Excess liver-related mortality among people with AIDS compared to the general population: an Italian nationwide cohort study using multiple causes of death.

OBJECTIVES: Liver diseases have become a leading cause of death among people with AIDS (PWA). This study aimed to investigate whether PWA experienced excess mortality related to liver diseases as compared to the general population (non-PWA), using a multiple cause of death (MCoD; i.e. all conditions reported on death certificates) approach. METHODS: A population-based, nationwide, retrospective cohort study was conducted among Italian people, aged 15-74 years, who had been diagnosed with AIDS since 2006. Date of death and MCoD data were retrieved, up to December 2015, by individual record linkage with national mortality data. Sex- and age-standardized mortality ratios (SMRs), with 95% confidence intervals (CIs), were estimated by dividing the observed number of deaths related to a specific condition among PWA to the expected number, based on non-PWA mortality rates. RESULTS: Among 7912 PWA (34 184 person-years), 2076 deaths occurred. The number of death certificates reporting liver diseases among MCoDs was 583 (28.1%), including 382 (18.4%) reporting viral hepatitis, 370 (17.8%) reporting nonviral liver diseases, and 41 (2.0%) reporting liver cancers. The corresponding SMRs were 40.4 (95% CI 37.2-43.8) for all liver diseases, 131.1 (95% CI 118.3-145.0) for viral hepatitis, 29.9 (95% CI 27.0-33.1) for nonviral liver diseases, and 11.2 (95% CI 8.1-15.3) for liver cancers. Particularly elevated SMRs emerged among PWA aged 15-49 years and those infected by injecting drug use. CONCLUSIONS: The high excess liver-related mortality observed among PWA warrants preventive actions to limit the burden of viral hepatitis coinfections, alcohol abuse, and metabolic disorders, especially among younger PWA and injecting drug users.

The main causes of death contributing to absolute and relative socio-economic inequality in Italy.

OBJECTIVES: Monitoring socio-economic inequality has become a priority for many governments, especially after the socio-economic changes that followed the 2008 financial crisis. This study aimed at detecting the causes of death with the largest socio-economic inequality in relative and absolute terms in Italy. STUDY DESIGN: This is a historical cohort study. METHODS: We used two regression-based measures of socio-economic inequality, the relative index of inequality (RII) and the slope index of inequality (SII), to rank the causes of death with the highest relative and absolute socio-economic inequality. We obtained these measures on a large census-based cohort study with more than 35 million individuals and 452,273 deaths registered in the period 2012-2014. RESULTS: The causes with the highest relative socio-economic inequality were the following: laryngeal cancer (RII: 6.1, 95% confidence interval [CI]: 4.8-7.78), AIDS/HIV (RII: 4.8, 95% CI: 3.1-7.4), chronic liver disease (RII: 4.8, 95% CI: 3.2-7.3), and chronic lower respiratory diseases (RII: 4.8, 95% CI: 3.5-6.5) in men, and diabetes (RII: 6.2, 95% CI: 4.8-7.9), AIDS/HIV (RII: 4.5, 95% CI: 2.7-7.7), genitourinary system (RII: 3.8, 95% CI: 2.6-5.4) and chronic liver diseases (RII: 3.6, 95% CI: 2.9-4.5) in women. In absolute terms, lung cancer and ischemic heart diseases contributed more to the overall socio-economic inequality in men, whereas diabetes and ischemic heart diseases accounted for most of the socio-economic inequality in women. CONCLUSIONS: Our findings call for effective policies to reduce the disparities in mortality from ischemic heart diseases, lung cancer, and diabetes taking into account the sex-specific pattern of inequality.

The persistent problem of late HIV diagnosis in people with AIDS: a population-based study in Italy, 1999-2013.

