[Patients' satisfaction for hospital care among the Italian Regions between 1997 and 2009]. / Soddisfazione dei cittadini per l'assistenza ospedaliera nelle regioni italiane tra il 1997 e il 2009.

Patients have a privileged perspective on health care quality, thus it is important to obtain from them judgments about offered services. Currently, there are no well developed quality monitoring systems related to the patient's perspective, though Istat data sources would b helpful on this issues. We performed a descriptive analysis relating to the satisfaction degree of Italian population for hospital admissions between 1997and 2009. Data were taken from the Istat Multipurpose analysis on some aspect of daylife. Our results show a positive appraisal for medical and nursing assistance; however the rating for the quality of food is lower Our analysis would give a contribution to the appraisal of an outstanding dimension of patients' appraisal of quality of care among the Regions, by considering the implementation of devolution in healthcare since 2001.

[Sensorineural hearing loss in childhood: evaluation of economic impact in view of vaccine prevention of cases due to congenital cytomegalovirus infection]. / Sordità neurosensoriale infantile: valutazione dell'impatto economico nella prospettiva della prevenzione vaccinale dei casi da infezione congenita da Cytomegalovirus.

Sensorineural hearing loss (SNHL) is a serious public health problem which affects 1-3% per hundred live born babies in developed countries. The congenital cytomegalovirus (CMV) infection is its most important non-genetic cause. The evaluation of the effectiveness of future programs of anti-CMV vaccination requires an assessment of the present costs of SNHL. Direct costs for the Italian public system were calculated per prosthesis child until his full age and turned out to add up to 260,000 euro. Private costs are difficult to be assessed and anyhow are highly dependent from the socio-economic level. This preliminary assessment suggests that the vaccination would be cost-saving if SNHL cases due to congenital CMV were more than 21 per year, corresponding to a congenital infection prevalence higher than 0.21%o.

Evaluation of allergenic potency by REAST inhibition. A new tool for the standardization of allergenic extracts.

The potency of allergenic extracts can be determined in vitro by RAST inhibition, and this has become the preferred method for the standardization of allergens. A disadvantage of this technique is the impossibility of obtaining data about allergens bound to the solid phase, i.e., the counterpart of the inhibiting extract. The REAST (reverse enzyme allergosorbent test) is based on the capture of IgE by a specific antibody bound to microtiter wells, the reaction of captured IgE with biotinylated allergen and the development of a colour reaction by subsequent addition of streptavidin-peroxidase and chromogenic substrate. The addition of an allergen extract in a dose-response fashion competes with the biotinylated allergen and inhibits the test. In the present study REAST inhibition has been evaluated with Dermatophagoides pteronyssinus, Parietaria judaica and mixed grass pollen extracts. The correlation of REAST inhibition with RAST inhibition and both intra-assay and inter-assay reproducibility have been evaluated. REAST inhibition is a potentially valuable new tool for the standardization of allergenic extracts.

Effects of treatment with verapamil SR and captopril on the lipid profile of hypertensive patients.

The potential beneficial effects of antihypertensive drugs on cardiovascular morbidity and mortality may be compromised by their adverse effects on serum lipid levels. In our study we compared verapamil and captopril and evaluated their effects on blood pressure and on serum lipid and lipoprotein levels, with particular attention to lipoprotein(a) [Lp(a)]. 20 hypertensive patients were treated with sustained release verapamil 240mg once daily or captopril 25mg twice daily for 3 months in a double-blind randomised study. Diastolic blood pressure was reduced from 100 +/- 3mm Hg to 87 +/- 6mm Hg (p < 0.01) and from 100 +/- 5mm Hg to 92 +/- 7mm Hg (p < 0.05) in the verapamil and captopril groups, respectively. Small but significant changes in serum lipid levels were noted: total cholesterol was reduced from 6 to 5.8 mmol/L (verapamil) and from 6.1 to 5.9 mmol/L (captopril); low density lipoprotein (LDL) cholesterol was reduced from 4 to 3.8 mmol/L (verapamil) and from 4.2 to 3.9 mmol/L (captopril); apolipoprotein C-III was reduced from 0.3 +/- 0.07 to 0.2 +/- 0.06 mmol/L (9.7 +/- 2.5 to 9.2 +/- 2.3 mg/dl) [verapamil] and from 0.2 +/- 0.1 to 0.2 +/- 0.09 mmol/L (9.1 +/- 3.7 to 8.3 +/- 3.4 mg/dl) [captopril]; apolipoprotein A-II increased only with verapamil (p < 0.02). Lp(a) levels showed only minor changes in individual patients. In conclusion, in our study verapamil and captopril were effective antihypertensive agents and did not adversely effect the lipid profile.

