Cancer mortality in Common Mental Disorders: A 10-year retrospective cohort study.

PURPOSE: Individuals with Common Mental Disorders (CMDs) may have a higher cancer mortality. The purpose of this study was to examine cancer-related mortality among patients with CMDs and verify which cancer types are predominantly involved. METHODS: We used the Regional Mental Health Registry of the Emilia-Romagna region, in Northern Italy to identify patients aged ≥ 18 years who received an ICD 9-CM diagnosis of CMDs (i.e., depressive and neurotic disorders) over a 10 year period (2008-2017). Information on cause of death was retrieved from the Regional Cause of Death Registry. Comparisons were made with data from the regional population without CMDs. RESULTS: Among 101,487 patients suffering from CMDs (55.7% depression; 44.3% neurotic disorders), 3,087 (37.8%) died from neoplasms. The total standardized mortality ratio (SMR) was 1.82 (95% CI 1.78-1.86) while the SMR for all neoplasms was 2.08 (95% CI 2.01-2.16). Individuals of both genders, with both depressive and neurotic disorders had a higher risk of death from almost all cancers compared with the regional population. CONCLUSION: Patients with CMDs have considerably higher cancer mortality risk than the general population. Higher mortality was observed for a broad range of cancers associated with different aetiologies. It is imperative to promote cancer awareness, prevention and treatment for people with CMDs.

Risk of SARS-CoV-2 infection, hospitalization and death for COVID-19 in people with Parkinson's disease or parkinsonism over a 15-month period: a cohort study.

BACKGROUND: The patterns of long term risk of SARS-CoV-2 infection, hospitalization for COVID-19 and related death are uncertain in people with Parkinson's disease (PD) or parkinsonism (PS). The aim of the study was to quantify these risks compared to a control population cohort, during the period March 2020-May 2021, in Bologna, northern Italy. METHOD: ParkLink Bologna cohort (759 PD; 192 PS) and controls (9,226) anonymously matched (ratio 1:10) for sex, age, district, comorbidity were included. Data were analysed in the whole period and in the two different pandemic waves (March-May 2020 and October 2020-May 2021). RESULTS: Adjusted hazard ratio of SARS-CoV-2 infection was 1.3 (95% CI 1.04-1.7) in PD and 1.9 (1.3-2.8) in PS compared to the controls. The trend was detected in both the pandemic waves. Adjusted hazard ratio of hospitalization for COVID-19 was 1.1 (95% CI 0.8-1.7) in PD and 1.8 (95% CI 0.97-3.1) in PS. A higher risk of hospital admission was detected in PS only in the first wave. The 30-day mortality risk after hospitalization was higher (p=0.048) in PS (58%) than in PD (19%) and controls (26%). CONCLUSIONS: Compared with controls, after adjustment for key covariates, people with PD and PS showed a higher risk of SARS-CoV-2 infection throughout the first 15 months of the pandemic. COVID-19 hospitalization risk was increased only in people with PS and only during the first wave. This group of patients was burdened by a very high risk of death after infection and hospitalization.

Mortality from cancer in people with severe mental disorders in Emilia Romagna Region, Italy.

OBJECTIVE: To examine cancer-related mortality in patients with severe mental disorders (SMI) in the Emilia Romagna (ER) Region, Northern Italy, during the period 2008-2017 and compare it with the regional population. METHODS: We used the ER Regional Mental Health Registry identifying all patients aged ≥18 years who had received an ICD-9CM system diagnosis of SMI (i.e., schizophrenia or other functional psychosis, mania, or bipolar affective disorders) during a 10-year period (2008-2017). Information on deaths (date and causes of death) were retrieved through the Regional Cause of Death Registry. Comparisons were made with the deaths and cause of deaths of the regional population over the same period. RESULTS: Amongst 12,385 patients suffering from SMI (64.1% schizophrenia spectrum and 36.9% bipolar spectrum disorders), 24% (range 21%-29%) died of cancer. In comparison with the general regional population, the mortality for cancer was about 50% higher among patients with SMI, irrespective if affected by schizophrenia or bipolar disorders. As for the site-specific cancers, significant excesses were reported for stomach, central nervous system, respiratory, and pancreas cancer with a variability according to psychiatric diagnosis and gender. CONCLUSIONS: Patients suffering from SMI had higher mortality risk than the regional population with some differences according to cancer type, gender, and psychiatric diagnosis. Proper cancer preventive and treatment interventions, including more effective risk modification strategies (e.g., smoking cessation, dietary habits) and screening for cancer, should be part of the agenda of all mental health departments in conjunction with other health care organizations, including psycho-oncology.

