Who are the superheroes? A cross-sectional study on the determinants of good health among Italian older adults.

BACKGROUND: People who reach old age enjoying good physical and mental health can be defined as (health) "superheroes", given their relatively low impact on healthcare expenditure and the desirable model they represent. AIM: To evaluate prevalence and possible determinants of being "physical superheroes" (i.e., free from the ten major chronic conditions, plus obesity), "mental superheroes" (i.e., free from major mental symptoms), and "superheroes" (i.e., both mental and physical superheroes). METHODS: A telephone-based cross-sectional study (LOST in Lombardia) was conducted in November 2020 (i.e., during the COVID-19 pandemic) on a representative sample of 4,400 adults aged ≥ 65 years from Lombardy region, northern Italy. All participants provided both current data and data referring to one year before. RESULTS: Mental and physical superheroes were 59.0% and 17.6%, respectively. Superheroes were 12.8% overall, 15.1% among men, and 11.1% among women; 20.2% among individuals aged 65-69 years, 11.3% among 70-74, 10.0% among 75-79, and 8.3% among ≥ 80 years. Multivariable analysis showed that female sex, higher age, disadvantaged socio-economic status, and physical inactivity (p for trend < 0.001) were inversely related to being superheroes. People not smoking (adjusted odds ratio, aOR = 1.40), alcohol abstainers (aOR = 1.30), and those free from feelings of hopelessness (aOR = 5.92) more frequently met the definition of superheroes. During COVID-19 pandemic, the proportion of superheroes decreased by 16.3%. CONCLUSIONS: Differences in the older adults' health status are largely attributable to their lifestyles but are also likely due to gender, educational, and socio-economic disparities, which should be properly addressed by public health policies.

A real world analysis of COVID-19 impact on hospitalizations in older adults with chronic conditions from an Italian region.

Healthcare delivery reorganization during the COVID-19 emergency may have had a significant impact on access to care for older adults with chronic conditions. We investigated such impact among all adults with chronic conditions aged ≥ 65 years, identified through the electronic health databases of two local health agencies-ATS Brianza and ATS Bergamo-from the Lombardy region, Italy. We considered hospitalizations for 2020 compared to the average 2017-2019 and quantified differences using rate ratios (RRs). Overall, in 2017-2019 there were a mean of 374,855 older adults with  ≥ 1 chronic condition per year in the two ATS and 405,371 in 2020. Hospitalizations significantly decreased from 84,624 (225.8/1000) in 2017-2019 to 78,345 (193.3/1000) in 2020 (RR 0.86). Declines were reported in individuals with many chronic conditions and for most Major Diagnostic Categories, except for diseases of the respiratory system. The strongest reductions were observed in hospitalizations for individuals with active tumours, particularly for surgical ones. Hospitalization rates increased in individuals with diabetes, likely due to COVID-19-related diseases. Although determinants of the decrease in demand and supply for care among chronic older adults are to be further explored, this raises awareness on their impacts on chronic patients' health in the medium and long run.

COVID-19 confinement impact on weight gain and physical activity in the older adult population: Data from the LOST in Lombardia study.

BACKGROUND & AIMS: COVID-19 containment measures significantly impacted lifestyle of the general population, including physical activity. Although the older adults are particularly susceptible to the potential consequences of sedentary lifestyle and inactivity, few studies investigated pandemic effects in this segment of the population. We aimed to evaluate COVID-19 pandemic effects on weight gain and physical activity in the Italian older adults, and assess the impact of possible changes in physical activity on mental health wellbeing. METHODS: In November 2020, a cross-sectional survey was conducted on a representative sample of 4400 older adults (aged 65 or more) from the Lombardy region, Northern Italy. Changes in body mass index (BMI) and physical activity were assessed, compared to the previous year. Using unconditional multiple logistic models, we estimated the odds ratios (OR) and the corresponding 95% confidence intervals (CI) of a decrease in physical activity during COVID-19 pandemic and we evaluated if decreased physical activity was a determinant of a worsening in psychological wellbeing. RESULTS: Neither weight gain nor increase in obesity prevalence occurred during the pandemic. Mean time spent in physical activity significantly decreased, with 43.8% of participants reporting a decrease of 1 h/week or more during COVID-19 pandemic. A decreased physical activity was determinant of a worsening of selected mental health outcomes, such as: sleep quality (OR = 2.45; 95% CI: 1.91-3.15) and quantity (OR = 1.54; 95% CI: 1.18-2.02), anxiety (OR = 1.31; 95% CI: 1.14-1.52) and depressive symptoms (OR = 1.61; 95% CI: 1.38-1.88). CONCLUSION: During the COVID-19 pandemic, while no major changes in BMI were observed, physical activity significantly declined in the older adults. In this population, the lack of physical activity might have contributed to the observed worsening in mental health. During emergency periods, encouraging physical activity might be effective also to preserve psychological wellbeing.

