Socio-economic inequalities in the use of drugs for the treatment of chronic diseases in Italy.

BACKGROUND: Since the use of medicines is strongly correlated to population health needs, higher drug consumption is expected in socio-economical deprived areas. However, no systematic study investigated the relationship between medications use in the treatment of chronic diseases and the socioeconomic position of patients. The purpose of the study is to provide a description, both at national level and with geographical detail, of the use of medicines, in terms of consumption, adherence and persistence, for the treatment of major chronic diseases in groups of population with different level of socioeconomic position.  METHODS: A cross-sectional study design was used to define the "prevalent" users during 2018. A longitudinal cohort study design was performed for each chronic disease in new drug users, in 2018 and the following year. A retrospective population-based study, considering all adult Italian residents (i.e. around 50.7 million people aged ≥ 18 years). Different medications were used as a proxy for underlying chronic diseases: hypertension, dyslipidemia, osteoporosis, diabetes and chronic obstructive pulmonary disease. Only "chronic" patients who had at least 2 prescriptions within the same subgroup of drugs or specific medications during the year were selected for the analysis. A multidimensional measures of socio-economic position, declined in a national deprivation index at the municipality level, was used to identify and estimate the relationship with drug use indicators. The medicine consumption rate for each pharmacological category was estimated for prevalent users while adherence and persistence to pharmacologic therapy at 12 months were evaluated for new users. RESULTS: The results highlighted how the socioeconomic deprivation is strongly correlated with the use of medicines: after adjustment by deprivation index, the drug consumption rates decreased, mainly in the most disadvantaged areas, where consumption levels are on average higher than in other areas. On the other hand, the adherence and persistence indicators did not show the same trend. CONCLUSIONS: This study showed that drug consumption is influenced by the level of deprivation consistently with the distribution of diseases. For this reason, the main levers on which it is necessary to act to reduce disparities in health status are mainly related to prevention. Moreover, it is worth pointing out that the use of a municipal deprivation indicator necessarily generates an ecological bias, however, the experience of the present study, which for the first-time deals with the complex and delicate issue of equity in Italian pharmaceutical assistance, sets the stage for new insights that could overcome the limits.

Antidepressants and the risk of arrhythmia in elderly affected by a previous cardiovascular disease: a real-life investigation from Italy.

PURPOSE: The study aimed to fill existing knowledge gaps on the safety of antidepressant drugs (ADs) by estimating the risk of hospitalization for arrhythmia associated with use of selective serotonin reuptake inhibitors (SSRIs) and newer atypical ADs (NAAs) among elderly with previous cardiovascular (CV) events. METHODS: The cohort was composed by 199,569 individuals aged ≥ 65 years from five Italian healthcare territorial units who were discharged for cardiovascular outcomes in the years 2008-2010. The 17,277 patients who experienced hospital admission for arrhythmia during follow-up were included as cases. Odds of current ADs use among cases (i.e., 14 days before hospital admission) was compared with (i) odds of current use of 1:5 matched controls (between-patients case-control) and with (ii) odds of previous use during 1:5 matched control periods (within-patient case-crossover). The risk of arrhythmia associated with ADs current use was modelled fitting a conditional logistic regression. A set of sensitivity analyses was performed to account for sources of systematic uncertainty. RESULTS: Current users of SSRIs and NAAs were at increased risk of arrhythmia with case-control odds ratios (OR) of 1.37 (95% confidence interval, CI 1.18 to 1.58) and 1.41 (1.16 to 1.71) and case-crossover OR of 1.48 (1.20 to 1.81) and 1.72 (1.31 to 2.27). An increased risk of arrhythmia was associated with current use of trazodone (NAA) consistently in case-control and case-crossover designs. CONCLUSIONS: Evidence that current use of SSRIs and NAAs is associated to an increased risk of arrhythmia among elderly with CV disease was consistently supplied by two observational approaches.

The fibroblast growth factor-23 and Vitamin D emerge as nontraditional risk factors and may affect cardiovascular risk.

