Prevalence and characteristics of HIV/HBV and HIV/HCV coinfections in Tuscany

Abstract Introduction Worldwide about 30% of HIV-infected patients are coinfected with HCV or HBV. The HIV/HCV coinfection is more common in individuals who have a history of drug addiction. The aims of this study were to assess the HCV and HBV prevalence in HIV-infected patients and analyze their characteristics. Methods We considered the new HIV diagnoses notified by the regional surveillance system of Tuscany from 2009 to 2013. Descriptive analyses were conducted on the socio-demographic characteristics, routes of transmission, and reason to perform the test. In coinfected patients we assessed the risk for being late presenter (LP) or the risk of having AIDS. Results In 5 years of surveillance a total of 1354 new HIV diagnoses were notified: 1188 (87.7%) were HIV alone, 106 (7.8%) HIV/HCV, 56 (4.1%) HIV/HBV, and 4 (0.33%) HIV/HCV/HBV. The main risk factor was injection drug use in 52.8% of HCV/HIV cases, while in HIV/HBV patients the main risk factor was sexual exposure. HIV/HBV coinfected patients showed worse clinical and immunological features than HIV and HIV/HCV patients: 78.6% had CD4 count less than 350 mm−3 (vs. 54.6% and 62.1%, respectively) and 39.4% had AIDS (vs 20.7% and 7.6%). The risk for being LP triples for HIV/HBV (OR 2.98; 95% IC: 1.56–5.70) than patients with HIV alone. Conclusions We have observed less advanced disease in HIV and HCV-HIV patients compared with HBV–HIV coinfected patients. Moreover, our results show a higher prevalence of HIV/HCV among drug addicts and in the age-group 35–59, corresponding to those born in years considered most at risk for addiction. This study also confirms the finding of a less advanced HIV disease in HIV/HCV coinfected patients.

Kawasaki disease: an epidemiological study in central Italy.

BACKGROUND: Kawasaki disease (KD) is a systemic vasculitis with an acute and self-limited course. The incidence of KD differs widely among ethnic groups and is higher in the Asian population. In Italy, no recent data are available. Our purpose is to define the epidemiology of Kawasaki disease in the years 2008-2013 in children aged < 14 years in the Italian regions of Tuscany and Emilia Romagna through administrative data. METHODS: We studied the epidemiology of KD in the years 2008-2013 in children 0-14 years old resident in Tuscany and in Emilia Romagna regions using hospital ICD-9 discharge codes with a thorough data cleaning for duplicates. RESULTS: The distribution of the KD patients across ages was similar for the two regions with a peak in the second year of life. When considering data of the two regions together, the rate of incidence was 17.6 for 100,000 children under 5 years. For both Regions the incidence rose slightly during the study period and had a seasonal distribution, with higher incidence in spring and winter. CONCLUSION: This is the first Italian study performed through the use of administrative data. Figures are in line but slightly higher than those published in other European countries.

Prevalence and characteristics of HIV/HBV and HIV/HCV coinfections in Tuscany.

INTRODUCTION: Worldwide about 30% of HIV-infected patients are coinfected with HCV or HBV. The HIV/HCV coinfection is more common in individuals who have a history of drug addiction. The aims of this study were to assess the HCV and HBV prevalence in HIV-infected patients and analyze their characteristics. METHODS: We considered the new HIV diagnoses notified by the regional surveillance system of Tuscany from 2009 to 2013. Descriptive analyses were conducted on the socio-demographic characteristics, routes of transmission, and reason to perform the test. In coinfected patients we assessed the risk for being late presenter (LP) or the risk of having AIDS. RESULTS: In 5 years of surveillance a total of 1354 new HIV diagnoses were notified: 1188 (87.7%) were HIV alone, 106 (7.8%) HIV/HCV, 56 (4.1%) HIV/HBV, and 4 (0.33%) HIV/HCV/HBV. The main risk factor was injection drug use in 52.8% of HCV/HIV cases, while in HIV/HBV patients the main risk factor was sexual exposure. HIV/HBV coinfected patients showed worse clinical and immunological features than HIV and HIV/HCV patients: 78.6% had CD4 count less than 350mm(-3) (vs. 54.6% and 62.1%, respectively) and 39.4% had AIDS (vs 20.7% and 7.6%). The risk for being LP triples for HIV/HBV (OR 2.98; 95% IC: 1.56-5.70) than patients with HIV alone. CONCLUSIONS: We have observed less advanced disease in HIV and HCV-HIV patients compared with HBV-HIV coinfected patients. Moreover, our results show a higher prevalence of HIV/HCV among drug addicts and in the age-group 35-59, corresponding to those born in years considered most at risk for addiction. This study also confirms the finding of a less advanced HIV disease in HIV/HCV coinfected patients.