Psoriasis severity matters when dealing with all-cause mortality in psoriasis patients: a record linkage analysis in Northern Italy.

Psoriasis has been linked with several comorbidities and increased all-cause mortality compared with the general population. Data are still limited concerning mortality especially from Southern European countries. Between January 2012 and December 2018, we conducted a retrospective cohort study on psoriasis patients and population controls in Northern Italy. Through record linkage of health-care databases, psoriasis cases were identified, and their morbidity and mortality were compared with the general population. The Charlson index was used as an index of comorbidities. Standardized mortality ratios (SMR) were estimated for overall psoriasis cases and for patients with mild vs moderate-to-severe disease, separately. We identified 12,693 psoriasis patients (mean age: 60.8 ± 16.3 years). They had a significantly higher Charlson index compared with the general population (p < 0.001). In spite of the higher rate of comorbidities, age-specific SMR was not increased in the psoriasis population as a whole (1.04 (95% CI 0.89-1.20)) or in people with mild psoriasis. However, a 40% higher than the expected risk of all-cause mortality was documented in individuals with moderate-to-severe psoriasis (SMR: 1.41; 95% CI 1.12-1.75). Notably, an excess mortality in these patients occurred as early as age 40-49 years. The proportion of deaths from malignancies and cardiovascular diseases was remarkably high. Our results support the notion that psoriasis severity influences mortality and indicate that patients with psoriasis, especially those with severe disease, should receive appropriate screening and health education.

Three-month mortality in permanently bedridden medical non-oncologic patients. The BECLAP study (permanently BEdridden, creatinine CLearance, albumin, previous hospital admissions study).

OBJECTIVE: To predict the 3-months mortality in permanently bedridden medical non-oncologic inpatients. PATIENTS AND METHODS: 2788 consecutive patients admitted in 5 Italian Internal Medicine units from January 2016 through January 2017 were prospectively screened; 644 oncologic patients were excluded; 2144 non-oncologic patients (1021 female) were followed-up for mortality for 6 months. Main outcome was 3-months mortality in permanently bedridden inpatients with at least 2 of: creatinine clearance <35 ml/min; albumin < 2.5 g/dl; at least 2 hospital admissions in the previous 6 months. Advanced dementia and dysphagia were also recorded. RESULTS: Mean age of the 2144 patients was 73.9 (SD, 14.9) years; 374 (17%) were permanently bedridden, 435 (20%) had a creatinine clearance <35 ml/min, 217 (10%) albumin <2,5 g/dl, 112 (5%) at least 2 hospital admissions in the previous 6 months. Seventy-seven (4%) patients were permanently bedridden with at least 2 of the above mentioned items, and 48 of them died within 3 months (62%) (p < 0.001;95% CI 51-73%). Regression coefficients of the variables associated with 3-months mortality in multivariate analysis in 998 patients of unit 1 (training cohort) were used to create a simple score, which was validated in the 1146 patients of the other units (validation cohort) and performed well in predicting the 3-months mortality (https://www.ejcrim.com/beclap/). CONCLUSIONS: Approximately two out of three non-oncologic medical patients permanently bedridden having 2 of the abovementioned items are dead 3 months after index admission; a simple score including bedridden status, creatinine clearance, albumin, dysphagia, age and sex may help discuss management priorities.

Acute appendicitis: Epidemiology, treatment and outcomes- analysis of 16544 consecutive cases.