Perceived work ability at return to work in women treated for breast cancer: a questionnaire-based study.

BACKGROUND: Breast cancer survivors often perceive reduced work ability upon returning to work. OBJECTIVES: To identify predictors of perceived reduced work ability following return to work among women treated for breast cancer and to describe workplace interventions and support after returning to work. METHODS: A questionnaire was sent to 18-65 years-old women (no. 1578) treated for breast cancer and residing in the catchment area of the Bologna Local Health Authority between 2010 and 2012. The study population was identified through a Hospital Discharge Database. The questionnaires included items about personal characteristics, cancer and work-related factors, perceived work ability and the return to work process. A multivariable logistic regression analysis was performed to identify predictors of reduced work ability upon returning to work. RESULTS: Among the 841 respondents, 503 questionnaires were evaluable. In the study, 43.5% of the respondents reported reduced work ability with respect to the pre-diagnosis period. Reduced work ability was more common in non-cohabiting (OR=1.81, 95%CI 1.10-2.98) than in cohabiting/married women, and after mastectomy (OR=2.77, 95%CI 1.26-6.11) than after breast-conserving surgery. Office staff/sales assistants and managers were less likely to report reduced work ability (OR=0.51, 95%CI 0.30-0.88 and OR=0.21, 95%CI 0.06-0.76, respectively) than labourers. Women who perceived reduced work ability reported more frequently adjustment of work assignments, consultation of an occupational physician, insufficient support from employers and colleagues and discrimination. CONCLUSIONS: Reduced work ability is commonly perceived among women who return to work after treatment for breast cancer. Occupational physicians and general practitioners should be aware of a wide range of factors influencing this perception in order to facilitate a successful return to work.

[Development of a predictive model of death or urgent hospitalization to identify frail elderly]. / Sviluppo di un modello predittivo di decesso o ricovero d'urgenza per l'individuazione degli anziani fragili.

OBJECTIVES: to develop and validate a predictive model of mortality or emergency hospitalization in all subjects aged 65 years and over. DESIGN: cohort study based on 9 different databases linked with each other. SETTING AND PARTICIPANTS: the model was developed on the population aged 65 years and over resident at 01.01.2011 for at least two years in the city of Bologna (Emilia-Romagna Region, Northern Italy); 96,000 persons were included. MAIN OUTCOME MEASURES: the outcome was defined in case of emergency hospitalization or death during the one-year follow-up and studied with a logistic regression model. The predictive ability of the model was evaluated by using the area under the Roc curve, the Hosmer-Lemeshow test, and the Brier score in the derivation sample (2/3 of the population). These tests were repeated in the validation sample (1/3 of the population) and in the population of Bologna aged 65 years and over on 01.01.2012, after applying the coefficients of the variables obtained in the derivation model. By using the regression coefficients, a frailty index (risk score) was calculated for each subject later categorized in risk classes. RESULTS: the model is composed of 28 variables and has good predictive abilities. The area under the Roc curve of the derivation sample is 0.77, the Hosmer-Lemeshow test is not significant, and the Brier score is 0.11. Similar performances are obtained in the other two samples. With increasing risk class, the mean age, number of hospitalizations, emergency room service consultations, and multiple drug prescriptions increase, while the average income decreases. CONCLUSION: the model has good predictive ability. The frailty index can be used to support a proactive medicine and stratify the population, plan clinical and preventive activities or identify the potential beneficiaries of specific health promotion projects.

Determinants of cesarean delivery: a classification tree analysis.