OBJECTIVES: Despite the wide accessibility to free human immunodeficiency virus (HIV) testing and combined antiretroviral therapy (cART), late HIV diagnosis remains common with severe consequences at individual and population level. This study aimed to describe trends of late HIV testing and to identify their determinants in the late cART era in Italy. STUDY DESIGN: We conducted a population-based, nationwide analysis of the Italian National AIDS Registry data (AIDS - acquired immune deficiency syndrome) for the years 1999-2013. METHODS: Late testers (LTs) were defined as people with AIDS (PWA) whose first HIV-positive test preceded AIDS diagnosis by 3 months or less. Odds ratios (ORs) with the corresponding 95% confidence intervals (CIs) were estimated to examine factors associated with being LTs. Joinpoint analysis was used to estimate annual percent changes (APCs) of LTs' proportion over time. RESULTS: Among 20,753 adult PWA, 50.8% were LTs. Italian PWA showed a lower proportion of LTs than non-Italian PWA (46.5% vs 68.2%). Among Italian PWA, the odds of being LTs was higher in men than in women (OR = 2.62, 95% CI: 2.38-2.90); in the age groups below 35 years and over 49 years at diagnosis (OR = 1.24, 95% CI: 1.12-1.37 and OR = 1.51, 95% CI: 1.38-1.67, respectively) vs PWA aged 35-49 years; and in those infected through sexual contact as compared with injecting drug use (OR = 13.34, 95% CI: 12.06-14.76 for heterosexual contact and OR = 8.13, 95% CI: 7.30-9.06 for male-to-male sexual contact). The proportion of LTs increased over time among Italians, especially in the latest period (APC2006-2013 = 5.3, 95% CI: 3.8-6.9). The LTs' proportion resulted higher, though stable, among PWA aged ≥50 years. Conversely, an increasing trend was observed among PWA aged 18-34 years (APC = 5.3, 95% CI: 4.5-6.1). The LTs' proportion was persistently higher among PWA who acquired HIV infection through sexual contact, even if a marked increase among injecting drug users was observed after 2005 (APC = 11.4, 95% CI: 5.7-17.5). CONCLUSIONS: The increasing trend of LTs' proportion in the late cART era highlights the need of new strategies tailored to groups who may not consider themselves to be at a high risk of infection. Active promotion of early testing and continuous education of infection, especially among young people, need to be implemented.

Cause-specific mortality in classic Kaposi's sarcoma: a population-based study in Italy (1995-2002).

BACKGROUND: Little information is available on the causes of death among persons with classic Kaposi's sarcoma (CKS). METHODS: We conducted a population-based study in Italy to identify deceased persons with CKS and the underlying causes of death among them, by reviewing multiple-causes-of-death records. Standardised mortality ratios (SMRs) and 95% confidence intervals were calculated to compare the distribution of causes to that among the same-age general population of deceased persons. The geographical distribution was also evaluated. RESULTS: Of the 946 deaths among persons with CKS, 65.9% were attributable to non-neoplastic conditions and 21.9% to malignancies. For 12.2%, no lethal pathology was identified and CKS was considered as the underlying cause. In 90% of these cases, there was visceral/nodal involvement, therapy-related complications, or neoplastic cachexia. Among persons with CKS who died of other causes, an excess for lymphoid malignancies emerged (SMR=4.40) (chronic lymphocytic leukaemia (11.03), non-Hodgkin's lymphoma (4.22), Hodgkin's lymphoma (11.80), and multiple myeloma (2.3)), balanced by a deficit for all solid cancers (0.56), with a marked deficit for lung cancer (0.41). We found an excess for respiratory diseases (chronic obstructive pulmonary disease (1.86)) and genitourinary diseases (chronic renal failure (6.47)). There was marked geographical heterogeneity in the distribution of deaths. CONCLUSIONS: Though referring specifically to Italy, the results are informative for other countries and populations and all cases of CKS in general.

Estimating population-based incidence and prevalence of major coronary events.

Population-based data on major coronary events (MCE) are generally lacking for large areas, such as at the nationwide level. While mortality data are currently and exhaustively collected in all developed countries and in most developing countries, incidence and prevalence are often available only for certain subgroups of the population under study. We propose a mathematical method to estimate incidence and prevalence using morality and survival data as input, and to forecast MCE occurrence using an age, period, and cohort approach. An application of the method is given to reconstruct incidence and prevalence of MCE in Italy from 1970 to 1990 and to project trends up to the year 2000. MCE incidence has been decreasing since 1974, four years before the observed mortality decline. Conversely, prevalence continues to increase up to the middle of the 1980, and declines thereafter.

Estimation and projections of colorectal cancer trends in Italy.

BACKGROUND: Occurrence of and prognosis for tumours of the colon and rectum are thought to be changing rapidly due to simultaneous changes in risk factor prevalence, early diagnosis and treatment. In this paper time trends of morbidity, survival and mortality for colorectal cancer during the period 1970-1990 are estimated and analysed. METHODS: Mortality trends were obtained from official death certificates. Relative survival rates were computed from population-based cancer registries. Incidence and prevalence rates were estimated from mortality and survival data. RESULTS: Incidence rates were increasing during the period considered, with a lower rate of increase for the youngest birth cohorts. Relative survival rates of both colon and rectum cancers were higher for women, and for younger age groups, and were positively associated with period of diagnosis. No significant survival difference among the cancer registries used was found. A total of about 155,000 prevalent cases, 40% of which had been diagnosed > or = 7 years before, were estimated in the Italian population for the year 1990. Mortality rates were slightly increasing for men and stable for women. Projections of colorectal cancer trends to the year 2000 indicate major expected rises in both incidence and prevalence. CONCLUSION: Colorectal cancer represents a problem of growing impact for health services in Italy. This conclusion can probably be extended to many developed countries.