OBJECTIVES: Fibroblast growth factor-23 (FGF-23) and vitamin D are hormones involved in phosphate homoeostasis. They also directly influence cardiomyocyte hypertrophy. We examined whether the relationships between levels of vitamin D or FGF-23, cardiac phenotype and outcome were independent of established cardiac biomarkers in a large cohort of community-dwelling elderly subjects. DESIGN AND SETTING: Plasma levels of FGF-23 and vitamin D were measured in 1851 men and women (65-84 years) resident in the Lazio region of Italy. Participants were referred to eight cardiology centres for clinical examination, electrocardiography, comprehensive Doppler echocardiography and blood sampling. All-cause mortality or hospitalizations were available after a median follow-up of 47 months with record linkage of administrative data. RESULTS: Vitamin D deficiency (<20 ng mL(-1) ) was found in 72.3% of subjects, but FGF-23 levels were normal [74 (58-97) RU per mL]. After adjustment for cardiovascular risk factors and morbidities, low concentrations of vitamin D and high levels of FGF-23 were associated with a higher left ventricular (LV) mass index. Levels of FGF-23 [hazard ratio (HR) (95% confidence interval (CI)) 1.71 (1.28-2.28), P < 0.0001] but not vitamin D [0.76 (0.57-1.01), P = 0.08] were independently associated with mortality after adjustment for clinical risk factors and two cardiac markers together (N-terminal pro-brain natriuretic peptide and high-sensitivity cardiac troponin T), but did not predict hospital admission. People with above median values of FGF-23 and below median values of vitamin D had greater LV hypertrophy and higher mortality. CONCLUSIONS: In community-dwelling elderly individuals with highly prevalent vitamin D deficiency, FGF-23 levels were associated with LV hypertrophy and predicted mortality independently of two robust cardiac biomarkers. A causal relationship was not demonstrated, but the hormones involved in mineral metabolism emerged as nontraditional risk factors and may affect cardiovascular risk.

Inequality in 30-day mortality and the wait for surgery after hip fracture: the impact of the regional health care evaluation program in Lazio (Italy).

INTERVENTIONS: that address inequalities in health care are a priority for public health research. We evaluated the impact of the Regional Health Care Evaluation Program in the Lazio region, which systematically calculates and publicly releases hospital performance data, on socioeconomic differences in the quality of healthcare for hip fracture. DESIGN: Retrospective cohort study. SETTING: and participants We identified, in the hospital information system, elderly patients hospitalized for hip fracture between 01 January 2006 and 31 December 2007 (period 1) and between 01 January 2009 and 30 November 2010 (period 2). MAIN OUTCOME MEASURES: We used multivariate regression models to test the association between socioeconomic position index (SEP, level I well-off to level III disadvantaged) and outcomes: mortality within 30 days of hospital arrival, median waiting time for surgery and proportion of interventions within 48 h. RESULTS: We studied 11 581 admissions. Lower SEP was associated with a higher risk of 30-day mortality in period 1 (relative risk (RR) = 1.42, P = 0.027), but not in period 2. Disadvantaged people were less likely to undergo intervention within 48 h than well-off persons in period 1 (level II: RR = 0.72, P < 0.001; level III: RR = 0.46, P < 0.001) and period 2 (level II: RR = 0.88, P = 0.037; level III: RR = 0.63, P < 0.001). We observed a higher probability of undergoing intervention within 48 h in period 2 compared with the period 1 for each socioeconomic level. CONCLUSION: This study suggests that a systematic evaluation of health outcome approach, including public disclosure of results, could reduce socioeconomic differences in healthcare through a general improvement in the quality of care.

High-sensitivity cardiac troponin T for detection of subtle abnormalities of cardiac phenotype in a general population of elderly individuals.

OBJECTIVE: To investigate the association between circulating cardiac biomarkers and minor abnormalities in cardiac phenotype [left ventricular (LV) mass and midwall fractional shortening (MFS)] in elderly individuals in a general population sample. DESIGN AND SETTING: We examined the relationship between plasma concentrations of high-sensitivity cardiac troponin T (hs-cTnT) or N-terminal probrain natriuretic peptide (NT-proBNP) and elevated LV mass (LV mass/body surface area >95 g m(-2) for women and 115 g m(-2) for men), reduced MFS (<15%) or isolated LV diastolic dysfunction in 1973 elderly subjects (mean age 73 ± 5 years, range 65-84) resident in the Lazio region of Italy and enrolled in the PREDICTOR study. RESULTS: Overall, 24.8% of subjects had elevated LV mass, and 30.4% had reduced MFS. Median [quartile 1-3] plasma concentrations of hs-cTnT and NT-proBNP were higher in individuals with elevated than those with normal LV mass: 6.6 [3.5-11.6] and 147 [64-296] ng L(-1) vs. 4.6 [3.0-8.1] and 79 [41-151] ng L(-1) respectively (P < 0.001). There was a graded increase in median hs-cTnT concentrations across clinical categories of LV hypertrophy: 4.6 [3.0-8.1], 5.8 [3.1-10.2], 7.6 [3.8-13.7] and 8.4 [3.8-17.6] ng L(-1) for subjects with normal LV mass and mild, moderate or severe LV hypertrophy respectively (P < 0.0001); hs-cTnT also increased with increasing quartiles of MFS or grades of isolated LV diastolic dysfunction. CONCLUSIONS: Within an extremely low range of concentrations, increased hs-cTnT amongst community-dwelling elderly subjects is associated with subtle alterations in cardiac phenotype, suggesting that minor injury to cardiac myocytes and subsequent release of troponin reflect subclinical pathophysiological LV deterioration in this population.

