Hospital admission rates, length of stay, and in-hospital mortality for common acute care conditions in COVID-19 vs. pre-COVID-19 era.

OBJECTIVES: The impact of COVID-19 upon acute care admission rates and patterns are unknown. We sought to determine the change in rates and types of admissions to tertiary and specialty care hospitals in the COVID-19 era compared with pre-COVID-19 era. METHODS: Acute care admissions to the largest tertiary care referral hospital, designated national referral centers for cardiac, cancer and maternity hospital in the State of Qatar during March 2020 (COVID-19 era) and January 2020 and March 2019 (pre-COVID-19 era) were compared. We calculated total admissions, admissions for eight specific acute care conditions, in-hospital mortality rate, and length of stay at each hospital. RESULTS: A total of 18,889 hospital admissions were recorded. A sharp decline ranging from 9% to 75% was observed in overall admissions. A decline in both elective and non-elective surgeries was observed. A decline of 9%-58% was observed in admissions for acute appendicitis, acute coronary syndrome, stroke, bone fractures, cancer, and live births, whereas an increase in admissions due to respiratory tract infections was observed. Overall length of stay was shorter in the COVID-19 period possibly suggesting lesser overall disease severity, with no significant change in in-hospital mortality. Unadjusted mortality rate for Qatar showed marginal increase in the COVID-19 period. CONCLUSIONS: We observed a sharp decline in acute care hospital admissions, with a significant decline in admissions due to seven out of eight acute care conditions. This decline was associated with a shorter length of stay but not associated with a change in in-hospital mortality rate.

Economic evidence for the clinical management of major depressive disorder: a systematic review and quality appraisal of economic evaluations alongside randomised controlled trials.

AIMS: The aim of this systematic review of economic evaluations alongside randomised controlled trials (RCTs) was to provide a comprehensive overview of the evidence concerning cost-effectiveness analyses of common treatment options for major depression. METHODS: An existing database was used to identify studies reporting cost-effectiveness results from RCTs. This database has been developed by a systematic literature search in the bibliographic databases of PubMed, PsychINFO, Embase and Cochrane library from database inception to December 2014. We evaluated the quality of economic evaluations using a 10-item short version of the Drummond checklist. Results were synthesised narratively. The risk of bias of the included RCTs was assessed, based on the Cochrane risk of bias assessment tool. RESULTS: Fourteen RCTs were included from the 5580 articles screened on titles and abstracts. The methodological quality of the health economic evaluations was relatively high and the majority of the included RCTs had low risk of bias in most of Cochrane items except blinding of participants and personnel. Cognitive behavioural therapy was examined in seven trials as part of a variety of treatment protocols and seems cost-effective compared with pharmacotherapy in the long-term. However cost-effectiveness results for the combination of psychotherapy with pharmacotherapy are conflicting and should be interpreted with caution due to limited comparability between the examined trials. For several treatments, only a single economic evaluation was reported as part of a clinical trial. This was the case for comparisons between different classes of antidepressants, for several types of psychotherapy (behavioural activation, occupational therapy, interpersonal psychotherapy, short-term psychotherapy, psychodynamic psychotherapy, rational emotive behavioural therapy, solution focused therapy), and for transcranial magnetic stimulation v. electroconvulsive therapy. The limited evidence base for these interventions means generalisations, based on economic evaluation alongside clinical trials, cannot easily be made. CONCLUSIONS: There is some economic evidence underpinning many of the common treatment options for major depression. Wide variability was observed in study outcomes, probably attributable to differences in population, interventions or follow-up periods. For many interventions, only a single economic evaluation alongside clinical trials was identified. Thus, significant economic evidence gaps remain in the area of major depressive disorder.

Health economic evidence gaps and methodological constraints in low back pain and neck pain: Results of the Research Agenda for Health Economic Evaluation (RAHEE) project.