Mortality and major morbidities in very preterm infants born from assisted conception or naturally conceived: results of the area-based ACTION study.

BACKGROUND: The use of assisted conception (AC) has been associated with higher risk of adverse perinatal outcome. Few data are available on the outcome of AC-neonates when pregnancy ends before 32 weeks of gestational age.The aim of this study was to compare the short-term outcome of AC- and naturally conceived preterm infants <32 weeks gestation. METHODS: The area-based cohort study ACTION collected data on births 22-31 weeks gestation occurred in 2003-05 in 6 Italian regions. Infants born to 2529 mothers with known mode of conception were studied. The main outcomes were hospital mortality and survival free from major morbidities (IVH grade 3-4, cPVL, ROP stage ≥3, BPD), and were assessed separately for single and multiple infants. Other outcomes were also investigated. Multivariable logistic analyses were used to adjust for maternal and infants' characteristics. To account for the correlation of observations within intensive care units, robust variance and standard error estimates of regression parameters were computed. RESULTS: AC was used in 6.4% of mothers. Infants were 2934; 314 (10.7%) were born after AC. Multiples were 86.0% among AC and 21.7% among non-AC babies. In multivariable analysis no statistically significant difference in hospital mortality and survival without major morbidities was found between AC and non-AC infants. The risk of BPD was lower in AC than in non-AC multiples (aOR 0.41, CI 0.20-0.87), and this finding did not change after controlling for mechanical ventilation (aOR 0.42, CI 0.20-0.85) or presence of a patent ductus arteriosus (aOR 0.39, CI 0.18-0.84). CONCLUSION: When the analysis is restricted to very preterm infants and stratified by multiplicity, no significant associations between AC and increased risk of short-term mortality and survival without major morbidities emerge. This result is consistent with previous studies, and may confirm the hypothesis that the adverse effects of AC are mediated by preterm birth. However, larger appropriately powered studies are needed before definitely excluding the possibility of adverse events linked to AC in infants born before 32 weeks gestation.

Acupuncture and traditional Chinese medicine for hot flushes in menopause: a randomized trial.

OBJECTIVE: To evaluate the effect of acupuncture on hot flushes and other menopause-related symptoms used in an integrated system, including such therapeutic techniques as diet therapy and Tuina self-massage. DESIGN: Randomized trial. SETTING: Outpatient center. PARTICIPANTS: One hundred women in spontaneous menopause with at least three episodes of hot flushes daily were randomly allocated to two treatment groups (50 per group): Women in group A were given diet, self-massage training, and treatment with acupuncture, and women in group B (the control group) were given the same diet and self-massage training, but treatment with acupuncture started 6 weeks after they were enrolled into the study. INTERVENTION: Acupuncture treatments were scheduled twice weekly for 6 consecutive weeks. OUTCOME MEASURES: Mean change in frequency and/or intensity in menopause-related symptoms were estimated by questionnaire after treatment at week 4. RESULTS: Treatment with acupuncture significantly reduced the occurrence of hot flushes and sudden sweating (p<.001). Other symptoms (sleep disorders, tightness in the chest, irritability, bone pain, feeling depressed) significantly improved. CONCLUSIONS: Acupuncture in an integrated system that includes therapeutic techniques such as diet therapy and Tuina self-massage can be used to treat hot flushes and selected symptoms in postmenopausal women.

Pregnancy disorders leading to very preterm birth influence neonatal outcomes: results of the population-based ACTION cohort study.