Cancer mortality in young adults: Italy 1955-1985.

Although cancer mortality in young adults accounts for only a small proportion of all cancer deaths, it is important since it provides useful indications of the most likely future trends, and relevant information on the role of exposure to specific, or newer, carcinogens. We, therefore, analysed trends in cancer mortality between 1955 and 1985 among Italian men and women aged 20-44 years. In those three decades, overall cancer mortality declined steadily, by 27% in young women (from 33.8 to 24.7/100,000, world standard) but only by 3% (from 27.3 to 26.4/100,000) among men. The decline for men, however, was 16% from the peak rate of 31.5 reached in 1970-1974. The major underlying component causing the different trends in the two sexes was lung and other tobacco-related neoplasms, which had been considerably on the increase in young men up to the early 1970s, and levelled-off thereafter, while showing no appreciable change in women. The falls were about 50% for stomach cancer in both sexes, and over 80% for cervical cancer. A clear impact of improved treatment was reflected in the substantial declines in Hodgkin's disease, of testicular cancer in the last decade and, possibly, in the favourable trends in cancers of the breast, bone, brain and leukemias over the most recent calendar periods. Only two sites showed appreciable and persisting upward trends: oral cavity in men and skin melanoma in both sexes. They therefore constitute priorities for intervention in the near future.

Mortality from alcohol related disease in Italy.

Trends in death certification rates from the five major alcohol related causes of death in Italy (cancers of the mouth or pharynx, oesophagus, larynx, liver and cirrhosis of the liver) were analysed over a period (1955-79) in which per capita alcohol consumption almost trebled. Age standardised mortality from liver cirrhosis almost doubled in males and increased over 70% in females. In males, mortality from cancers of the upper digestive or respiratory tract showed increases of between 27% and 44%, and liver cancer increased by over 100%. In the late 1970s, the four alcohol related cancer sites accounted for about 12% of all cancer deaths in males and 4.5% in females. Mortality from liver cirrhosis alone accounted for 4.8% of all deaths in males (9.2% of manpower years lost) and 2.3% in females (6.3% manpower years lost) in females. These figures were even higher in selected areas of north eastern Italy, where alcohol consumption is greater. In absolute terms, the upward trends observed correspond to about 10,000 excess deaths per year in the late 1970s compared with rates observed two decades earlier and are thus second only to the increase in tobacco related causes of death over the same calendar period.

Pollen mixtures used as health food may be a harmful source of allergens.

We describe herein one case of systemic anaphylaxis due to the ingestion of an undefined mixture of pollens, sold as a dietary supplement. The patient, who suffered from rhinoconjunctivitis due to grass pollen (with sensitization to several trees), had a severe episode of anaphylaxis immediately after eating this health food. The episode required emergency care. We attempted to study the pollen mixture responsible, but no pollen granules could be identified. We prepared a solid phase with the pollen mixture, and we observed a RAST positivity with the patient's serum and pools of sera containing specific IgE to trees. Furthermore, a RAST-inhibition assay of the patient's serum showed highly positive results with grasses, birch, alder and Compositae. Therefore, we concluded that the pollen mixture contained determinants capable of cross-reacting with the patient's IgE. This case report is evidence of the possible risks due to the use of undefined herbal products by allergic patients.