Incidence, mortality and prevalence of stomach cancer in Italian regions.

The basic descriptive epidemiologic data on stomach cancer occurrence in Italian regions are presented and discussed. Incidence and prevalence were estimated from official mortality and survival data provided by four population-based Italian cancer registries. Age-adjusted mortality, incidence, and prevalence rates are presented by region for the year 1990. Time trends of incidence and their projection for the year 2000 are also presented by region and three broad age classes. Although the occurrence of stomach cancer has been decreasing in Italy and most western countries over the last decades a substantial slowing down of this decrease was evidenced in Italy, especially for women under 65 and for the regions of southern Italy. A marked tendency towards a reduction of geographic heterogeneity in stomach cancer occurrence was also shown. Such a phenomenon is consistent with the observed changes of dietary habbits in Italian regions. The regions of Umbria and The Marches seem to emerge as new areas at relatively high risk of stomach cancer incidence and mortality. About 45,000 prevalent cases were estimated in Italy by 1990, half of which have been diagnosed before 1984.

Trends of colorectal cancer incidence and prevalence in Italian regions.

Incidence and prevalence of tumors of colon and rectum, estimated from mortality and survival data, are presented for Italian regions and for the period 1970-1990. Projected rates to the year 2000 are also given. Age-standardized incidence rates have increased during the considered period. The increase has been higher for southern regions, which had, during the 70's, the lowest incidence and mortality levels. Geographic heterogeneity of colorectal cancer occurrence across Italian regions is therefore decreasing. The phenomenon parallels a tendency towards the homogenization of dietary habits observed in the Italian population. Estimated incidence levels increased less for the younger generation and appear stable for people born after 1940. More than 150,000 prevalent cases were estimated by the year 1990. The number is likely to increase owing to the simultaneous increasing tendency in incidence and survival rates.

MIAMOD: a computer package to estimate chronic disease morbidity using mortality and survival data.

The MIAMOD package is for use in epidemiological analysis of chronic degenerative diseases. The package has been designed to use survival and mortality data supplied by the user, to estimate incidence and prevalence rates, to forecast future mortality and morbidity levels and to provide life tables. Estimates are derived by modelling incidence as an age-period-cohort function and by the equations relating specific cause mortality and prevalence to incidence and survival. The model parameters are evaluated by fitting mortality data by means of a weighted non-linear regression model. Numerical and statistical methods used to solve the regression and to compute standard errors, projections, and life tables are discussed. The program is written in standard FORTRAN 77 and runs on a mainframe computer. The different program units are illustrated together with the principal implementation options. An example of application is provided to show a typical output pattern.

[Use of mortality statistics for the study of the distribution of digestive system tumors: characteristics and quality of the data]. / Uso delle statistiche di mortalità per lo studio della diffusione dei tumori dell'apparato digerente: caratteristiche e qualità dei dati.

We present an evaluation of the accuracy of death certificates in Italy for patients with cancers of the digestive apparatus in Italy: oral cavity and pharynx, oesophagus, stomach, colon rectum, liver, bilious ducts, pancreas. The diagnosis reported on death certificates is compared to post mortem examinations, diagnoses histologically confirmed, clinical and cancer registry records. For oropharynx cancer mortality data available from official statistics are underreported when compared to cancer registry data. The oesophagus presents misclassification problems with gastric cancer. Mortality data of stomach cancer show a good agreement with incidence and mortality data from cancer registries. No major differences are revealed among the various sources for colorectal cancer mortality. On the contrary the separate analysis of colon and rectum evidentiates diagnostical difficulties in identifying the primary site of intestinal cancers. Cancers of liver, bilious ducts and pancreas have a low percentage of cases with histological confirm and a high frequency of death certificate only (DCO) due to diagnostical difficulties.

[Incidence and prevalence of digestive system tumors in Italy: estimates from mortality data]. / Incidenza e prevalenza dei tumori dell' apparato digerente in Italia: stime dai dati di mortalità.

This work presents estimates and middle-term projections of incidence and prevalence levels in Italy for cancers of the oral cavity and pharynx, of the stomach, and of colon and rectum. The estimation procedure was previously validated using incidence data observed by Italian cancer registries operating in limited geographical areas. Projections up to the year 2000 of mortality, incidence, and prevalence rates and estimated cohort effects are reported for stomach and colorectal cancers only. For both cancer sites, cohort effects, rather than period effects, result to be responsible for mortality and incidence dynamics. Incidence levels show a general decreasing trend for stomach cancer and an increasing one for colorectal cancer. Cumulative risk trend tends, however, to level-off for the youngest cohorts. Moreover, the well known geographical differences between the North and the South of the country seem to be progressively reducing.