AIM: To investigate the epidemiology, treatment and outcomes of acute appendicitis (AA) in a large population study. METHODS: This is a retrospective cohort study derived from the administrative dataset of the Bergamo district healthcare system (more than 1 million inhabitants) from 1997 to 2013. Data about treatment, surgery, length of stay were collected. Moreover for each patients were registered data about relapse of appendicitis and hospital admission due to intestinal obstruction. RESULTS: From 1997 to 2013 in the Bergamo district we collected 16544 cases of AA, with a crude incidence rate of 89/100000 inhabitants per year; mean age was 24.51 ± 16.17, 54.7% were male and the mean Charlson's comorbidity index was 0.32 ± 0.92. Mortality was < 0.0001%. Appendectomy was performed in 94.7% of the patients and the mean length of stay was 5.08 ± 2.88 d; the cumulative hospital stay was 5.19 ± 3.36 d and 1.2% of patients had at least one further hospitalization due intestinal occlusion. Laparoscopic appendectomy was performed in 48% of cases. Percent of 5.34 the patients were treated conservatively with a mean length of stay of 3.98 ± 3.96 d; the relapse rate was 23.1% and the cumulative hospital stay during the study period was 5.46 ± 6.05 d. CONCLUSION: The treatment of acute appendicitis in Northern Italy is slowly changing, with the large diffusion of laparoscopic approach; conservative treatment of non-complicated appendicitis is still a neglected option, but rich of promising results.

[Development of a teledermatology system for the melanoma diagnosis. The pilot experience of the project Clicca il neo]. / Sviluppo di un sistema di teledermatologia per la diagnosi precoce del melanoma. L'esperienza pilota del progetto Clicca il neo.

INTRODUCTION: Cutaneous melanoma is a significant cause of mortality, and since the skin is easily accessible for inspection, it is amenable to interventions of education and promotion of early diagnosis through the use of telemedicine systems. METHODS: Clicca il neo is a programme for the early diagnosis of skin cancer employing tools of teledermatology with a store-and-forward modality. The system uses a web form for data collection and upload of skin photographs taken by users. The target geographic area in which the pilot phase of the project was conduced has been the province of Bergamo (1,100,000 inhabitants according to data from ISTAT 2011) with an incidence of melanoma of approximately 14 cases per 100,000 inhabitants per year. Two main result indicators were adopted: 1) the proportion of assessable images over the total (expected threshold more than 75%); 2) the identification during the study period of at least one melanoma. RESULTS: Between July 1, 2015 and December 31, 2015, a total of 302 images of skin lesions were sent to the system -Clicca il neo, by people resident in the province of Bergamo. Of the images sent, 256 (84.7%) were of sufficient quality for evaluation, and of these, 11 (4.3%) were considered as images of highly suspicious lesions, 4 (1.6%) of a suspected squamous cell carcinoma and 6 (2.3%) of a suspected melanoma. Two of the 4 suspected squamous cell carcinomas and 3 of the 6 suspected melanomas received a diagnostic confirmation after surgical excision and histological examination. Remarkably, the excised melanomas were in 2 cases thin melanomas (thickness less than 1 mm) and, in 1 case, a melanoma in situ. DISCUSSION: This pilot project demonstrates the technical feasibility and potential utility of a teledermatology system to promote early detection of skin cancers. Several aspects remain to define including accessibility, reliability, and preventive effectiveness in reducing melanoma mortality and morbidity by early diagnosis.

Epidemiology of acute cholecystitis and its treatment in Bergamo District, Northern Italy.

BACKGROUND: Acute calcolous cholecystitis (ACC) is a very common pathology in western countries. The aim of our work was to assess the epidemiology of ACC and its treatment in Bergamo, a northern Italy province, during the last seventeen years. METHODS: A restrospective analysis, covering 1997 to 2013, was performed based on the administrative register of the province Health System. Only patients admitted for ACC were selected. From 1997 to 2013 were collected 8959 cases of ACC, mean age was 61.28, 51.5% were male. RESULTS: The incidence of ACC was 48/100.000 per year; the operation rate was 66%. Overall mortality was 0.7%, mean hospitalization time was 9.7 days. The treatment of ACC in Bergamo Province seemed to be acceptable and comparable to literature results. Over the last years, laparoscopy has become the standard treatment. CONCLUSIONS: This study outlined some criticisms on the selection's methodology sourcing data from administrative registers, raising questions about truthfulness of results and usefulness for health policy issues.