Socio-demographic differences in adherence to evidence-based drug therapy after hospital discharge from acute myocardial infarction: a population-based cohort study in Rome, Italy.

WHAT IS KNOWN AND OBJECTIVE: Adherence to evidence-based drug therapy after acute myocardial infarction has increased over the last decades, but is still unsatisfactory. Our objectives are to set out to analyse patterns of evidence-based drug therapy after acute myocardial infarction (AMI), and evaluating socio-demographic differences. METHODS: A cohort of 3920 AMI patients discharged from hospital in Rome (2006-2007) was selected. Drugs claimed during the 12 months after discharge were retrieved. Drug utilization was defined as density of use (boxes claimed/individual follow-up; chronic use = 6+ boxes/365 days) and therapeutic coverage, calculated through Defined Daily Doses (chronic use: ≥80% of individual follow-up). Patterns of use of single drugs and their combination were described. The association between poly-therapy and gender, age and socio-economic position (small-area composite index based on census data) was analysed through logistic regression, accounting for potential confounders. RESULTS AND DISCUSSION: Most patients used single drugs: 90·5% platelet aggregation inhibitors (antiplatelets), 60·0%ß-blockers, 78·1% agents acting on the renin-angiotensin system (ACEIs/ARBs), 77·8% HMG CoA reductase inhibitors (statins). Percentages of patients with ≥80% of therapeutic coverage were 81·9% for antiplatelets, 17·8% for ß-blockers, 64·4% for ACEIs/ARBs and 76·1% for statins. The multivariate analysis showed gender and age differences in adherence to poly-therapy (females: OR = 0·84; 95% CI 0·72-0·99; 71-80 years age-group: OR = 0·82; 95% CI 0·68-0·99). No differences were observed with respect to socio-economic position. WHAT IS NEW AND CONCLUSION: The availability of information systems offers the opportunity to monitor the quality of care and identify weaknesses in public health-care systems. Our results identify specific factors contributing to non-adherence and hence define areas for more targeted health-care interventions. Our results suggest that efforts to improve adherence should focus on women and older patients.

Profiling hospital performance to monitor the quality of care: the case of COPD.

Comparative outcomes data are widely used to monitor quality of care in the cardiovascular area; little is available in the respiratory field. We applied validated methods to compare hospital outcomes for chronic obstructive pulmonary disease (COPD) exacerbation. From the hospital information system, we selected all hospital admissions for COPD exacerbation in Rome (for 2001-2005). Vital status within 30 days was obtained from the municipality mortality register. Each hospital was compared to a pool of hospitals with the lowest adjusted mortality rate (the benchmark). Age, sex and several potential clinical predictors were covariates in logistic regression analysis. 12,756 exacerbated COPD patients were analysed (mean age 74 yrs, 71% males). Diabetes, hypertension, ischaemic heart disease, heart failure and arrhythmia were the most common coexisting conditions. The average crude mortality in the benchmark group was 3.8%; in the remaining population it was 7.5% (range 5.2-17.2%). In comparison with the benchmark, the relative risk of 30-day mortality varied widely across the hospitals (range 1.5-5.9%). A large variability in 30-day mortality after COPD exacerbation exists even considering patients' characteristics. Although these results do not detect mechanisms related to worse outcomes, they may be useful to stimulate providers to revision and improvement of COPD care management.

The association of socioeconomic disadvantage with postoperative complications after major elective cardiovascular surgery.

