Cardiovascular disease burden: Italian and global perspectives.

BACKGROUND: Cardiovascular disease (CVD) is still the leading cause of death worldwide, responsible for an estimated 17.8 million deaths globally in 2017, accounting for 31.8% of all deaths. In this review, we aim to provide an updated overview of CVD burden from an Italian and a global perspective. METHODS: Crude and age-standardized incidence and prevalence, as well as age-standardized mortality rate and morbidity rate (expressed as disability-adjusted life years - DALYs), of different cardiovascular conditions, derived from the Global Burden of Disease Injuries, and Risk Factors Study (GBD) 2017, were reported and compared between Italy and the world. RESULTS: Crude prevalence of CVD in Italy is nearly twofold higher than global prevalence (12.9% vs. 6.6%), while age-standardized estimates are similar (6.2% vs. 6.3%). Mortality and morbidity from CVD are reduced in Italy, as compared to worldwide estimates (age-standardized mortality rate 113/100,000 vs. 233/100,000; age-standardized rate of DALYs lost 1764/100,000 vs. 4598/100,000). Of the evaluated cardiovascular conditions, the most important CVD burden is due to ischemic heart disease, which show a crude prevalence of 3.6% in Italy (age-standardized: 1.7%), doubling the corresponding crude global estimate (1.7%; age-standardized: 1.6%). CONCLUSIONS: This latest update on the epidemiology of CVD within Italy and the world summarizes the burden of major cardiovascular conditions. CVD, especially ischemic heart disease, is still an important cause of mortality and morbidity. The impact of increasing life-expectancy is a key determinant of CVD epidemiology in Italy, if compared to worldwide data, since older age is one of the major risk factors for CVD.

Single center retrospective analysis of early vs. delayed treatment in acute calculous cholecystitis: application of a clinical pathway and an economic analysis.

BACKGROUND: Treatment option and timing for surgery in case of acute calculous cholecystitis (ACC) is still a matter of discussion. Tokyo Guidelines (TG13) offers some rules but they don't reflect entirely the information of Evidence Based Medicine (EBM). This study aimed to draw some consideration from our practice in the application of the guidelines and put forward the clinical, economic and organizational effect of it. METHODS: The study is a single center retrospective study based on administrative database formed by gathering information from clinical registry. Data were collected between January 1st, 2008 and April 30th, 2013. A cutoff point was established on May 15th, 2010 when we moved from a single surgeon method to a shared EBM method to treat ACC. The economic aspect was developed considering health service reimburse and hospital costs. RESULTS: Five hundred and two patients were selected, 203 patients before the organizational change (Group 0) and 299 after (Group 1). In Group 0, 24.63% of the patients were treated with early laparoscopic cholecystectomy (ELC) and 39.4% received surgery delayed in second admission (DLC). After the change, 57.5% of the patients were treated with ELC while 13% were treated with DLC. Median length of stay (LOS) was significantly lower after the change (9.5 vs. 7.3, p<0.0001), and no difference in terms of complication was noticed. CONCLUSION: Application of evidence based medicine in clinical practice resulted in better results. Economically, the clinical change resulted in a proper use of resources with a positive gap between the costs and refund to the hospital.

Time trends in health care needs of non-EU citizens from developing countries, admitted to a general hospital in northern Italy.