Cancer mortality in broad Italian geographical areas, 1975-1977.

Death certification rates from various cancers or groups of cancers in broad Italian geographical areas (North/Center/South) over the period 1975-1977 were analyzed. In both sexes, there was a clear North/South gradient, with considerably higher rates in the North for total cancer mortality as well as for most common neoplasms. The geographical variation was more marked in males (North/South ratio for total cancer mortality = 1.75 at all ages and 1.70 truncated 35-64 years) than in females (ratio = 1.48 at all ages and 1.28 truncated 35-64). Although, in general terms, the present results confirm previous analyses of cancer mortality in Italy, a few interesting tendencies should be noted. First, the geographical differences in the mid-late 1970's were much more marked for tobacco-related cancers (a factor of over two in males in the North/South ratio) than for other chiefly epithelial carcinomas or nonepithelial cancers. In general, variations for nontobacco-related cancers tended to level off over more recent calendar periods. However, there was little tendency towards decreasing differences in gastric cancer mortality (which was markedly elevated in the North and Center), at least in males. During the 1970's death certification rates from cancer of the (cervix) uteri decreased in northern and central more than in southern Italy. This pattern of trends may have been influenced by a different impact of cervical screening in various areas of the country.

PIP: Differences in cancer mortality by sex and major region of Italy are analyzed for the period 1975-1977 using data from death certificates. Distinct differences in mortality from tobacco-related causes by region are noted. Variations in cancer mortality from other causes tended to level off in recent years.

Descriptive epidemiology of Hodgkin's disease in Italy.

Death certification data on Hodgkin's disease in Italy over the period 1955-84 were studied in terms of age-standardized and age-specific national trends, and of geographical variation in mortality. There were substantial declines in death rates from the early 1970's onward, which can be largely attributed to therapeutic improvements. These led to avoidance of about 350 deaths, with a total 950 reported, which is probably the major absolute therapeutic advance identified for any cancer site. The declines started earlier in childhood and young adult age, and were restricted to population below age 60. The age distribution of the disease was different in the two sexes, since the age curve for males showed steady rises up to age 75, whereas that for females was clearly bimodal, with a peak around age 30, and another at oldest age. This divergent pattern is consistent with different exposure to (infectious) agent(s) in children of the two sexes, but also to occupational exposures potentially related to the risk of the disease. Examination of rates in various geographical areas showed generally higher rates in the North, and a few provinces with exceedingly high mortality in the central part of Northern Italy, particularly in a chiefly rural province (Mantua). This excess mortality (and, more in general, the observation that rates for Northern Italy are higher than in any other area of the EEC) could not be explained by obvious diagnostic or classification problems, were evident in both sexes, appeared to be consistent over the last decade and are reflected in available Italian cancer registration data.

Comparative completeness and correspondence of cancer mortality data as collected by ISTAT and Cancer Registries.

The authors have compared individual cancer mortality records from the file of the Central Statistics Office (ISTAT) with those of the Cancer Registries of Varese and Torino for the period July-December 1976. Most diagnoses ascertained by the Cancer Registries were histologically confirmed. The results showed a high degree of reciprocal completeness (over 90%) for both systems (Cancer Registries and mortality statistics) and a satisfactory level of concordance (75% at Varese, 70% at Torino). The discrepancies, concentrated in certain nosologic codes, were analyzed. The conclusions suggest that the correspondence between mortality statistics and clinical diagnoses is high, at least in the geographical areas examined.

Cancer mortality in Italy, 1994, and an overview of trends from 1955 to 1994.