Despite the increased interest in economic evaluations, there are difficulties in applying the results of such studies in practice. Therefore, the "Research Agenda for Health Economic Evaluation" (RAHEE) project was initiated, which aimed to improve the use of health economic evidence in practice for the 10 highest burden conditions in the European Union (including low back pain [LBP] and neck pain [NP]). This was done by undertaking literature mapping and convening an Expert Panel meeting, during which the literature mapping results were discussed and evidence gaps and methodological constraints were identified. The current paper is a part of the RAHEE project and aimed to identify economic evidence gaps and methodological constraints in the LBP and NP literature, in particular. The literature mapping revealed that economic evidence was unavailable for various commonly used LBP and NP treatments (e.g., injections, traction, and discography). Even if economic evidence was available, many treatments were only evaluated in a single study or studies for the same intervention were highly heterogeneous in terms of their patient population, control condition, follow-up duration, setting, and/or economic perspective. Up until now, this has prevented economic evaluation results from being statistically pooled in the LBP and NP literature, and strong conclusions about the cost-effectiveness of LBP and NP treatments can therefore not be made. The Expert Panel identified the need for further high-quality economic evaluations, especially on surgery versus conservative care and competing treatment options for chronic LBP. Handling of uncertainty and reporting quality were considered the most important methodological challenges.

Survival of children with Down syndrome in Italy.

A cohort of 917 Down syndrome (DS) children born in Italy between 1978 and 1984 was studied for survival through the age of 8 years. The highest mortality occurred in the first month of life (7.9%); survival was about 80% at 1 year, 78% at 2 years, and 76% at 5 years, with small decreases thereafter. At the univariate analysis, survival was lower for subjects with congenital heart disease (CHD), birth weight less than 2,500 g, parity of 3 or plus, maternal age greater than or equal to 35 years, and for those born in Southern Italy compared with Northern Italy. No differences in survival were observed by sex and by socioeconomic status. The Cox proportional hazard model was used to evaluate the effect of each variable adjusted for all the others present in the model. Presence of CHD (odds ratio = 3.27; 95% confidence interval (C.I.) 2.31-4.63), birth in the South (odds ratio = 2.69; 95% C.I. 1.91-3.79), and low birth weight (odds ratio = 1.87; 95% C.I. 1.29-2.72) were independently associated with survival. None of the other variables emerged as a statistically significant prognostic factor. Various hypotheses were considered to interpret the unexpected effect of place of birth on survival. Quality of medical care provided in the South of Italy is the most likely determinant of the high mortality observed among children with DS born in that area of Italy. Such differences in survival within the same country could occur in other developed nations as well.

Indices of nonspecific bronchial responsiveness in a pediatric population.

A cross-sectional survey of the prevalence of asthma and bronchial hyperreactivity among schoolchildren (7 to 11 years old) was carried out in three areas of the Latium region (Central Italy). Out of 1,777 children tested with methacholine challenge (MCT), 15.1 percent had a 20 percent fall in FEV1 after a provocative concentration (PC20FEV1) of 4 mg/ml of methacholine or less; 69.7 percent had a PC20FEV1 less than 64.0 mg/ml, whereas 50.3 percent were nonresponders. Two continuous measures of bronchial responsiveness, the slope (percentage of change in FEV1 per mg/ml of methacholine) and the area under the dose response curve, were calculated in order to avoid the loss of information in nonresponders. Applying a receiver operating characteristic (ROC) curve analysis, the three estimators did not show any statistically significant difference in their overall performance in detecting asthma (ROC areas: PC20FEV1 = 0.683, slope = 0.681, area = 0.702 or asthma-like symptoms. The log transformation of slope, having a unimodal and slightly skewed shape, is an appealing continuous measure of bronchial responsiveness useful for epidemiologic studies. The final choice of an appropriate estimator of the concentration-response curve to methacholine, however, depends upon both the statistical tests or the modelling procedures to be used and clarification of the prognostic value of different indices of bronchial responsiveness.

Reduction of births in Italy after the Chernobyl accident.

After the Chernobyl accident serious concern spread throughout Italy about the possible effects of the consequent exposure to radioactivity on fetuses. A reduction of births in the first three months of 1987, and particularly in February (7.2% reduction in the birth rate), was observed throughout Italy. In April-June 1987 a 4.8% increase in the number of births was observed. The magnitude of both phenomena varied in different areas of the country. The total number of births in the first six months of 1987 was very similar to the expected (264,241 versus 263,659). Induced abortions increased in Lombardia (northern Italy) in June (+1.6%) and July of 1986 (+3.4%) and in Campania (southern Italy) in June (+12.7%) and August (+4.3%). No increase in legal abortions was detected in Lazio (central Italy). Italian data suggest a voluntary decrease in the number of planned pregnancies and the termination of some of them in the first weeks after the accident as a consequence of postdisaster stress.