Hospitalizations of foreign patients from developing countries outside the European Union were examined for the period 1999-2004, focusing on infectious diseases and on pregnancy issues. Patients over 14 years old had 6,003 admissions, leading to 7,231 overall diagnoses. During the 6-year study period, female hospitalizations increased steadily, with a peak in 2002 (p .001). This trend was mainly due to the rise in women from Eastern Europe (p .001), which occurs at a younger mean age versus that of males (p .001). Admission of illegal immigrants, performed on an emergency basis, accounted for an average of 9.4%. This phenomenon was very frequent in 1999 (43% of admissions), but dropped sharply after 2002 (p .001), caused by changes in Italian law. The prevalent women diagnoses were ob/gyn ones: voluntary pregnancy interruption, spontaneous abortion or pregnancy complications in 30.6% of cases, and childbirths or controls of pregnancies with a favourable outcome in 18.2% of patients. These diagnoses covered nearly 50% of hospitalizations of migrant women: other admissions were due to organic, dysmetabolic, or functional disorders, while infectious diseases were less frequent (4.6%). Among men, dysmetabolic disorder and organic-degenerative diseases, or functional illnesses (36.2%), were prominent, and significantly more frequent versus women (p .001), as well as post-traumatic diseases (16.5%), and infectious illnesses (12.1%; p .001). Also generic-undefined diagnoses were proportionally numerous (6.6%): cultural-language deficiencies affected the physician-patient relationship. Among infectious diseases, the main causative organisms were Mycobacterium tuberculosis (14.9%), HIV (7.1%), HBV (3.3%), and HCV (2.6%). Upper-lower airways represented the most involved organ system (45% of discharges), followed by the gastroenteric tract (16.4%), and skin-soft tissues (7.4%), while systemic infectious diseases accounted for 14.9% of episodes. Such disorders predominated (up to 90% of cases) among non-regular migrants during 1999-2000, while after 2002 an increase in infectious disorders was observed among patients from Eastern Europe. From a health care-social perspective, although a reduced incidence of infectious diseases did not occur, the possibility of attributing them to individuals of ascertained identity and housing makes it possible to trace index patients, and ultimately strive towards well-planned and effective therapeutic-preventive interventions.

Causes of hospitalization among extra-European Union children in a large hospital of Northern Italy, in a five-year observation period.

The hospitalizations of 1,239 patients aged 14 years or less and immigrated from extra-European Union countries in Italy were assessed in the 6-year period, from 1999 to 2004. The main demographic and clinical features were analyzed according to several variables, also distiguishing patients aged less than one year, from those aged 1-14 years. The introduction of a deed of indemnity law in 2001 profoundly changed the pattern of admissions and health care needs and exploitation during subsequent years, leading to a massive regularization of clandestine immigrants.

Causes of hospitalization among extra-European Union children in a large hospital of Northern Italy, in a five-year observation period

The hospitalizations of 1,239 patients aged 14 years or less and immigrated from extra-European Union countries in Italy were assessed in the 6-year period, from 1999 to 2004. The main demographic and clinical features were analyzed according to several variables, also distiguishing patients aged less than one year, from those aged 1-14 years. The introduction of a deed of indemnity law in 2001 profoundly changed the pattern of admissions and health care needs and exploitation during subsequent years, leading to a massive regularization of clandestine immigrants.

Admission of foreign citizens to the general teaching hospital of Bologna, northeastern Italy: an epidemiological and clinical survey.

BACKGROUND: The emergency regarding recent immigration waves into Italy makes continued healthcare monitoring of these populations necessary. METHODS: Through a survey of hospital admissions carried out during the last five years at the S. Orsola-Malpighi General Hospital of Bologna (Italy), all causes of admission of these subjects were evaluated, together with their correlates. Subsequently, we focused on admissions due to infectious diseases. All available data regarding foreign citizens admitted as inpatients or in Day-Hospital settings of our teaching hospital from January 1, 1999, to March 31, 2004, were assessed. Diagnosis-related group (DRG) features, and single discharge diagnoses, were also evaluated, and a further assessment of infectious diseases was subsequently made. RESULTS: Within a comprehensive pool of 339,051 hospitalized patients, foreign citizen discharges numbered 7,312 (2.15%), including 2,542 males (34.8%) and 4,769 females (65.2%). Males had a mean age of 36.8+/-14.7 years, while females were aged 30.8+/-12.2 years. In the assessment of the areas of origin, 34.6% of hospitalizations were attributed to patients coming from Eastern Europe, 15.3% from Northern Africa, 7.3% (comprehensively) from Western Europe and United States, 6.9% from the Indian subcontinent, 5.9% from sub-Saharan Africa, 5.7% from Latin America, 4.1% from China, 2.5% from the Philippines, and 1.1% from the Middle East. Among women, most hospitalizations (58.8%) were due to obstetrical-gynecological procedures or diseases, including assistance with delivery (27.1%), and pregnancy complications (18.7%), followed by psycho-social disturbances (5.9%), malignancies (5.1%), gastrointestinal diseases (4.7%), and voluntary pregnancy interruption (4.4%). Among men, the most frequent causes of admissions were related to trauma (15.9%), followed by gastroenteric disorders (12%), heart-vascular diseases (8.9%), psycho-social disorders (8.4%), respiratory (7.1%), kidney (6.1%), liver (5.2%), and metabolic (4.9%) diseases, and alcohol or substance abuse (4.2%). Infectious diseases (alone or with concurrent disorders) were reported in 881 discharged individuals, representing 12.1% of the 7,312 DRGs attributed to foreign patients. The comprehensive patient population discharged from our hospital with at least one infectious disease diagnosis had lower rates of respiratory tract infections, followed by chronic viral hepatitis, HIV infection and related diseases, enterocolitis, pulmonary tuberculosis, pyelonephritis, severe skin and soft tissue infection, meningoencephalitis, and malaria, as the most frequently-reported disorders. CONCLUSIONS: Our survey, through a combined analysis of both DRGs and discharge diagnoses, allowed us to conclude that 12.1% of foreign citizens hospitalized at our General teaching Hospital of Bologna (Italy) suffered from at least one infectious disease. Respiratory tract, liver, and gastrointestinal infections, and HIV infection, were found with an appreciable frequency among discharge diagnoses, while the frequency of malaria and meningoencephalitis was lower, compared with other series. Among disorders other than infectious diseases, obstetric-gynecological conditions and post-traumatic episodes (for male patients) were the most frequent causes of hospitalization.