BACKGROUND: We examined the relationships between -pregnancy disorders leading to very preterm birth -(spontaneous preterm labor, prelabor premature rupture of -membranes (PPROM), hypertension/preeclampsia, -intrauterine growth restriction (IUGR), antenatal hemorrhage, and maternal -infection), both in isolation and grouped together as -"disorders of placentation" (hypertensive disorders and IUGR) vs. -"presumed infection/inflammation" (all the others), and several unfavorable neonatal outcomes. METHODS: We examined a population-based prospective cohort of 2,085 singleton infants of 23-31 wk gestational age (GA) born in six Italian regions (the Accesso alle Cure e Terapie Intensive Ostetriche e Neonatali (ACTION) study). RESULTS: Neonates born following disorders of placentation had a higher GA and better overall outcomes than those born following infection/inflammation. After adjustment for GA, however, they showed higher risk of mortality (odds ratio, OR: 1.4; 95% confidence interval, CI: 1.0-2.0), bronchopulmonary dysplasia (BPD) (OR: 2.5; CI: 1.8-3.6), and retinopathy of prematurity (ROP) (OR: 2.0; CI: 1.1-3.5), especially in growth-restricted infants, and a lower risk of intraventricular hemorrhage (IVH) (OR: 0.5; CI: 0.3-0.8) and periventricular leukomalacia (PVL) (OR: 0.6; CI: 0.4-1.1) as compared with infants born following -infection/inflammation disorders. CONCLUSION: Our data confirm the hypothesis that, in very preterm infants, adverse outcomes are both a function of immaturity (low GA) and of complications leading to preterm birth. The profile of risk is different in different pregnancy disorders.

Increased morbidity and mortality in very preterm/VLBW infants with congenital heart disease.

PURPOSE: To study the association between congenital heart diseases (CHD) and in-hospital mortality and morbidity of very preterm/very low birth weight (VLBW) infants. METHODS: The area-based prospective cohort study ACTION included all infants with gestational age (GA) 22-31 weeks or birth weight <1,500 g admitted to neonatal care between July 2003 and June 2005 in six Italian regions (n = 3,684). CHD were coded according to ICD9-CM. Cluster multivariable logistic regression analyses were used to assess the relationship between CHD and mortality and selected morbidities [neonatal infection, ultrasound brain abnormalities, retinopathy of prematurity (ROP), and bronchopulmonary dysplasia (BPD)] adjusting for potential confounders. RESULTS: Seventy-one patients had CHD [19.3 ‰, 95 % confidence interval (CI) 15.1-24.2 ‰]. The most common lesions were isolated atrial and ventricular septal defects (31.1 and 26.8 %, respectively), pulmonary valvar stenosis (12.7 %), and tetralogy of Fallot (5.6 %). Compared with other infants, CHD patients showed significantly higher GA and frequency of small for gestational age (SGA, i.e., birth weight ≤3rd centile). After adjustment for GA, sex, SGA, presence of extracardiac malformations or chromosomal anomalies, and region of birth, CHD patients had a significantly higher likelihood of infection, BPD, ROP, and, after 27 weeks gestation only, hospital mortality. The increased risk of ROP appeared to be partly due to infection. CONCLUSIONS: In very preterm/VLBW infants CHD are more prevalent than in the general liveborn population, and confer an increased risk of death and serious morbidities independently of other risk factors. These results may be useful to better tailor prognostic assessment and diagnostic and therapeutic interventions for these children.

Cause-specific mortality of very preterm infants and antenatal events.

OBJECTIVE: To assess the relationship between antenatal factors and cause-specific risk of death in a large area-based cohort of very preterm infants. STUDY DESIGN: The ACTION (Accesso alle Cure e Terapie Intensive Ostetriche e Neonatali) study recruited during an 18-month period all infants 22-31 weeks' gestational age admitted to neonatal care in 6 Italian regions (n=3040). We analyzed the data of 2974 babies without lethal or acutely life-threatening malformations. Cause-specific risks of death adjusted for competing causes were calculated, and region-stratified multiple Cox regression analyses were used to study the association between cause-specific mortality and infants' characteristics, pregnancy complications, antenatal steroids, and place of birth. RESULTS: Deaths attributable to respiratory problems and intraventricular hemorrhage prevailed in the first 2 weeks of life, and those attributable to infections and gastrointestinal diseases afterwards. Antepartum hemorrhage was associated with respiratory deaths (hazard ratio [HR] 1.6, 95% CI 1.1-2.4), and maternal infection with deaths attributable to asphyxia (HR 32.5, 95% CI 4.1-259.4) and to respiratory problems (HR 2.8, 95% CI 1.6-5.2). Preterm premature rupture of membranes increased the likelihood of deaths due to neonatal infection (HR 1.8, 95% CI 1.0-3.1), and preterm labor/contractions of those due to respiratory (HR 1.5, 95% CI 1.1-2.0) and gastrointestinal diseases (HR 5.8, 95% CI 2.1-16.3). In addition, a birth weight z-score<-1 was associated with increasing hazards of death resulting from asphyxia, late infections, respiratory, and gastrointestinal diseases. CONCLUSIONS: Different complications of pregnancy lead to different cause-specific mortality patterns in very preterm infants.