BACKGROUND: Data and statistics are presented on cancer death certification in Italy, updating previous publications covering the period 1955-1993. METHODS: Data for 1994 and the quinquennium 1990-94 subdivided into 30 cancer sites are presented in 8 tables, including age- and sex-specific absolute and percentage frequencies of cancer deaths, and crude, age-specific and age-standardized rates, at all ages and truncated for the 35-64 year age group. Trends in age-standardized rates for major cancer sites are plotted from 1955 to 1994. RESULTS: The age-standardized (world standard) death certification rates from all neoplasms steadily declined from the peak of 199.2/100,000 males in 1988 to 186.3 in 1994, and in females from 102.5 in 1989 to 98.6 in 1994. Ever larger was the decline in truncated rates, for males from the peak of 275.1/100,000 in 1983 to 223.2 (-19%) in 1994, and for females from 151.6/100,000 in 1987 to 136.4 (-10%). A major component of the favourable cancer mortality trends in males was lung cancer (accounting for 31,000 deaths in both sexes combined in 1994), whose overall age-standardized rates declined from 60.3 in 1987-89 to 54.6/100,000 males in 1994 (-9%), and from the peak of 96.7 in 1983 at ages 35 to 64 to 72.7 in 1994 (-25%). In contrast, female lung cancer rates have remained stable from 1992 onwards, but have increased from 7.2 to 7.7 at all ages and from 10.6 to 11.0 at age 35-64 between 1985-89 and 1990-94. These different trends in the two sexes reflect the patterns and trends in smoking among Italian males and females. CONCLUSIONS: Cancer mortality trends in Italy over the period 1990-94 were relatively favourable, mainly reflecting the decline in lung cancer rates in males, together with the persistent declines in gastric cancer in both sexes and in cervix uteri for women. Continuous advancements were registered for neoplasms amenable to treatment, essentially testicular cancer, Hodgkin's disease and childhood leukaemias. The major unfavourable trends were observed for non Hodgkin's lymphomas, and require therefore further monitoring, besides a clearer understanding of their determinants. Italy maintains an intermediate level of cancer mortality on a European scale, suggesting that further progress is possible, mostly for tobacco-related neoplasms in males.

Cancer mortality in Italy: an overview of age-specific and age-standardised trends from 1955 to 1984.

Number of certified deaths, age-specific and age-standardised rates and percentages of all cancer deaths from 30 cancers or groups of cancers (plus total cancer mortality) for each five-year calendar period between 1955 and 1984 in Italy are presented in tabular form. From these data, three graphs are derived, including trends in age-standardised rates, age-specific rates centered on birth cohorts and maps plotted in different shades of grey to represent the surfaces defined by the matrix of various age-specific rates. These analyses quantified the rises in overall cancer mortality in males (from 137 to 192/100,000 world standard), chiefly due to increases in lung and other tobacco-related neoplasms. Overall cancer mortality was stable in females (around 100/100,000). Appreciable cohort effects were evident for tobacco related neoplasms, but also for other major cancer sites, such as intestines or breast, whose rates, after earlier rises, are now stable in earlier middle age. Since the early 1970's, cancer mortality rates have been declining in all age groups below 40 in males and below 55 in females. These declines reflect improvements in therapy for leukemias, lymphomas and germ cell tumors, and general improvements in food availability and storage, hygiene and early diagnosis, which have led to the declines in stomach and cervical cancer. Although moderate in absolute terms and smaller than in other western countries where tobacco-related neoplasms have also been falling in more recent cohorts, these declines are encouraging for the indication they provide on the most likely patterns over the next decades in the same and subsequent generations.

Cancer mortality in migrant populations within Italy.

Italian death certification rates from all causes of death, all diseases of the circulatory system, all neoplasms, and cancers of the upper digestive and respiratory tract, stomach, intestines, lung and breast in middle age (45-64 years) were analyzed according to selected geographic areas of birth and residence at death. For total cancer mortality and most neoplasms considered, the rates in middle age were closer to those of place of birth than to those of area of residence, although this pattern was more evident for some sites (e.g., mouth or pharynx, esophagus, larynx, stomach or bladder) than for others (e.g., intestines or breast). In most cases, migration had an adverse effect on cancer rates, and the lowest mortality was reported among stable populations (i.e., those with the same area of birth and death). These findings are discussed in relation to the major migration fluxes within Italy during the current century. Moreover, these analyses give information on the quality of Italian cancer death certification, since the observation that area of birth is often a more important determinant of cancer rates than area of residence provides indirect evidence that cancer death certification in various Italian geographic areas is satisfactorily reliable and consistent.