[Hormone replacement therapy and cardiovascular diseases: different populations, different risks]. / Terapia ormonale sostitutiva e malattie cardiovascolari: popolazioni differenti, rischi differenti.

Observational studies indicate that oral hormone replacement therapy (HRT) in menopause is associated with a 20-40% reduction of coronary risk. Population risk/benefit analyses on mortality after large-scale HRT use indicate that excess deaths can be counted when coronary heart disease is relatively less frequent than breast cancer before age 60 (as occurs in Italy). The decline in mortality trends for coronary heart disease support a word for caution for a large scale use of HRT in the next years even in those populations for which a relative advantage is presently estimated.

[Evolution of voluntary interruption of pregnancy in Italy from its legalization until today]. / L'evoluzione dell'interruzione volontaria di gravidanza in Italia dalla legalizzazione ad oggi.

Induced abortion was legalized in Italy in 1978. After an initial increase in the incidence, from 187,631 in 1979 to 234,801 in 1983, induced abortion has steadily decreased to 140,398 in 1996. Analysis of the abortion rates has shown that the main decrease has been among married women aged 25-35, while there has been an increase among unmarried women. Women with lower levels of education tend to have higher rates and housewives have higher rates than women in paid work. Programmes for the prevention of induced abortion should be directed at directed at easily accessible groups: women who have just delivered a baby, couples who marry, teenagers in school and women who have already had an induced abortion. In any case, the need for rationalisation of the procedure to obtain an induced abortion is urgent.

Large-scale hormone replacement therapy and life expectancy: results from an international comparison among European and North American populations.

OBJECTIVES: An analysis was performed to determine the risks and benefits of a 10-year hormone replacement therapy regimen that had been applied to all women at 50 years of age in 8 countries. METHODS: Cumulative mortality with and without hormone replacement therapy over 20 years was estimated, with both current and predicted total and disease-specific secular mortality trends and the influence of a generational cohort effect taken into account. RESULTS: In countries with high ischemic heart disease frequency and predictable relative predominance of ischemic heart disease rates over breast cancer rates for the next 20 years, hormone replacement therapy could result in benefits with regard to overall mortality; this advantage decreases in younger-generation cohorts. In countries in which breast cancer mortality predominates over ischemic heart disease in early postmenopause and in which the predictable trends for both diseases reinforce this condition, a negative effect on overall mortality would be observed. In the United States, the effect of large-scale hormone replacement therapy would change over time. CONCLUSIONS: The long-term effect of hormone replacement therapy on life expectancy of postmenopausal women may vary among countries.

Estimation and projections of stomach cancer trends in Italy.

Mortality data from official sources, and survival data from population-based cancer registries, are used for the estimation of incidence and prevalence of stomach cancer. Time trends of morbidity, survival, and mortality during the period 1970-90 are presented and analyzed. Incidence rates were decreasing during the considered period, but the rate of decrease was slowing down during the last decade. Almost stable rates, and even slightly increasing for women, were estimated for the youngest cohorts. Relative survival for stomach cancer was higher for women and for young ages; it was associated positively with period of diagnosis, and presented a significant South-North geographic gradient. Prevalence was estimated as decreasing during the period 1970-80, but increasing during the successive decade, due to both better survival and population aging. Projection of stomach cancer morbidity and mortality to the year 2000 showed that the disease should still be considered in Italy as a major public health problem.

Childhood Acute Lymphoblastic Leukemia: A Cluster in Southwestern Sardinia (Italy).

In response to public concern about an increase in the incidence of leukemia among children in southwestern Sardinia (Italy), incident cases of childhood cancer (ages 0-14) were ascertained among residents in the province of Cagliari, which comprises all of southern Sardinia, in 1974-89. Completeness of the ascertainment of leukemia cases was validated by comparison with estimates derived from official statistics of mortality and survival curves. A significant excess risk of childhood acute lymphoblastic leukemia (cALL) was found for children residing in the town of Carbonia. The risk was highest in 1983-85, when seven cases occurred versus 0.8 expected. No birth-cohort effect was observed. The cALL incidence rate was significantly higher among children born and residing in Carbonia than among children born in Carbonia but residing elsewhere. However, the cALL cases did not cluster within the town of Carbonia. The proximity of the largest industrial settlement in the region of Sardinia raised the suspicion that environmental pollution was responsible for the observed excess. Information about industrial emissions from this settlement prior to the appearance of the cALL cluster was not sufficient to reject or confirm the hypothesis.