Indicators based on registers and administrative data for breast cancer: routine evaluation of oncologic care pathway can be implemented.

RATIONALE, AIMS AND OBJECTIVES: Assuring the best standards of care - in a sustainable way - in chronic diseases as breast cancer is nowadays an important challenge for any health system. The aim of this study was to present the methodology used to define a set of quality indicators, computable from administrative data for the pathway of care of breast cancer, and its application at a population level. METHOD: The cohort of 2007-2009 incident cases of breast cancer was identified through a network of six cancer registers in Northern Italy. Cases of sarcoma and lymphoma, patients with multiple primary cancers and those metastatic at diagnosis were excluded; 9614 women were retained for the analysis. For each indicator, the sub-cohort of women eligible for the diagnostic/therapeutic procedures was identified and calculations were performed through record linkage between the cohort and sources of health information. Data on potential available confounders or prognostic factors were also collected. RESULTS: For a few indicators, such as cyto-histological assessment before surgery (62%) and intensive follow-up (79%), deviation from recommendations was evident. Younger patients (≤50 years) more frequently needed a short term re-intervention, while older patients less frequently underwent reconstructive surgery and received palliative care. Several indicators had a great variability across hospitals. In some cases, this heterogeneity appeared to be related to the hospital size, with high-volume hospitals being more compliant to guidelines. CONCLUSION: It is possible to evaluate the quality of cancer care delivered in clinical practice in recent years, in order to implement interventions aimed to improve adherence to international standards of care.

Serum antinuclear and extractable nuclear antigen antibody prevalence and associated morbidity and mortality in the general population over 15 years.

The prevalence of ANA and anti-ENA in the general population is not well established, especially their clinical significance in healthy subjects. We herein determined the prevalence and predictive value of serum ANA and anti-ENA for connective tissue diseases (CTD), cancer, and mortality. We took advantage of a randomly selected sample of the 1998 general population (Isola I) consisting of 2828 subjects (53% women, age 43±13 years) from a well-defined Northern Italian area. Serum ANA and anti-ENA were tested on the 2690 samples available in 2012 (Isola II, 50% women, age 58±13 years). Administrative databases were searched for CTD, cancer diagnosis, and death cases occurring between enrollment and December 31, 2013. The hazard ratio (HR) was calculated for incident cases. Serum ANA is positive in 18.1% for any titer and 6.1% for titers ≥1:160, 23% in subjects over 50 years and 13.1% and 6.1% for any titer and titers ≥1:160, respectively, in women. The HR for CTD development was significantly high for all ANA titers, with the highest for ANA ≥1:160 (HR 14.19, 95% CI 3.07-65.68). ANA positivity was not associated with cancer (HR 1.03; 95% CI 0.75-1.43), or with mortality (HR adjusted for age and sex 1.40; 95% CI 0.94-2.09). Serum anti-ENA is positive in a minority of subjects with highest figures for anti-nucleosome (1.9%), -histone (1.6%) and -PM/Scl (1.5%). In conclusion, serum ANA prevalence in the general population is highest in senior subjects and in women, while the female predominance is significantly lower compared to overt CTD. Serum ANA is associated with an increased probability of CTD development over time, but does not influence survival or cancer risk.

[A set of indicators to monitor the adherence to the guidelines for the diagnosis and treatment of breast cancer]. / Indicatori per il monitoraggio dei percorsi diagnostico-terapeutici del tumore della mammella.