Trend surface models in the representation and analysis of time factors in cancer mortality.

A method of graphic representation of time factors in cancer mortality is presented, based on different tonalities of grey applied to the surface of the matrix defined by various age-specific rates. It is illustrated using mortality data from cancers of the mouth or pharynx, oesophagus, larynx and lung in Italian and Swiss males. Progressively more complex regression surface equations are defined, on the basis of two independent variables (age and cohort) and a dependent one (each age-specific rate). General patterns of trends were thus identified, showing important similarities in cohort and period effects, but also noticeable differences in time-related factors in mortality from various neoplasms of the upper digestive and respiratory tract. For instance, there were declines in mortality from cancers of the mouth or pharynx in the oldest age groups, whereas rates were appreciably upwards at younger and middle age, particularly in Italy. Likewise, cancers of the oesophagus and, chiefly, of the larynx were substantially increasing, on a cohort basis, in oldest Italian males. Temporal pattern for laryngeal cancer in Italy was similar to that of lung cancer, thus suggesting that (cigarette) smoking has a greater impact on this cancer site as compared with alcohol. However, it is difficult to explain, on this basis alone, the totally diverging pattern for cancer of the larynx (downwards) and of the lung (upwards) observed among older Swiss males. These examples indicate that trend surface models are a useful summary guide to illustrate and understand the general patterns of age, period and cohort effects in cancer mortality.

Trends surface models applied to the analysis of geographical variations in cancer mortality.

To discuss different trends of the geographical distribution of cancer mortality, progressively more complex surface models were fitted to cancer death certification data in the 95 Italian provinces for the period 1975-77, using trend surface analysis. This method is based on fitting first to sixth order regression equations, where dependent variables are latitude and longitude, and the independent one is the standardized mortality ratio (SMR) for various cancer sites. The procedure was implemented using the SYMAP package and appropriate routines ad hoc developed. General patterns in geography of cancer in Italy were therefore identified (such as the marked North/South gradient in mortality from most sites), thus helping in discerning main underlying pictures and permitting identification of local abnormalities (positive or negative residuals, corresponding to high or low mortality areas), which are often obscured by more general patterns using standard methods of analysis. Results and maps are presented and discussed in detail with reference to total mortality and three major sites (lung and intestines in males and female breast) for which regression surfaces with satisfactory fitting were identified. Some of the positive residuals (i.e. those for lung and breast cancer in women in urban concentrations of Central and Southern Italy) were already known, and explainable in terms of available knowledge of the causes of the neoplasms, chiefly smoking and reproductive habits in the past. Other findings, such as the consistent area of positive residuals in a chiefly rural area around the mouth of the river Po, offer useful suggestions for further aetiological research.

The application of trend surface models to the analysis of time factors in Swiss cancer mortality.

To study different temporal components on cancer mortality (age, period and cohort) methods of graphic representation were applied to Swiss mortality data from 1950 to 1984. Maps using continuous slopes ("contour maps") and based on eight tones of grey according to the absolute distribution of rates were used to represent the surfaces defined by the matrix of various age-specific rates. Further, progressively more complex regression surface equations were defined, on the basis of two independent variables (age/cohort) and a dependent one (each age-specific mortality rate). General patterns of trends in cancer mortality were thus identified, permitting definition of important cohort (e.g., upwards for lung and other tobacco-related neoplasms, or downwards for stomach) or period (e.g., downwards for intestines or thyroid cancers) effects, besides the major underlying age component. For most cancer sites, even the lower order (1st to 3rd) models utilised provided excellent fitting, allowing immediate identification of the residuals (e.g., high or low mortality points) as well as estimates of first-order interactions between the three factors, although the parameters of the main effects remained still undetermined. Thus, the method should be essentially used as summary guide to illustrate and understand the general patterns of age, period and cohort effects in (cancer) mortality, although they cannot conceptually solve the inherent problem of identifiability of the three components.