Admission of foreign citizens to the general teaching hospital of bologna, northeastern Italy: an epidemiological and clinical survey

BACKGROUND: The emergency regarding recent immigration waves into Italy makes continued healthcare monitoring of these populations necessary. METHODS: Through a survey of hospital admissions carried out during the last five years at the S. Orsola-Malpighi General Hospital of Bologna (Italy), all causes of admission of these subjects were evaluated, together with their correlates. Subsequently, we focused on admissions due to infectious diseases. All available data regarding foreign citizens admitted as inpatients or in Day-Hospital settings of our teaching hospital from January 1, 1999, to March 31, 2004, were assessed. Diagnosis-related group (DRG) features, and single discharge diagnoses, were also evaluated, and a further assessment of infectious diseases was subsequently made. RESULTS: Within a comprehensive pool of 339,051 hospitalized patients, foreign citizen discharges numbered 7,312 (2.15 percent), including 2,542 males (34.8 percent) and 4,769 females (65.2 percent). Males had a mean age of 36.8±14.7 years, while females were aged 30.8±12.2 years. In the assessment of the areas of origin, 34.6 percent of hospitalizations were attributed to patients coming from Eastern Europe, 15.3 percent from Northern Africa, 7.3 percent (comprehensively) from Western Europe and United States, 6.9 percent from the Indian subcontinent, 5.9 percent from sub-Saharan Africa, 5.7 percent from Latin America, 4.1 percent from China, 2.5 percent from the Philippines, and 1.1 percent from the Middle East. Among women, most hospitalizations (58.8 percent) were due to obstetrical-gynecological procedures or diseases, including assistance with delivery (27.1 percent), and pregnancy complications (18.7 percent), followed by psycho-social disturbances (5.9 percent), malignancies (5.1 percent), gastrointestinal diseases (4.7 percent), and voluntary pregnancy interruption (4.4 percent). Among men, the most frequent causes of admissions were related to trauma (15.9 percent), followed by gastroenteric disorders (12 percent), heart-vascular diseases (8.9 percent), psycho-social disorders (8.4 percent), respiratory (7.1 percent), kidney (6.1 percent), liver (5.2 percent), and metabolic (4.9 percent) diseases, and alcohol or substance abuse (4.2 percent). Infectious diseases (alone or with concurrent disorders) were reported in 881 discharged individuals, representing 12.1 percent of the 7,312 DRGs attributed to foreign patients.

High-risk dysmetabolism disorders associated with HAART-treated HIV disease, and reimbursement of lipid-lowering drugs, in a clinical and a socio-economic perspective.

The significant advances achieved in the management of HIV disease, thanks to highly active antiretroviral therapy, are at risk of being frustrated by the recent changes in the cost reimbursement rules for all lipid-lowering drugs available in Italy. Unfortunately, the remarkably increased life expectancy achieved since mid-1996 by HIV-infected persons after the introduction of protease inhibitors and combined anti-HIV treatment, is accompanied by significant risks of developing diet-uncontrolled hypercholesterolemia and/or hypertriglyceridemia, often concurrent with insulin resistance, visceral adiposity, and hypertension, all known factors which can strongly predispose to severe cardiovascular events. International and national health care system recommendations regarding the reimbursability of lipid-lowering drugs have to take into careful consideration of this "special" category of patients (HIV-infected ones). These patients are exposed to a very frequent and severe, drug-induced dyslipidemia, and a subsequently elevated and progressively increasing cardiovascular risk, despite their proportionally lower mean age compared with that of the general at-risk population, and the lack of many concurrent risk factors which are employed to calculate the strict need for a lipid-lowering therapy, and its consequent cost reimbursement by the different health care systems.