Homeopathic aggravation with Quinquagintamillesimal potencies.

INTRODUCTION: Homeopathic aggravation is the exacerbation of some symptoms or the whole pathological situation, followed by improvement of the patient's conditions. AIM: To evaluate the typology, intensity and frequency of homeopathic aggravation, especially with Quinquagintamillesimal (Q, LM) potencies and its prognostic value. METHODS: The homeopathic prescription strategy evaluated consists in the administration of a single homeopathic medicine in Q dilutions, starting with 6Q, then a progressive scale of Q potencies. Patients whose symptoms could be attributed to a wrong and inappropriate prescription, according to the criteria previously described, were excluded. RESULTS: Data was collected on 1108 patients consecutively visited from 3rd October 2002 to 31st December 2007, and 441 cases followed for at least 2 months (40% of total cases). 63 of these cases (14%) reported homeopathic aggravation: 7% reported 'slight', 5% 'medium', 2% 'intense' and 0.4% 'very intense' aggravation. Homeopathic aggravation was present in 21% of paediatric patients (≤ 14 years). About 50% of the cases manifested homeopathic aggravation 1 or 2 days after the prescription and for 67% of patients the symptoms lasted 1 week or less. Patients with aggravation of the original disease had significantly greater improvement than those patients showing the aggravation of other, new or different, symptoms or conditions, or no aggravation. CONCLUSIONS: These data show that homeopathic aggravation with Q potencies is quite frequent in homeopathic clinical practice and seems to be associated with better treatment outcome.

Homeopathy in paediatric atopic diseases: long-term results in children with atopic dermatitis.

AIM: To study the socio-demographic features, the prescribed remedies and the outcome of atopic diseases in children treated with homeopathy at the Homeopathic Clinic of Lucca (Italy), and the long-term outcome of children suffering from atopic dermatitis (AD) after an approximate 8-year period (range 5-10 years). METHODS: Our data derive from an observational longitudinal study carried out on 213 children (38.6%) with atopic diseases out of 551 children consecutively examined from September 1998 to December 2008. We used the Glasgow Homeopathic Hospital Outcome Score to evaluate the results that were classified on the basis of a Likert scale. RESULTS: Eighty-three (39%) children were affected by asthma, 51 (24%) by allergic rhinoconjunctivitis, 76 (36%) by AD and 3 (1%) by food intolerance. Follow-up patients were 104 (48.8%), and 65 (62.5%) of them reported a major improvement or resolution. The parents of paediatric patients suffering from AD, who had started homeopathic treatment at <4.9 years of age were invited to follow-up assessment 8 years later and 40 children (mean age 12.9) were examined; 28/40 (70%) had a complete disappearance of AD, 12/40 children (30.0%) were still affected by AD; 8/40 (20%) had asthma and 8/40 patients had, or developed, allergic rhinitis. CONCLUSION: These preliminary results seem to confirm a positive therapeutic effect of homeopathy in atopic children. Furthermore, according to the data from the literature paediatric patients treated with homeopathy seem to show a reduced tendency to maintain AD and develop asthma (and allergic rhinitis) in adult age.

[The health conditions of prison inmates in Tuscany]. / Lo stato di salute della popolazione detenuta all'interno delle strutture penitenziarie della Regione Toscana.

