Italian multicentre study on type A acute aortic dissection: a 33-year follow-up†.

OBJECTIVES: Despite substantial progress in surgical techniques and perioperative management, the treatment and long-term follow-up of type A acute aortic dissection (AAD) still remain a major challenge. The objective of this retrospective, multicentre study was to assess in a large series of patients the early and long-term results after surgery for type A AAD. METHODS: We analysed the preoperative, intraoperative and postoperative conditions of 1.148 consecutive patients surgically treated in seven large referral centres from 1981 to 2013. We applied to each patient three different multi-parameter risk profiles (preadmission risk, admission risk and post-surgery risk) in order to compare risk factors and outcome. Long-term Kaplan-Meier survival was evaluated. RESULTS: The median age was 64 years and the male population was predominant (66%). Identified diagnosis of collagen disease was present in 9%, and Marfan syndrome in 5%. Bicuspid aortic valve was present in 69 patients (6%). Previous cardiac surgery was identified in 10% of the patients. During surgery, the native aortic valve was preserved in 72% of the cases, including leaflet resuspension in 23% and David operation in 1.2%. Considering aortic valve replacement (AVR: 28%), bioprosthesis implantation was performed in 14.7% of the subjects. Neurological impairment at discharge was shown in 23% of the cases among which 21% of patients had new neurological impairment versus preoperative conditions. The overall 30-day mortality rate was 25.7%. All risk profiles remained independently associated with in-hospital mortality. During the available follow-up of hospital survivors (median: 70 months, interquartile range: 34-113, maximum: 396), cardiac-related death occurred in 7.9% of the subjects. The cumulative survival rate for cardiac death was 95.3% at 5 years, 92.8% at 10 years and 52.8% at 20 years. Severe aortic regurgitation (AR) (grade 3-4) at the time of surgery showed to be a significant risk factor for reintervention during the follow-up (P < 0.001). Among risk profiles, only the preadmission risk was independently associated with late mortality after multivariate analysis. Unexpectedly, there was no difference in freedom from cardiac death between patients with and without AVR. CONCLUSIONS: Although surgery for type A has remained challenging over more than three decades, there is a positive trend in terms of hospital mortality and long-term follow-up. About 90% of patients were free from reoperation in the long term, although late AR remains a critical issue, suggesting that a thorough debate on surgical options, assessment and results of a conservative approach should be considered.

Individual and contextual determinants of inequalities in health: the Italian case.

The geographic distribution of health status across Italian regions shows a North-South gradient, with better conditions in the North for both males and females. Using data from the 2000 National Health Interview Survey, the authors first analyze the geographic variation in subjective health and presence of chronic conditions, with specific attention to the effects of individual and area-based socioeconomic conditions and their heterogeneity across regions. The results suggest the North-South gradient in health is mainly affected, at least for subjective health, by the different composition of macro-areas with respect to individual education, and is slightly influenced by contextual circumstances. Moreover, being less educated results in poorer health in some regions (mainly South and Isles) than in others (mainly Northeast). The authors next analyze the circumstances affecting the presence of more disadvantaged people in the South, to highlight features of the Southern context that might exacerbate social inequalities in health and features of Northern areas that might allay them. Indicators of inequalities, welfare, labor, and power resources were analyzed. The results confirm the disadvantage of the South in terms of social, economic, and cultural features, mainly revealing the compositional effects found in the first part of the study. However, the contextual predictive value of income inequalities, quality of care, and social cohesion can have a supplementary effect on health outcomes of disadvantaged persons.

[Inequalities in health in Italy]. / Diseguaglianze di salute in Italia.