OBJECTIVES: to present a set of indicators developed from six Local Health Authorities of the Lombardy Region to monitor the diagnostic and therapeutic pathway of breast cancer patients, applied to 2007-2009 incident cases. DESIGN: retrospective cohort study. SETTING AND PARTICIPANTS: all subjects with primary breast cancer, incident in the period 2007-2009, and collected by cancer registries of Milano 1, Bergamo, Cremona, Milano, Milano 2 and Monza-Brianza (5,320,272 inhabitants) were included. MAIN OUTCOME MEASURES: through the use of combined current health databases (health registry, hospitalizations, outpatient, pharmaceutical prescription and specific database for anticancer drugs), for each incident case 34 different indicators have been developed to measure the appropriateness of the procedures provided for diagnosis, treatment (surgical and medical) and follow-up. For each indicator, we analyzed the relationship with age, stage, deprivation index, type of treatment, volume of the specific procedure of the hospital where primary surgery was performed. Estimates were adjusted using multilevel regression models. RESULTS: 12,988 incident cases, without metastatic diseases and other cancers, were included in the cohort: 62% were localized to the breast, 33% to the axillary lymph-nodes, 3% metastatic ab initio, and 2% with unknown stage. Deviations from the expected value of different magnitude depending on the type of indicator were observed: the most important differences were detected for the follow-up indicators. There was, in fact, an excess of several procedures in the first year of follow-up: 75% of the cases performed a dosage of a tumor marker, 67% an ecography or a CT scan or an MR, and 37% a bone scan. On the other hand, the access to neoadjuvant and adjuvant treatments in older women was far below the expected values. CONCLUSIONS: the study presents data derived from a large cohort of population cases; the set of indicators was validated by a board of oncologists. The use of indicators calculated by linking the cancer registries (that provide staging) and administrative databases allows the assessment of compliance to the guidelines for diagnosis and treatment of tumours. This experience shows that it is possible to develop a methodology, shared with clinicians, to define indicators that measure the distance between guidelines and current clinical practice in order to decrease variability, to limit inappropriateness, and to reduce unnecessary diagnostic tests for patients (and, consequently, hospitals organizational overload). In order to be sustainable and equitable, a health care system must be able to ensure implementation of protocols/procedures based exclusively on the best available scientific evidences.

Impact of a population-based colorectal cancer screening program on local health services demand in Italy: a 7-year survey in a northern province.

OBJECTIVES: In 2005, the National Health Service recommended a population-based colorectal cancer (CRC) screening program using biennial fecal occult blood testing (FOBT), followed by total colonoscopy in positive patients. So far, no studies have been performed to evaluate the impact of a mass-screening CRC campaign on the health system services at the community level in Italy. We have therefore assessed the workload generated by the first two biennial rounds of screening program on the activity of hospital services involved in CRC diagnosis in the Lecco province. METHODS: Routine data from all hospital services of our province were collected on activity levels related to CRC diagnosis from January 2003 to December 2009. This time span covered the 2 years prior to, as well as the two biennial rounds of the CRC screening program. In particular, we focused on the volume of outpatient FOBTs and colonoscopies (both diagnostic and interventional) performed among subjects outside the screening program. Joinpoint models were used to test whether an apparent change in trend of examination over time was statistically significant in different age cohorts of the population (<50 years, 50-69 years, and ≥70 years). RESULTS: The volume of "extra-screening" per-patient/FOBTs and colonoscopies increased significantly over the evaluated periods in all ages, until year 2008, when a steady trend was beginning; the AAPCs (average of the annual percent changes) values were 5.7, 3.1, and 8.4 for FOBT and 14.6, 13.4, and 16.7 for colonoscopy in the three age cohorts, respectively. However, the increase in both FOBT and colonoscopy demand was maximal in the cohort ≥70 years, where three statistically significant annual percent changes (APCs) were identified (in 2003-2005, 2005-2006, and 2006-2007 APCs were 12.3, 14.9, and 15.9 for FOBT, and 18.7, 36.8, and 25.4 for colonoscopy, respectively). CONCLUSIONS: After the implementation of a FOBT-based mass-screening program for CRC, careful consideration must be given to the significant increase in the workload of hospital services involved in CRC diagnosis, outside the screening campaign. The extra-work mainly involves gastroenterologists performing colonoscopy, whose activity increased over the 5-year period by 118%, as well as laboratory services, where the demand of FOBTs rose by 40%. This phenomenon, mainly attributable to a profound change in the attitude toward CRC screening by those age cohorts outside the program, covers a time span of two full rounds of screening, whereupon a steady trend for colonoscopy is apparent.