BACKGROUND: Cesarean delivery (CD) rates are rising in many parts of the world. To define strategies to reduce them, it is important to identify their clinical and organizational determinants. The objective of this cross-sectional study is to identify sub-types of women at higher risk of CD using demographic, clinical and organizational variables. METHODS: All hospital discharge records of women who delivered between 2005 and mid-2010 in the Emilia-Romagna Region of Italy were retrieved and linked with birth certificates. Sociodemographic and clinical information was retrieved from the two data sources. Organizational variables included activity volume (number of births per year), hospital type, and hour and day of delivery. A classification tree analysis was used to identify the variables and the combinations of variables that best discriminated cesarean from vaginal delivery. RESULTS: The classification tree analysis indicated that the most important variables discriminating the sub-groups of women at different risk of cesarean section were: previous cesarean, mal-position/mal-presentation, fetal distress, and abruptio placentae or placenta previa or ante-partum hemorrhage. These variables account for more than 60% of all cesarean deliveries. A sensitivity analysis identified multiparity and fetal weight as additional discriminatory variables. CONCLUSIONS: Clinical variables are important predictors of CD. To reduce the CD rate, audit activities should examine in more detail the clinical conditions for which the need of CD is questionable or inappropriate.

Does breast cancer screening level health inequalities out? A population-based study in an Italian region.

BACKGROUND: Although population-based screening has the potential to reduce inequalities in breast cancer survival, evidence on this topic is controversial. The objective of this study was to evaluate whether the full implementation of a mammography screening programme in Emilia-Romagna in Italy had an impact on variations in breast cancer survival by educational level. METHODS: A cohort study was performed, including all women <70 years and residing in Emilia-Romagna who had infiltrating breast cancer registered in 1997-2000 (transitional screening period) or 2001-03 (consolidation screening period). Cancer cases were retrieved from the regional Breast Cancer Registry and followed up for 5 years. Educational level was determined from census data and allocated to cancer cases by individual record linkage. Age at diagnosis was classified into two groups (30-49, 50-69: screening target population). RESULTS: A total of 9639 cases were analyzed. In the 1997-2000 period, low-educated women had significantly lower survival compared with high-educated women, both in the younger and in the older age-groups. After the full implementation of the screening programme, these differences decreased in both age-groups, until disappearing completely among women in the age-group invited to screening. CONCLUSIONS: Our findings suggest that a fee-free population-based organized mammography screening programme with active invitation of the whole target population could be effective in reducing differences in survival in the population targeted by the screening.

Risk adjustment for cesarean delivery rates: how many variables do we need? An observational study using administrative databases.

BACKGROUND: Various studies indicate that inter-hospital comparisons have to take case mix into account and that risk adjustment procedures are necessary to control for potential predictors of cesarean delivery (CD). Different data sources have been used to retrieve information on potential predictors of CD. The aim of this study was to compare the discrimination capacity and fit of predictive models of CD created using different sources and to assess whether more complex models improve inter-hospital comparisons. METHODS: We created 4 predictive models of CD. One model included only variables from Hospital Discharge Records of the index hospitalization, one included also information from previous hospitalizations, one also clinical variables from birth certificates (BC) and one also socio-demographic variables. We compared the four models using the Receiver Operator Curve and the Akaike and Bayesian Information Criteria. RESULTS: Information from Birth Certificates improved the discrimination and model fit. Adding socio-demographic variables or past comorbidities did not improve the discrimination capacity or the model fit. Hospital-specific CD resulting from the models were highly correlated. CONCLUSIONS: Record linkage improves the performance of the models but does not affect inter-hospital comparisons.

[Air pollution and mortality in twenty-five Italian cities: results of the EpiAir2 Project]. / Inquinamento atmosferico e mortalità in venticinque città italiane: risultati del progetto EpiAir2.