OBJECTIVE: Investigation of health conditions of prison inmates in Tuscany (Italy) compared with non-institutionalized population and literature data. DESIGN: Cross-sectional descriptive study of a sample recruited for a prospective cohort study. SETTING E PARTICIPANTS: Prison inmates detained in Tuscany on June 15th 2009. Istat data concerning the survey "Aspects of daily life" 2006-2009 has been used for comparison. MAIN OUTCOME MEASURES: The measures used for the analysis are prevalence data by age classes and odds ratios obtained through a logistic regression model. Outcome variables are: broad disease groups, in particular infectious and parasitic diseases and psychic disorders. RESULTS: Prison inmates from Northern Africa and Eastern Europe are 40% of the population studied. A high consumption of tobacco is observed, with 70.6% of regular smokers among prisoners vs 33.2% among free citizens. Digestive system diseases are the most frequent diseases (25.1%), followed by infectious and parasitic diseases (15.7%). Among digestive disease,more than half are teeth and oral cavity pathologies that affect 13.7% of prisoners.Other frequently reported disease groups were diseases of the bone-muscular and connective systems (11.0%), of the circulatory system (10.8%), endocrine and metabolic systems (9.2%), traumatisms and poisonings (6.8%), respiratory system diseases (5.9%), and nervous system diseases (4.9%). The prevalence of ischemic heart diseases, diabetes, obesity and esophagitis, gastritis and gastro-duodenal ulcers is significantly higher among prisoners than in the general population. The most frequent infectious and parasitic diseases are Hepatitis C Virus (HCV) infection with a prevalence of 9.0%, Hepatitis B Virus (HBV) infection (2.2%), and Human Immunodeficiency Virus (HIV) infection (1.4%). Hepatitis C, HIV and hepatitis A have a higher prevalence among inmates of Italian nationality, while syphilis is more common among prisoners from Eastern Europe (1.2%). The prevalence of psychic disorders among prison inmates is 33.3% (vs 11.6% in the general population), while it decreases to 29.3% if we exclude the population detained in the Psychiatric Prison. CONCLUSIONS: According to previous national and international studies, the cohort is more affected than the general population by physical and psychic disorders, partly associated to the prison inmate's country of origin.

Homeopathy in the public health system: a seven-year observational study at Lucca Hospital (Italy).

OBJECTIVE: To evaluate the response to homeopathic treatment in a public homeopathic clinic of all patients attending between September 1998 until December 2005, and to analyze homeopathic practice. METHODS AND SETTING: Longitudinal observational study in a homeopathic clinic based in a public hospital in Lucca, Italy. Data relating to patient details, clinical diagnosis, remedy prescribed, potency of dosage, prescription strategy and identification of the case as acute-chronic-recurrent were analyzed. Clinical response was assessed by the Glasgow Homeopathic Hospital Outcome Score. RESULTS: Overall 74% of patients reported at least moderate improvement. Outcomes were better with longer treatment duration and younger age of patients. Respiratory, followed by dermatological and gastrointestinal pathologies responded best, psychological problems relatively poorly. CONCLUSIONS: Homeopathic therapy is associated with improvement in a range of chronic and recurring pathologies. Certain characteristics of patient and pathology influence the outcome.

Cesarean delivery on maternal request: can the ethical problem be solved by the principlist approach?

In this article, we use the principlist approach to identify, analyse and attempt to solve the ethical problem raised by a pregnant woman's request for cesarean delivery in absence of medical indications. We use two different types of premises: factual (facts about cesarean delivery and specifically attitudes of obstetricians as derived from the EUROBS European study) and value premises (principles of beneficence and non-maleficence, respect for autonomy and justice).Beneficence/non-maleficence entails physicians' responsibility to minimise harms and maximise benefits. Avoiding its inherent risks makes a prima facie case against cesarean section without medical indication. However, as vaginal delivery can have unintended consequences, there is a need to balance the somewhat dissimilar risks and benefits. The principle of autonomy poses a challenge in case of disagreement between the pregnant woman and the physician. Improved communication aimed to enable better informed choice may overcome some instances of disagreement. The principle of justice prohibits unfair discrimination, and broadly favours optimising resource utilisation. Available evidence supports vaginal birth in uncomplicated term pregnancies as the standard of care. The principlist approach offered a useful framework for ethical analysis of cesarean delivery on maternal request, identified the rights and duties of those involved, and helped reach a conclusion, although conflict at the individual level may remain challenging.

Accuracy and reproducibility of pleural effusion cytology.