[Analysis of the geographic distribution of mortality in Italy caused by tumors of the respiratory system]. / Analisi della distribuzione geografica della mortalità in Italia per tumori dell'apparato respiratorio.

This paper describes the geographical distribution of respiratory cancers in Italy during the period 1970-87. We analysed mortality rates for cancers of the larynx, of the lung, of the paranasal sinuses, and of the pleura in the 95 Italian provinces. For all considered sites, Northern Italy showed the highest levels of mortality. Only Rome and Naples, the most urbanized provinces in the Central and Southern Italy respectively, presented mortality rates comparable to the Northern provinces, particularly in the early 1970's. The geographical distribution of mortality for all considered sites appears to be consistent between the two sexes. For lung cancer, however, the difference between the North and the rest of the country during the considered period decreased in men but steadily increased in women.

[Geographic distribution of digestive system tumor mortality in Italy, 1970-87]. / Distribuzione geografica della mortalità per tumori dell'apparato digerente in Italia, 1970-1987.

The geographical distribution of mortality rates from tumours of digestive tract in Italy is analyzed in this paper. The analysis is based on official mortality data collected by the National Institute of Statistics (ISTAT). Age-adjusted mortality rates for stomach cancer presented the highest values in some provinces of the North and the Center, and the lowest values in the South of Italy. A same geographical pattern was observed for men and women, and during the whole considered period. Colorectal cancer presented the highest rates in the North-West of the country, and in some provinces of Liguria and Tuscany. The lowes rates were observed in the South, particularly in Calabria and Sicily. Mortality for this cancer was positively associated with degree of urbanization. The geographical pattern remained fairly constant in time, but the North-South differences narrowed during the years 1980s. A similar geographical distribution, characterized by the highest mortality levels in the north-eastern regions of Italy, was observed for cancers of the oral cavity and pharynx, of the oesophagus, of the pancreas, and for male tumours of the liver. Female liver cancer presented, on the contrary, the highest mortality levels in the southern regions.

[The analysis of the spatial aggregation of health events using risk surface density estimation methods]. / Analisi della concentrazione spaziale di eventi per mezzo delle superfici di densità.

Methods for the analysis of the spatial aggregation of health events has received growing attention under the pressure of public opinion concern and as tools for the identification of potential risk sources, for monitoring relevant geographical areas and, finally, for public health decisions. The development of statistical methods for the detection and localization of spatial clusters has mainly concerned individual data. This paper is aimed at describing one of the methods proposed for the identification of clusters in the case of information at individual level and at presenting its extension to grouped data. This method, the surface density estimation method using the Kernel approach, offers remarkable advantages in terms of simplicity of implementation and flexibility, this latter being an extremely important characteristic in the case of exploratory analyses. For exemplification purposes, the density estimation method has been applied to individual data concerning the spatial distribution of cerebral tumors in Campi Bisenzio (FI) and to the distribution of gastric cancer mortality in the municipalities around Arezzo and Pesaro.

[A new approach for the automatic detection of health event clusters]. / Un metodo per l'identificazione automatica di aggregati di casi in mappe di eventi sanitari.

The Italian Morality Atlas at municipality level, sponsored by the Health Ministry and realized by the Emilia-Romagna region in collaboration with the Institute of Medical Statistics of Milano, is aimed at: 1) supporting and stimulating the local production of mortality maps and the use of geographical data; 2) providing a working and research tool to local health planners; 3) setting a routine procedure for the detection of spatial clusters. This procedure is organized in several steps: the definition of the spatial domain and of the spatial distance metrics; the choice of the effect indicator and the standard population; the estimate of the density risk surface via kernel methods; the identification of "local maxima"; the analysis of local maxima for cluster detection; the description of the identified clusters. The paper investigates the meaning and the characteristics of spatial clusters, describes the procedure for their identification and discusses the opportunity to use an automated approach for map reading.