OBJECTIVES: this study aims at presenting the results from the Italian EpiaAir2 Project on the short-term effects of air pollution on adult population (35+ years old) in 25 Italian cities. DESIGN: the short-term effects of air pollution on resident people died in their city were analysed adopting the time series approach. The association between increases in 10µg/m(3) in PM10, PM2.5, NO2 and O3 air concentration and natural, cardiac, cerebrovascular and respiratory mortality was studied. City-specific Poisson models were fitted to estimate the association of daily concentrations of pollutants with daily counts of deaths. The analysis took into account temporal and meteorological factors to control for potential confounding effect. Pooled estimates have been derived from random effects meta-analysis, evaluating the presence of heterogeneity in the city specific results. SETTING AND PARTICIPANTS: it was analysed 422,723 deaths in the 25 cities of the project among people aged 35 years or more, resident in each city during the period 2006-2010. MAIN OUTCOME MEASURES: daily counts of natural, cardiac, cerebrovascular, and respiratory mortality, obtained from the registries of each city. Demographic information were obtained by record linkage procedure with the civil registry of each city. RESULTS: mean number of deaths for natural causes ranged from 513 in Rovigo to 20,959 in Rome. About 25% of deaths are due to cardiac diseases, 10% to cerebrovascular diseases, and 7% to respiratory diseases. It was found an immediate effect of PM10 on natural mortality (0.51%; 95%CI 0.16-0.86; lag 0-1). More relevant and prolonged effects (lag 0-5) have been found for PM2.5 (0.78%; 95%CI 0.12-1.46) and NO2 (1.10%; 95%CI 0.63-1.58). Increases in cardiac mortality are associated with PM10 (0.93%; 95%CI 0.16-1.70) and PM2.5 (1.25%; 95%CI 0.17-2.34), while for respiratory mortality exposure to NO2 has an important role (1.67%; 95%CI 0.23-3.13; lag 2-5), as well as PM10 (1.41%; 95%CI - 0.23;+3.08). Results are strongly homogeneous among cities, except for respiratory mortality. No effect has been found for cerebrovascular mortality and weak evidence of association has been observed between ozone and mortality. CONCLUSIONS: a clear increase in mortality associated to air pollutants was observed. More important are the effects of NO2 (on natural mortality), mostly associated with traffic emissions, and of PM2.5 (on cardiac and respiratory mortality). Nitrogen dioxide shows an independent effect from the particulate matter, as observed in the bi-pollutant models.

Ethnic variation in the prevalence of depression and anxiety in primary care: a systematic review and meta-analysis.

Primary care plays a key role in the detection and management of depression and anxiety. At present it is not clear if the prevalence of depression and anxiety in primary care differs between migrants and ethnic minorities (MI) and natives and ethnic majorities (MA). A systematic review and a meta-analysis of studies comparing the prevalence of depression and anxiety in MI and MA in primary care were performed. Studies were identified by searching MEDLINE, PsychINFO, EMBASE and through hand-search. We included 25 studies, most of which had a relatively small sample size. Significant variations were found in the prevalence of anxiety and depression across studies. Pooled analyses were carried out for 23 studies, based on random-effects models. Pooled RR of depression and anxiety in MI were 1.21 (95% CI 1.04-1.40, p=0.012) and 1.01 (95% CI 0.76-1.32, p=0.971), with high heterogeneity (I²=87.2% and I²=73%). Differences in prevalence rates among studies can be accounted for by inclusion criteria, sampling methods, diagnostic instruments and study design. Further research on larger samples and with culturally adapted instruments is needed to estimate the prevalence of depression and anxiety in MI seeking help for these disorders.

Risk adjustment models for interhospital comparison of CS rates using Robson's ten group classification system and other socio-demographic and clinical variables.

BACKGROUND: Caesarean section (CS) rate is a quality of health care indicator frequently used at national and international level. The aim of this study was to assess whether adjustment for Robson's Ten Group Classification System (TGCS), and clinical and socio-demographic variables of the mother and the fetus is necessary for inter-hospital comparisons of CS rates. METHODS: The study population includes 64,423 deliveries in Emilia-Romagna between January 1, 2003 and December 31, 2004, classified according to theTGCS. Poisson regression was used to estimate crude and adjusted hospital relative risks of CS compared to a reference category. Analyses were carried out in the overall population and separately according to the Robson groups (groups I, II, III, IV and V-X combined). Adjusted relative risks (RR) of CS were estimated using two risk-adjustment models; the first (M1) including the TGCS group as the only adjustment factor; the second (M2) including in addition demographic and clinical confounders identified using a stepwise selection procedure. Percentage variations between crude and adjusted RRs by hospital were calculated to evaluate the confounding effect of covariates. RESULTS: The percentage variations from crude to adjusted RR proved to be similar in M1 and M2 model. However, stratified analyses by Robson's classification groups showed that residual confounding for clinical and demographic variables was present in groups I (nulliparous, single, cephalic, ≥37 weeks, spontaneous labour) and III (multiparous, excluding previous CS, single, cephalic, ≥37 weeks, spontaneous labour) and IV (multiparous, excluding previous CS, single, cephalic, ≥37 weeks, induced or CS before labour) and to a minor extent in groups II (nulliparous, single, cephalic, ≥37 weeks, induced or CS before labour) and IV (multiparous, excluding previous CS, single, cephalic, ≥37 weeks, induced or CS before labour). CONCLUSIONS: The TGCS classification is useful for inter-hospital comparison of CS section rates, but residual confounding is present in the TGCS strata.