BACKGROUND: Understanding the mechanism by which both patient- and hospital level factors act in generating disparities has important implications for clinicians and policy-makers. OBJECTIVE: To measure the association between socioeconomic position (SEP) and postoperative complications after major elective cardiovascular procedures. DESIGN: Multicity hospital-based study. SUBJECTS: Using Hospital Discharge Registries (ICD-9-CM codes), 19 310 patients were identified undergoing five cardiovascular operations (coronary artery bypass grafting (CABG), valve replacement, carotid endarterectomy, major vascular bypass, repair of unruptured abdominal aorta aneurysm (AAA repair)) in four Italian cities, 1997-2000. MEASURES: For each patient, a five-level median income index by census block of residence was calculated. In-hospital 30-day mortality, cardiovascular complications (CCs) and non-cardiovascular complications (NCCs) were the outcomes. Odds ratios (ORs) were estimated with multilevel logistic regression adjusting for city of residence, gender, age and comorbidities taking into account hospital and individual dependencies. MAIN RESULTS: In-hospital 30-day mortality varied by type of surgery (CABG 3.7%, valve replacement 5.7%, carotid endarterectomy 0.9%, major vascular bypass 8.8%, AAA repair 4.0%). Disadvantaged people were more likely to die after CABG (lowest vs highest income OR 1.93, p trend 0.023). For other surgeries, the relationship between SEP and mortality was less clear. For cardiac surgery, SEP differences in mortality were higher for publicly funded patients in low-volume hospitals (lowest vs highest income OR 3.90, p trend 0.039) than for privately funded patients (OR 1.46, p trend 0.444); however, the difference in the SEP gradients was not statistically significant. CONCLUSIONS: Disadvantaged people seem particularly vulnerable to mortality after cardiovascular surgery. Efforts are needed to identify structural factors that may enlarge SEP disparities within hospitals.

[Outcomes of hip replacement: a hospital-based longitudinal study in Lazio region (Italy)]. / Esiti degli interventi di protesi d'anca: uno studio longitudinale su base ospedaliera nel Lazio.

Hip replacement (HR) is a very effective procedure for chronic hip diseases especially in elderly. The aims of this study were: 1) to describe the typology of HRs; 2) to assess short and long term outcomes; 3) to evaluate the relationship between both individual and hospital characteristics with the outcomes. Regional hospital discharge data and mortality register were used. The study population included residents of the Lazio region, over 17 years of age, who underwent HR in any private or public hospital in Italy. We used logistic regression analysis to examine in-hospital mortality, 30-day mortality, 90-day mortality. Cox regression analysis was run to investigate revision and 3-5 year mortality. Out of 8159 HRs, 69.5% were total hip replacements (THR) conducted predominantly on females over 70 years of age. We observed 262 in-hospital deaths (7.4% endoprothesis, 1.4% THR). Thirty and 90-day mortality also showed a different pattern among the two procedures (endoprothesis 8.0% and 15.8%, THR 1.3% and 2.2%). At the end of the follow-up, 21% of patients had died and 204 revisions had been carried out (1.4% endoprothesis, 3.0% THR). Overall, 1898 patients (23.3%) had a revision or died. The main short and long term mortality risk factors were: age, male gender and comorbidities. Hospital volume was not associated with a significant mortality risk. For endoprothesis, waiting time before surgery longer than 7 days was associated with a 30-day mortality risk of 2.83. The present study prompted us to test methodologies to evaluate quality levels in orthopaedic surgery units throughout the region using information systems. Further studies are needed to better understand the variability in the characteristics of care that emerged in Lazio hospitals.

[Epidemiology of femur fracture and characteristics of hospital care in Lazio]. / Epidemiologia della frattura del femore e fattori correlati alla mortalità intraospedaliera nel Lazio.

UNLABELLED: We aimed at describing the epidemiology of femur fracture in elderly hospitalized for femur fracture in Lazio (Italy), and evaluating the association between patient's and hospital characteristics on in-hospital mortality. We conducted a population- and hospital-based study (Lazio region: 5.233.233 inhabitants) among people 65+ years aged. SOURCE OF DATA: regional hospital register 2002-2003; ICD-9-CM codes for patients' selection 820 e 821. Direct standardization (rate x 1000) and logistic regression analysis (OR, 95% CI) were performed. Overall hospitalization rate in elderly was 7.5%o (10.l%o females vs. 3.9%0 males). 12.033 patients with femur fractures were enrolled in the study period; 21,6% were not treated surgically: in comparison with those who underwent surgery, they were males, residents out of Rome, older and with worst health status. In-hospital mortality rate was 7,97%. In-hospital mortality determinants were: male gender (OR=0.56), older age (85+, OR=3.30), living out of Rome (OR=0.50), comorbidities (Charlson 'index 3: OR=4.44), "others and unspecified parts of femur" as site of fracture (OR=1.84), admission to a private hospital (OR=O. 79) and a surgical treatment (OR=0.20). In conclusion, this study showed the effect of selected individual characteristics on in hospital mortality and suggested a role of early surgical treatment and access to private sector. Regional hospital information systems represent useful tools to address epidemiological impact of hip fracture and its health care resources utilization.