Analysis of the prognostic factors of endometrial carcinoma. A retrospective study of 144 patients.

One hundred and fourty-four patients with endometrial carcinoma who had undergone surgery as primary treatment were retrospectively studied from January 1980 to September 1990 for the purpose of correlating the survival rate with known or presumed prognostic factors. The patients averaged 63.1 years of age (range 32-88 years); 106 were classified as having Stage I disease, 10 Stage II, 16 Stage III and 2 Stage IV. Histology confirmed pure adenocarcinomas in 77%, adenosquamous carcinoma in 3.5%, clear cell carcinomas in 2.5% and serous papillary in 17%. Surgical treatment consisted of extrafasial hysterectomy with pelvic lymphadenectomy up to the aortic bifurcation in 69 patients (48%), Wertheim's hysterectomy in 10 (7%), simple or vaginal hysterectomy in the remaining 65 patients (45%). Five-year survival rate in all the case series was 74.3% whereas for patients with Stage I carcinoma it was 79.9%. Different prognostic factors were correlated in a multivariate analysis with the outcome of the disease. Myometrial invasion presented a mortality ODDS RATIO (OR) of 3.18 (95% CI 1.25-8.06), for histologic grade OR 4.33 (95% CI 1.74-10.74) and for stage (2-3 vs 1) OR of 2.73 (95% CI 1.09-6.83) demonstrating a high significance, whereas pregnancy, excess body weight, age and histotype were not considered as relevant factors for prognosis. For age we found mortality OR 2.54 (95% CI 0.75-8.59) for women greater than 55y.

Declining trends of male proportion at birth in Europe.

Declining trends in male proportion at birth observed in several Western countries might reflect widespread exposure to pollutants capable of interfering with human reproduction. In this study, the authors describe male live birth proportion trends in 23 European countries from 1950 to 1996 (total of 305 million live births). Overall, there was a significant linearly decreasing trend of 10 fewer males per 100,000 births each year, resulting in a loss of 73,462 boys during a 47-yr period. The proportion of male births during the first 3 yr of the study period was higher than in the last 3 yr in 18 countries (i.e., 78%). Decreasing trends, which varied in slope and shape, were observed in 11 countries; no significant trend was found in 8 countries, and male birth proportion increased in 4 countries. The results of this study confirmed that the proportion of male births is declining in Europe, and differences exist by region and country. Social and cultural aggregations of countries with decreasing trends suggest that sociodemographic characteristics might be more likely to explain trends than environmental exposures to chemicals. Investigators should evaluate this hypothesis to assess the usefulness of male birth proportion as a sentinel event.

What is a human teratogen: clinical and epidemiological criteria.

Known human teratogens explain only 6% of all birth defects. The epidemiological approaches used to study birth defects in human populations were reviewed together with some of the most important methodological problems encountered in this field. The criteria of causality to be met to conclude on the teratogenicity of a given substance were also discussed. A list of the known teratogens with mention of the main birth defects attributed to each of them is enclosed.

[Mortality and care level of very low birth weight newborn infants. A population study]. / Mortalità e livello delle cure in neonati di peso molto basso. Uno studio di popolazione.

A population study on 314 very low birth weight infants (VLBW) was carried out in 1987 in the Lazio Region of Italy to investigate the relation between the availability at birth of neonatal intensive care and infant mortality. Fifty-two percent of VLBW infants did not survive the first year of life. The mortality Odds Ratios, adjusted for four potential confounding variables, did not show a beneficial effect of Maternity units with neonatal intensive care (level 3) compared with those with special (level 2) and normal care (level 1). The overall high crude mortality rate together with the homogeneity of odds ratios among the different levels of care suggest that, when a regionalized perinatal care system is missing, as in Lazio region, the availability of neonatal intensive care, per se, does not improve the survival on this group of infants.

Fetal growth in the offspring of epileptic women: results of an Italian multicentric cohort study.