Short-term mortality following COVID-19 vaccination in Bologna, Italy: a one-year study.

The main objective of the study is to assess whether there is an increased risk of mortality in the days following the administration of COVID-19 vaccines in Bologna Health Authority in the first year of COVID-19 vaccination campaign. A secondary objective was to describe causes of deaths occurred in the days after vaccination. We conducted a retrospective observational study on all residents of Bologna Health Authority who received at least one COVID-19 vaccination dose from December 27, 2020 to December 31, 2021 and compared mortality in the 3, 7, 14 30 days after vaccination (risk interval) with the mortality in the period of the same length (3, 7, 14 and 30 days) beyond the 30th day after the last dose of vaccination (control interval). The cohort included 717,538 people. The mortality rate was 2.24 per 100 person-years during the 30 days risk interval vs 2.72 in the control interval with an adjusted incidence rate ratio equal to 0.76 (95% CI: 0.70-0.83, p < 0.001). The risk of mortality is significantly lower (p < 0.001) also in the 3, 7, 14 days risk intervals than in the control intervals. This study shows that there is no increase in mortality in the short-term period after COVID-19 vaccines.

Emergency Department Visits and Summer Temperatures in Bologna, Northern Italy, 2010-2019: A Case-Crossover Study and Geographically Weighted Regression Methods.

The aim of the study is to evaluate the association between summer temperatures and emergency department visits (EDVs) in Bologna (Italy) and assess whether this association varies across areas with different socioeconomic and microclimatic characteristics. We included all EDVs within Bologna residences during the summers of 2010-2019. Each subject is attributed a deprivation and a microclimatic discomfort index according to the residence. A time-stratified case-crossover design was conducted to estimate the risk of EDV associated with temperature and the effect modification of deprivation and microclimatic characteristics. In addition, a spatial analysis of data aggregated at the census block level was conducted by applying a Poisson and a geographically weighted Poisson regression model. For each unit increase in temperature above 26 °C, the risk of EDV increases by 0.4% (95%CI: 0.05-0.8). The temperature-EDV relationship is not modified by the microclimatic discomfort index but rather by the deprivation index. The spatial analysis shows that the EDV rate increases with deprivation homogeneously, while it diminishes with increases in median income and microclimatic discomfort, with differences across areas. In conclusion, in Bologna, the EDV risk associated with high temperatures is not very relevant overall, but it tends to increase in areas with a low socioeconomic level.

COVID-19 vaccine effectiveness among the staff of the Bologna Health Trust, Italy, December 2020-April 2021.

BACKGROUND AND AIM: Randomized controlled trials have shown that mRNA vaccines are highly effective in preventing SARS-CoV2 infection. We conducted a study to assess the real-world effectiveness of mRNA vaccines (Pfizer-BioNTech or Moderna) in preventing all and symptomatic SARS-CoV2 infections and COVID-19 related hospitalizations in the staff of the Bologna Health Trust (HT), Italy Methods: We followed up retrospectively 9839 staff of the Bologna HT from December 27, 2020 to April 3, 2020 and calculated the effectiveness in partially and fully vaccinated subjects by applying a multivariable Cox proportional hazard model. RESULTS: Vaccine effectiveness in preventing SARS-CoV2 infections is 85.5% (95%CI: 75.9-91.3) in the partially vaccinated and 84.8% (95%CI: 73.2-91.4) in the fully vaccinated. In preventing symptomatic infection effectiveness is 81.7% (95%CI: 62.7-91.0) in the partially and 87.1% (95%CI: 69.3-94.6) in the fully vaccinated. There were no COVID-19-related hospitalizations in the partially or fully vaccinated vs 15 hospitalization in the unvaccinated cohort. CONCLUSIONS: Our results confirm the effectiveness of mRNA vaccines in a real-world setting in Northern Italy.

Mortality in mental health patients of the Emilia-Romagna region of Italy: A registry-based study.