HIV infection and advanced age emerging epidemiological, clinical, and management issues.

While the mean age of HIV/AIDS patients at first diagnosis is progressively rising, no updated epidemiological estimates, controlled clinical data, and randomized therapeutic trials, are available regarding clinical and laboratory response to antiretroviral therapy, safety of anti-HIV compounds and their associations, potential drug-drug interactions, short- and long-term toxicity, consequences on underlying disorders, or interactions with concomitant pharmacological regimens, in the elderly. The life expectancy of HIV-infected persons treated with highly active antiretroviral therapy (HAART) now approximates that of general population matched for age, while also AIDS definition itself has lost most of its epidemiological and clinical significance, thanks to the immunoreconstitution resulting from the large-scale use of potent HAART regimens. The increased survival of HIV-infected patients, the late recognition of other subjects with missed or delayed diagnosis are responsible for a further expected rise of mean age of HIV-infected individuals, so that the patient population aged 60-70 years or more is expected to increase in coming years. Unfortunately, the majority of therapeutic trials involving antiretroviral therapy, as well as antimicrobial chemoprophylaxis for AIDS-related opportunistic complications, have advanced age and/or concurrent end-organ disorders among main exclusion criteria, or the design of these studies does not allow to extrapolate data regarding older patients, compared with younger ones. The very limited data presently available seem to demonstrate that HAART has a virological efficacy in the elderly comparable with that of younger adults, but immunological recovery is often slower and blunted, although several studies clearly demonstrated that thymic function is preserved until late adult age. When facing an HIV-infected patient with advanced age, health care givers have to pay careful attention to eventual end-organ disorders, all possible pharmacological interactions, overlapping toxicity due to concurrent drug administration. All these issues may significantly interfere with HAART activity, patient's adherence to prescribed medications, and frequency and severity of untoward effects. The guidelines of antiretroviral therapy and those of treatment and prophylaxis of AIDS-related diseases deserve appropriate updates, paralleling the increasing mean age of HIV-infected population. Moreover, epidemiological figures need an increased focus on older age, while clinical trials specifically targeting on the elderly population are mandatory to have reliable data on all aspects of HAART administration in advanced age.

Hyperlipidaemia in patients with HIV-1 infection receiving highly active antiretroviral therapy: epidemiology, pathogenesis, clinical course and management.

A wide range of abnormalities of lipid metabolism have been recently described in HIV-infected patients receiving a protease inhibitor (PI)-based highly active antiretroviral therapy, including hypertriglyceridaemia and hypercholesterolaemia. The increase of plasma lipid concentrations may involve up to 70-80% of HIV-positive subjects treated with a PI-containing regimen and are frequently (but not always) associated with the fat redistribution or the lipodystrophy syndrome. Multiple pathogenetic mechanisms by which antiretroviral agents lead to dyslipidaemia have been hypothesized, but they are still controversial. The potential clinicopathological consequences of HIV-associated hyperlipidaemia are not completely known, but several anecdotal observations report an increased risk of premature coronary artery diseases in young HIV-positive individuals receiving PIs, besides peripheral atherosclerosis and acute pancreatitis. A limited-to-significant improvement of increased triglyceride and cholesterol plasma levels was described in patients who replaced PIs with nevirapine, efavirenz or abacavir, but the risks of long-term toxicity and virological relapse of this treatment switching are not completely defined. A hypolipidaemic diet and regular physical exercise may act favorably on dyslipidaemia, but pharmacological therapy becomes necessary when hyperlipidaemia is severe or persists for a long time. The choice of hypolipidaemic drugs is problematic because of potential pharmacological interactions with antiretroviral compounds and other antimicrobial agents, associated with an increased risk of toxicity and intolerance. Statins are considered the first-line therapy for the PI-related hypercholesterolaemia, while fibrates are the cornerstone of drug therapy when predominant hypertriglyceridaemia is of concern.