The increasing number of Malignant Mesothelioma (MM) cases that arrive for expert examinations to court for compensation reasons in subjects exposed to asbestos, in many instances rely exclusively on cytological smears of pleural effusion. We evaluated the accuracy and reproducibility of cytological pleural effusions, based on morphological criteria alone. Nine pathologists and eight residents from seven institutions in north-east Italy blindly examined 45 smears of MM (17), metastases (14) and benign effusions (14), in two rounds. Diagnoses had been confirmed by immunohistochemical and clinical follow-up, and eventually at autopsy. Diagnostic accuracy, interobserver and intraobserver agreement in the distinction of benign vs malignant cases, and in the differentiation of primary from metastatic malignancies, were evaluated. The distinction of benign from malignant smears resulted rather satisfactory (k=0.514), but markedly decreased in differentiation of MM from metastases (overall agreement: k=0.343), as well as when readings from residents were analyzed (k=0.132). Cytology is a useful and reliable tool in the identification of malignancies, but when the distinction of primary from metastatic tumors is addressed morphological criteria alone are not sufficient for a definite diagnosis of MM and the use of cell blocks, immunohistochemistry (IHC) and molecular ancillary techniques are recommended.

General practitioners' knowledge and practice of complementary/alternative medicine and its relationship with life-styles: a population-based survey in Italy.

BACKGROUND: The growing popularity of CAM among the public is coupled with an ongoing debate on its effectiveness, safety, and its implications on the reimbursement system. This issue is critically important for GPs, who have a "gatekeeping" role with respect to health care expenditure. GPs must be aware of medications' uses, limitations and possible adverse effects. Our objective was to explore GPs' knowledge of CAM and patterns of recommendation and practice, as well as the relationship between such patterns and GPs' life-styles. METHODS: A cross-sectional study was conducted in Tuscany, a region of central Italy. One hundred percent female GPs (498) and a 60% random sample of male GPs (1310) practising in the region were contacted through a self-administered postal questionnaire followed by a postal reminder and telephone interview. RESULTS: Overall response rate was 82.1%. Most respondents (58%) recommended CAM but a far smaller fraction (13%) practised it; yet 36% of CAM practitioners had no certificated training. Being female, younger age, practising in larger communities, having had some training in CAM as well as following a vegetarian or macrobiotic diet and doing physical activity were independent predictors of CAM recommendation and practice. However, 42% of GPs did not recommend CAM to patients mostly because of the insufficient evidence of its effectiveness. CONCLUSION: CAM knowledge among GPs is not as widespread as the public demand seems to require, and the scarce evidence of CAM effectiveness hinders its professional use among a considerable number of GPs. Sound research on CAM effectiveness is needed to guide physicians' behaviour, to safeguard patients' safety, and to assist policy-makers in planning regulations for CAM usage.

Patient refusal of emergency cesarean delivery: a study of obstetricians' attitudes in Europe.

OBJECTIVE: To compare the attitudes of a large sample of obstetricians from eight European countries toward a competent woman's refusal to consent to an emergency cesarean delivery for acute fetal distress. METHODS: Obstetricians' attitudes in response to a hypothetical clinical case were surveyed through an anonymous, self-administered questionnaire. The sample included 1,530 obstetricians (response rate 77%) from 105 maternity units (response rate 70%) in eight countries: France, Germany, Italy, Luxembourg, Netherlands, Spain, Sweden and the United Kingdom. RESULTS: In every country, the majority of obstetricians would keep trying to persuade the woman, telling her that failure to perform cesarean delivery might result in the fetus surviving with disability, or even that her own life might be endangered. In Spain, France, Italy, and, to a lesser extent, Germany and Luxembourg, a consistent proportion of physicians would seek a court order to protect fetal welfare or avoid possible legal liability or both. In the United Kingdom, Sweden, and Netherlands, several respondents (59%, 41%, and 37%, respectively) would accept the woman's decision and assist vaginal delivery. Only a small minority (from 0 in the United Kingdom to 10% in France) would proceed with cesarean delivery without a court order. CONCLUSION: Case law arising from a few countries (United States, Canada, and the United Kingdom) and professional guidelines favoring women's autonomy have not solved the underlying ethical conflict, and in Europe acceptance of a woman's right to refuse cesarean delivery, at least in emergency situations, is not uniform. Differing attitudes between obstetricians from the eight countries may reflect diverse legal and ethical environments. LEVEL OF EVIDENCE: III.