Evidence from previous research demonstrated a gap in mortality between patients with mental disorders and the general population. However, a more exhaustive assessment is required to address this public health issue. The aim of this study was to provide comprehensive analysis of mortality examining all causes of death and all psychiatric diagnoses. We conducted a 10-year retrospective cohort study, including all in and out patients registered in the Mental Health Registry of Emilia-Romagna, Italy. Standardized mortality ratios (SMRs) were calculated. The cohort consisted of 137,351 patients 11,236 of whom died during the study period and the overall SMR was 1.99. 85.9 % of excess mortality was attributable to a broad range of natural causes. Diseases of circulatory and respiratory systems as well as neoplasms were the principal contributors to the mortality gap. All psychiatric conditions led to a higher risk of death. The greatest excess was due to neoplasms in depressed and neurotic patients and to cardiovascular diseases in patients with schizophrenia and personality disorders. Our results highlight the need for close collaboration between mental and primary health care services with the aim of reducing excess mortality as a result of medical diseases among all patients suffering from psychiatric condition.

Peripartum hysterectomy and cesarean delivery: a population-based study.

OBJECTIVE: To estimate the incidence of peripartum hysterectomy in an Italian Region (Emilia-Romagna) and investigate its association with cesarean delivery. DESIGN: Population-based retrospective study using hospital discharge records. SETTING: All public and private hospitals in Emilia-Romagna region, Italy. POPULATION: A total of 151,494 women delivering between 2003 and 2006, 131 of whom had a peripartum hysterectomy. METHODS: Peripartum hysterectomy was defined as a hysterectomy performed at the time of delivery or afterwards during the same hospitalization. Incidence rates were calculated by type of delivery. Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated with logistic regression to evaluate the association between peripartum hysterectomy and delivery type. MAIN OUTCOME MEASURES: Incidence rates of peripartum hysterectomy by type of delivery; odds of peripartum hysterectomy after primary or repeat cesarean compared with vaginal delivery without previous cesarean. RESULTS: A total of 131 peripartum hysterectomies were performed among 151,494 deliveries (0.86/1,000 deliveries; 95% CI 0.72-1.03) with 20.7% primary and 9.6% repeat cesarean deliveries. Women undergoing a primary caesarean delivery were more likely to have a peripartum hysterectomy than women having a vaginal delivery who had never had a cesarean delivery (OR 6.48; 95% CI 4.16-10.07). Women undergoing a repeat caesarean delivery were also at increased risk (OR 3.69; 95% CI 2.11-6.46). CONCLUSIONS: In this population, primary and repeat cesarean deliveries are associated with an increased risk of peripartum hysterectomy. These results are of particular concern given the steady increase in the cesarean delivery rate in many countries. The pathological mechanism of this association requires further investigation.

COVID-19 cases before and after the "I Stay at home" decree, Bologna Local Health Authority, Italy.

BACKGROUND AND AIM OF THE WORK: Various measures have been taken by the Italian Government to contain and mitigate the COVID-19 outbreak and on March 11th a decree called "I stay at home" put the whole nation under lockdown. Our aim is to describe sociodemographic and transmission profile of COVID-19 cases that were transmitted before and after the introduction of the decree in the Bologna Local Health Authority. METHODS: Cases were classified as transmitted before or after the decree according to the date of last contact with a COVID-19 case or, if this date was unavailable, we used the date of onset of symptoms considering the incubation period. Sociodemographic, clinical and epidemiological information was collected by using the infectious disease monitoring database, hospital discharge, deprivation index and long term care facility databases. RESULTS: In the period after the publication of the decree, there were more elderly, females, strangers, retired, residents in nursing homes and deprived people than in the first period. There were also more health care personnel and less professionals/managers, sales or office workers. In both phases, family is mentioned as the first community attended although less frequently in the second group. CONCLUSIONS: The profile of the new COVID-19 cases changed during the outbreak suggesting a differential effect of lockdown measures on the population. An equity lens should be used when analyzing the impact of pandemia and the measures taken to curb it.

Mental Health Disorders and Summer Temperature-Related Mortality: A Case Crossover Study.