Number of offspring and maternal allergy.

The consistent association seen between family size and childhood allergy has led to the 'hygiene hypothesis', namely that a lower frequency of infections in early childhood is associated with an increased risk of asthma and hay fever. Maternal atopy, however, is a strong predictor of childhood asthma and hay fever. If maternal atopy is inversely related to the number of siblings then the role of siblings in the development of childhood atopy, the basic tenet of the 'hygiene hypothesis', is challenged. We evaluated the association between number of pregnancies and number of live births with lifetime occurrence of maternal wheeze, asthma, allergic rhinitis, and allergic conjunctivitis in a cross-sectional study in four areas in Italy. A total of 1755 (35-74 year old) nonsmoking women filled a questionnaire on reproductive history as well as on lifetime occurrence of symptoms/diseases. The number of live births was inversely related to lifetime allergic rhinitis (P-value for trend=0.031) and allergic conjunctivitis (P-value for trend=0.011). The odds ratios for those with 4+ children (in comparison with those having 0-1) were: 0.53 (95% CI: 0.27-1.04) and 0.42 (95% CI: 0.22-0.81), respectively. A similar trend was seen for number of pregnancies, although not statistically significant. No association was found between number of pregnancies and number of live births with wheeze or asthma. The results may be interpreted as an indication that maternal atopy influences pregnancy outcomes or that pregnancy itself has an effect on maternal atopy.

[Factors related to in-hospital mortality after stroke in Lazio region, Italy]. / Determinanti della mortalità intra-ospedaliera in seguito a ictus cerebrale nel Lazio.

The use of hospital discharge abstracts in estimating the outcome of hospital care represents an ongoing interest in public health. However standardized methodologies are still not available. We carried out a retrospective study to estimate the association between demographic and clinical characteristics and in-hospital mortality after stroke by using administrative data from the Hospital Information System in Lazio Region. We also assessed the relationship between the presence of neurology services and the outcome. We found 12,781 incident episodes of stroke (main diagnosis ICD-9: 430-431-434-436) (49.3% male, mean age = 74 years) admitted in 126 hospitals in the Lazio region for the period 1999-2000. From the hospital discharge abstracts we collected patient demographic and clinical data. The hospitals were classified in centres with and without neurology services. Admissions to hospitals with neurology services were evaluated as predictors of in-hospital mortality after adjustment for gender, age, residence, education, source of admission, type of stroke, heart disease, kidney disease and history of atrial fibrillation. In-hospital mortality (within 30 day) was 25.1%. Female gender, advanced age, residence in Rome, urgent transport, kidney disease and history of atrial fibrillation were associated with an increased risk. Hemorrhagic stroke (ICD-9 = 430-431) had a worse outcome than ischemic stroke (ICD-9 = 434) and acute undefined cerebrovascular disease (ICD-9 = 436). Patients admitted to hospitals with neurology services showed a significantly decreased risk (OR = 0.88, IC95% = 0.79-0.98), particularly in occlusion of cerebral artery (ICD-9 = 434) and in undefined cerebrovascular disease (ICD-9 = 436). Demographic and clinical variables are associated with the outcome of hospitalised stroke patients. Admissions of acute stroke patients in specialized hospitals seem to play a role in reducing the risk of in-hospital mortality.

The burden of hospitalised pneumonia in Lazio, Italy, 1997-1999.

OBJECTIVE: To evaluate the burden of hospitalised pneumonia in adults in the Lazio region (1997-1999); to describe community-acquired pneumonia (CAP), suspected nosocomial infection (NI) and AIDS-related pneumonia. METHODS: Using data from the Hospital Information System, we traced the hospitalisation history of patients and classified CAP, NI and AIDS-related pneumonia. RESULTS: During the study period, 30517 incident events of pneumonia occurred: 20497 CAP, 9760 NI, and 964 AIDS-related pneumonia; 704 of these were also NI (annual incidence rate 158, 75 and 7.4 per 100 000 population, respectively). The mean ages were 65, 69 and 38 years for CAP, NI, and AIDS-related pneumonia, respectively. Higher hospitalisation rates were observed in Rome than in the rest of the region for NI and AIDS-related cases, but not for CAP. Lower socioeconomic groups showed a higher incidence of CAP and AIDS-related pneumonia. Peaks of incidence were observed in winter for CAP and NI. Only 20% of pneumonias have an aetiological diagnosis. In-hospital fatality rates were 9.4%, 29.3% and 11.2% for CAP, NI and AIDS-related pneumonia, respectively. CONCLUSION: The high incidence and fatality of CAP and NI, especially among the elderly, makes these diseases a problem that is re-emerging in industrialised countries with an ageing population.