Socioeconomic inequality and its impact on health is a growing concern in the European public health debate. In many countries, the issue is moving away from description towards the identification of the determinants of inequalities and the development of policies explicitly aimed at reducing inequalities in health. In Italy, ten years after the publication of the first report on inequalities in health, this topic is seldom present on the agenda of public policy makers. The purpose of this report is to update the Italian profile of social variation in health and health care in order to stimulate the debate on ways to tackle inequalities in health that are preventable. In the first section of this book, the threefold objective is to describe the principal mechanisms involved in the generation of social inequalities in health (Introduction); to report Italian data on the distribution and magnitude of this phenomenon in the last decade; and to evaluate policies and interventions in both the social (chapter 1.9, Section I) and the health sector (chapter 2.3, Section I), which are potentially useful to reduce health inequalities. It is intended for anyone who is in a position to contribute t o decision-making that will benefit the health of communities. For this reason, chapters are organized by specific determinants of inequalities on which interentions may have an impact. The methodological approach in the second section focuses on the best methods to monitor social inequalities including recommendations on social indicators, sources of information and study models, based on European guidelines revised for the Italian situation. According to data from national and local studies, mortality increases linearly with social disadvantage for a wide range of indicators at both the individual (education, social class, income, quality of housing) and the geographical level (deprivation indexes computed at different levels of aggregation). This positive correlation is evident for both sexes, with the steepest gradient observed among adults of working age, although differences persist also among the elderly. The causes of death found to be most highly correlated with social inequality, and largely responsible for the increasing inequality over the last decade, are those associated with addiction and exclusion (drug, alcohol and violence related deaths), with smoking (lung cancer) and with safety in the workplace and on the roads (accidents). Similar gradients and trends have been observed with different outcomes, such as self-reported morbidity, disability and cancer incidence (chapter 1.1, Section I). Reproductive outcomes confiirm this picture: compared to women belonging to the upper classes, those women in low conditions experience more spontaneous abortions and their children suffer from higher infant mortality and low birth weight. This is a critical issue since poor infant health, particularly for metabolic and respiratory pathologies, affects health in adult life. There is now substantive evidence showing that also socioeconomic circumstances at birth or during adolescence may have a strong impact on adult health (chapter 1.2, Section I). Differences in harmful lifestyles, such as smoking, heavy drinking, drug use, unhealthy diet, obesity and physical inactivity, have a similar effect. The only exception is smoking among women, which is positively correlated with socioeconomic status; however, since women in the upper classes have a greater tendency to quit smoking, the gradient will soon be reversed (chapter 1.7, Section I). On the other hand, most of these behaviours do not follow from free and conscious individual choice; they are a form of adaptation to chronic stress originating in the work-place (chapter 1.4, Section I), or to particularly unfavourable events and conditions, such as unemployment (chapter 1.5, Section I) or lack of family and social support (chapter 1.6, Section I). Poor socioeconomic circumstances are the threshold of absolute poverty and may lead to social exclusion, a condition with a heavy impact on health, which in Italy includes marginal groups of the native population and broader classes of immigrants (chapter 1.3, Section I). Finally, there is recent and consistent evidence on the existence of a "contextual" effect on health, as opposed to the "compositional" effect given solely by the aggregation of individual processes. According to this hypothesis, characteristics of the infrastructure, and the physical and socioeconomic environment of an area would have an impact on individual health independent from the cultural and economic resources personally available to people living in that area (chapter 1.8, Section I). With respect to the health care system, various studies are in agreement in demonstrating that poor and less educated people have inadequate access both to primary prevention and early diagnosis (chapter 2.1, Section I), and to early and appropriate care (chapter 2.2, Section I). They also experience higher rates of hospitalization, particularly in emergencies and with advanced levels of severity.

Glass-glass transition and new dynamical singularity points in an analytically solvable p-spin glasslike model.

We introduce and analytically study a generalized p-spin glasslike model that captures some of the main features of attractive glasses, recently found by mode coupling investigations, such as a glass-glass transition line and dynamical singularity points characterized by a logarithmic time dependence of the relaxation. The model also displays features not predicted by the mode coupling scenario that could further describe the attractive glasses behavior, such as aging effects with new dynamical singularity points ruled by logarithmic laws or the presence of a glass spinodal line.