Identifying the most vulnerable subjects is crucial for the effectiveness of health interventions aimed at limiting the adverse consequences of high temperatures. We conducted a case crossover study aimed at assessing whether suffering from mental health disorders modifies the effect of high temperatures on mortality. We included all deaths occurred in the area of Bologna Local Health Trust during the summers 2004-2017. Subjects with mental disorders were identified by using the local Mental Health Registry. A conditional logistic model was applied, and a z-test was used to study the effect modification. Several models were estimated stratifying by subjects' characteristics. For every 1 °C above 24 °C, mortality among people without mental disorders increased by 1.9% (95% CI 1.0-2.6, p < 0.0001), while among mental health service users, mortality increased by 5.5% (95% CI 2.4-8.6, p < 0.0001) (z-test equal to p = 0.0259). The effect modification varied according to gender, residency and cause of death. The highest probability of dying due to an increase in temperature was registered in patients with depression and cognitive decline. In order to reduce the effects of high temperatures on mortality, health intervention strategies should include mental health patients among the most vulnerable subjects taking account of their demographic and clinical characteristics.

Risk adjustment for inter-hospital comparison of primary cesarean section rates: need, validity and parsimony.

BACKGROUND: Cesarean section rates is often used as an indicator of quality of care in maternity hospitals. The assumption is that lower rates reflect in developed countries more appropriate clinical practice and general better performances. Hospitals are thus often ranked on the basis of caesarean section rates. The aim of this study is to assess whether the adjustment for clinical and sociodemographic variables of the mother and the fetus is necessary for inter-hospital comparisons of cesarean section (c-section) rates and to assess whether a risk adjustment model based on a limited number of variables could be identified and used. METHODS: Discharge abstracts of labouring women without prior cesarean were linked with abstracts of newborns discharged from 29 hospitals of the Emilia-Romagna Region (Italy) from 2003 to 2004. Adjusted ORs of cesarean by hospital were estimated by using two logistic regression models: 1) a full model including the potential confounders selected by a backward procedure; 2) a parsimonious model including only actual confounders identified by the "change-in-estimate" procedure. Hospital rankings, based on ORs were examined. RESULTS: 24 risk factors for c-section were included in the full model and 7 (marital status, maternal age, infant weight, fetopelvic disproportion, eclampsia or pre-eclampsia, placenta previa/abruptio placentae, malposition/malpresentation) in the parsimonious model. Hospital ranking using the adjusted ORs from both models was different from that obtained using the crude ORs. The correlation between the rankings of the two models was 0.92. The crude ORs were smaller than ORs adjusted by both models, with the parsimonious ones producing more precise estimates. CONCLUSION: Risk adjustment is necessary to compare hospital c-section rates, it shows differences in rankings and highlights inappropriateness of some hospitals. By adjusting for only actual confounders valid and more precise estimates could be obtained.

Acupuncture As an Integrative Approach for the Treatment of Hot Flashes in Women With Breast Cancer: A Prospective Multicenter Randomized Controlled Trial (AcCliMaT).

PURPOSE: To determine the effectiveness of acupuncture for the management of hot flashes in women with breast cancer. PATIENTS AND METHODS: We conducted a pragmatic, randomized controlled trial comparing acupuncture plus enhanced self-care versus enhanced self-care alone. A total of 190 women with breast cancer were randomly assigned. Random assignment was performed with stratification for hormonal therapy; the allocation ratio was 1:1. Both groups received a booklet with information about climacteric syndrome and its management to be followed for at least 12 weeks. In addition, the acupuncture group received 10 traditional acupuncture treatment sessions involving needling of predefined acupoints. The primary outcome was hot flash score at the end of treatment (week 12), calculated as the frequency multiplied by the average severity of hot flashes. The secondary outcomes were climacteric symptoms and quality of life, measured by the Greene Climacteric and Menopause Quality of Life scales. Health outcomes were measured for up to 6 months after treatment. Expectation and satisfaction of treatment effect and safety were also evaluated. We used intention-to-treat analyses. RESULTS: Of the participants, 105 were randomly assigned to enhanced self-care and 85 to acupuncture plus enhanced self-care. Acupuncture plus enhanced self-care was associated with a significantly lower hot flash score than enhanced self-care at the end of treatment (P < .001) and at 3- and 6-month post-treatment follow-up visits (P = .0028 and .001, respectively). Acupuncture was also associated with fewer climacteric symptoms and higher quality of life in the vasomotor, physical, and psychosocial dimensions (P < .05). CONCLUSION: Acupuncture in association with enhanced self-care is an effective integrative intervention for managing hot flashes and improving quality of life in women with breast cancer.