An historical cohort study of the association between maternal epilepsy, anticonvulsant drugs and fetal growth was carried out among 47 hospitals collaborating in the Italian Multicentric Registry on Birth Defects (IPIMC). Birth weight, head circumference and body length were studied in 164 babies of epileptic women and compared to 185 controls. Seventy-nine epileptic women were treated by monotherapy, 59 by polytherapy and 26 took no anticonvulsant during pregnancy. An intrauterine growth retardation and a smaller head circumference was observed among babies of epileptic women. No effect was evident for body length. When specific anticonvulsant therapies were taken into account, only phenobarbital showed an effect on birth weight and head circumference; a reduction in head circumference was observed also in the babies of untreated epileptic women. The other antiepileptics (carbamazepine and valproic acid) showed no influence on the outcome considered. The observed effects on fetal growth can be interpreted as a result of an interaction between the effect of the maternal disease and that of the anticonvulsants.

Maternal epilepsy and birth defects: a case-control study in the Italian Multicentric Registry of Birth Defects (IPIMC).

A case control study on the association between maternal epilepsy, anticonvulsants use during pregnancy and birth defects was carried out in the Italian Multicentric Registry of Birth Defects (IPIMC). In the period 1980-1983, 7,607 malformed babies out of 439,717 total births (still + live) were registered. Fourty-one malformed babies with maternal epilepsy were identified (5.39 X 1,000). The overall relative risk of having a malformed baby among pregnant epileptic women was 1.87. Spina Bifida, Congenital Heart Defects, Clefts, Diaphragmatic Hernia and Trisomy 18 were more frequent than expected among babies with maternal epilepsy. The different therapeutic regimens were also tested to identify the possible independent teratogenic effect of anticonvulsants. A statistically significant association between Spina Bifida and Valproic Acid (odds ratio 22.7; Fisher p value = 0.0364) was observed: no other anticonvulsant tested showed any association with any type of malformation.

Health impact assessment of air pollution: providing further evidence for public health action.

Many epidemiological studies have demonstrated the importance of air pollution as a risk factor and characterised dose-response relationships between health endpoints and pollutants. The association between particulate matter (PM) and health is generally regarded as causal, and a nonthreshold linear relationship with, for example, mortality and hospital admission has been observed in several settings. The ubiquitous PM air pollution is likely to have a large overall impact on human health, even if risks are relatively small. There have recently been a large number of papers reporting quantitative estimations of the health impact of PM on health, as measured by the proportion of excess events that are attributable to PM exposures in the general population, mainly in industrialised countries. For example, in the eight largest Italian cities it has been estimated that concentrations beyond 30 microg x m(-3) are responsible for about 3,500 extra deaths per year. A similar study has been carried out for France, Austria and Switzerland. These evaluations fill a knowledge gap between the laboratory and clinical studies on the pathophysiological mechanisms, the epidemiological research on the nature and strength of the association at the population level, and the risk management needs for developing appropriate preventive policies. Some limitations in the methodology deserve further research, however health impact assessment type studies are informative and effective tools of communication with the general public and policy makers.

Cesarean section rates in Italy by hospital payment mode: an analysis based on birth certificates.

The study, based on birth certificate data from 1985 through 1987, investigated cesarean section (CS) rates in the Lazio region of Italy and their relationship with mode of hospital care payment. Use of abdominal delivery increased from 22.3% in 1985 to 24.3% in 1987. CS rates were highest (34.7%) in private hospitals. A marked variation in the use of CS was associated with mode of hospital care payment independently from other predictors of abdominal delivery.

Anticonvulsant drugs in monotherapy. Effect on the fetus.

We describe a material of 577 infants born of epileptic women treated with anticonvulsants in monotherapy during early pregnancy and collected from France, Italy, and Sweden. The incidence of major malformations is increased compared with the general population but no definite difference in risk can be demonstrated between the various anticonvulsants, but valproic acid was associated with a doubling of the average risk. The increased risk for facial clefts and for cardiac malformations, described from most studies on epilepsy during pregnancy, cannot be seen in this material. Unusually many cases of penis abnormalities (micropenis, hypospadias) were noted. An effect on fetal growth can be demonstrated and is apparently more pronounced for carbamazepine than for the other drugs. It results in a reduced birth weight in spite of normal gestational length, reduced body length and head circumference. The possible biological significance of this finding is discussed.