutions) and non-infection-associated Bc ATCC10987 and Bc 14579 SCWPs. Ba-specific monoclonal antibody EAII-6G6-2-3 demonstrated a 10–20 fold reduced reactivity to Bc G9241 and Bc 03BB87 SCWPs compared to Ba 7702/34F2, and low/undetectable reactivity to SCWPs from Bc CI, Bc CA, Ba CDC684, and non-infection-associated Bc strains. Our data indicate that the HexNAc motif is conserved among infection-associated Ba and Bc isolates (regardless of human or great ape origin), and that the number, positions and structures of Gal substitutions confer unique antigenic properties. The conservation of this structural motif could open a new diagnostic route in detection of pathogenic Bc strains.

A novel pathogenic variant in the FZD6 gene causes recessive nail dysplasia in a large Iranian kindred

BackgroundNail disorder nonsyndromic congenital (NDNC) is a very rare clinically and genetically heterogeneous disease inherited both in recessive or dominant modes. FZD6 is a component of Wnt-FZD signaling pathway in which recessive loss-of-function variants in the corresponding genes could lead to nail anomalies. ObjectiveA large multiplex family with NDNC was referred for genetic counselling. Thorough genetic evaluation was performed. MethodsPCR-Sanger sequencing was carried out for the coding exons and exon-intron boundaries of the FZD6 gene. Co-segregation analysis, in silico evaluation and computational protein modeling was accomplished. ResultsA homozygous 1bp deletion variant, c.1859delC (p.Ser620Cysfs*75), leading to a truncating protein was found in the patient. Parents were heterozygous for the variant. The variant was found to be co-segreagting with the phenotype in the family. Computational analysis and protein modeling revealed its pathogenic consequence by disturbing the cytoplasmic domain structure and signaling through loss of phosphorylation residues. The variant met the criteria of being pathogenic according to the ACMG guideline. ConclusionsThis is the first report of the genetic diagnosis of NDNC in Iran. We also report a novel pathogenic variant. The study of the FZD6 gene is recommended as the first step in the diagnostic routing of the autosomal recessive NDNC patients with enlarged nails.

L’ambulatorio di medicina del lavoro nel Dipartimento di prevenzione delle USL, dalla riforma sanitaria ad oggi: continuità del mandato in un mutato contesto sociale ed epidemiologico

Aims and Tasks provided by the Health Reform Act in 1978 and entrusted to the Health and Safety local Units are still in force. Their validity is confirmed and the change in their organization, due to a variation of the social context, as well as the evolution of clinical and epidemiological profile of occupational diseases are analysed. In particular the need of an improved diagnostic route, an accurate estimate of past exposures reconstruction and the exposure-risk correlation are stressed. Occupational physicians are nowadays facing with delicate judgements of working fitness given the ageing of the working population. In these contexts Public Health Services should be a solid point of reference for occupational physicians, workers and companies. The experience of the Health and Safety Unit in Florence, adjusted to the new challenges in occupational healthcare activity. is described. Some indicators like number of examinations, occupational diseases diagnosed and relationships with other specialized physicians and prevention campaigns encourage to carry on with the mission.

COLLABORADI: a rule-based diagnostic imaging prescription system to help the general practitioner to choose the most appropriate radiological imaging procedures.

Significant advances in medical imaging have been made in the past decades, enabling physicians to reach high precision in diagnosing patients' diseases by means of sophisticated imaging tools. However, the use of sophisticated tools is limited by the high costs and, in some cases, by the utilization of ionizing radiation, which have both great impact on the economy of a nation and on citizens' health, respectively. Guidelines have been published among countries to provide physicians with structured rules to be followed to suggest the correct imaging technique, suiting better the diagnostic question and avoiding inappropriate imaging requests. The COLLABORADI is a research project that addressed the phenomenon of inappropriate imaging prescriptions in Sicily (Italy) and proposed the design and implementation of a clinical decision support system to help physicians to set up the most appropriate diagnostic route for their patients. The aim of this paper is to describe the characteristics of the COLLABORADI software and its potential impact in diminishing inappropriate imaging.