Dietary factors associated with wheezing and allergic rhinitis in children.

The effect of dietary factors on asthma is controversial. This study examined food consumption and the use of fats in relation to wheezing and allergic rhinitis in children. Baseline questionnaire data on individual and family characteristics were recorded by parents of 5,257 children aged 6-7 yrs living in central Italy participating in the International Study on Asthma and Allergies in Childhood study. A total of 4,104 children (78.1%) were reinvestigated after 1 yr using a second parental questionnaire to record occurrence of respiratory symptoms over the intervening 12 months. Consumption of foods rich in antioxidants, such as vitamins C and E, animal fats, and food containing omega-3 fatty acids were investigated using a food-frequency questionnaire. Frequency of use of fats was also evaluated. Wheezing, shortness of breath with wheeze, and symptoms of allergic rhinitis in the past 12 months were considered. Intake of cooked vegetables, tomatoes, and fruit were protective factors for any wheeze in the last 12 months and shortness of breath with wheeze. Consumption of citrus fruit had a protective role for shortness of breath with wheeze. Consumption of bread and margarine was associated with an increased risk of wheeze, while bread and butter was associated with shortness of breath with wheeze. Dietary antioxidants in vegetables may reduce wheezing symptoms in childhood, whereas both butter and margarine may increase the occurrence of such symptoms.

Implementation of a surveillance system for stroke based on administrative and clinical data in the Lazio region (Italy): methodological aspects.

Stroke is the third leading cause of death and the most important cause of long-term disability in Italy and other developed countries, heavily influencing quality of life and costs of health care. In spite of the widespread occurrence of the disease and its relevant impact in Italy, there is neither a national nor a regional surveillance system of cerebrovascular diseases. A regional surveillance system for stroke has two important aims: to help to interpret the geographical and temporal trends of the disease for health care planning and resource allocation and to allow close monitoring of the quality of stroke services. Age-standardized mortality rates for cerebrovascular diseases in the Lazio region (5,242,709 inhabitants) in the period 1998-99 were 69.4 for males and 59.4 for females per 100,000 inhabitants. In the year 2000, about 3% of all hospital discharges were for cerebrovascular diseases with a hospitalisation rate of 4.36 per 1000 inhabitants. The mean length of stay is 12 days (median of 9 days) and in-hospital death is 15.4%. The admission rate for cerebrovascular diseases to emergency departments is 3.40 per 1000 inhabitants. The goal of the Lazio Regional Health Authority is to implement a surveillance system for stroke based both on current data (mortality and discharge data) and on information collected in a registry for quality assessment of stroke care. The first step of the study is to develop a regional register of acute stroke using an 'ad hoc' data sheet integrated in the computer-based patient record system of clinical and administrative data (GIPSE) operating in all emergency departments in the region.

Subpopulations at increased risk of adverse health outcomes from air pollution.

Epidemiological research to identify subpopulations with enhanced susceptibility to air pollution is still at an early stage. From the available studies, there is evidence that both "endogenous" and "exogenous" factors contribute to individual susceptibility. Females and the elderly are at an increased risk of pollution-related diseases. Moreover, some chronic clinical conditions seem to be good candidates for identifying the "frail" populations: chronic obstructive pulmonary disease including asthma, coronary heart diseases, congestive heart failure, and heart rhythm disorders. It seems clear that epidemiological research on susceptibility in the future should investigate the underlying biological and physiological mechanisms, in addition to the environmental and toxicological effects.

Passive smoking and lung function in alpha(1)-antitrypsin heterozygote schoolchildren.

BACKGROUND: A study was performed to determine whether Pi heterozygotes exposed to smoking have a higher risk of reduced lung function than Pi M homozygotes. METHODS: The effect of passive smoking on lung function was investigated in a cross sectional study of 997 primary and secondary schoolchildren aged 11-13 years categorised by Pi phenotype as either PiM homozygotes or Pi heterozygotes. Data on respiratory health and risk factors were collected by questionnaire, lung function was measured by spirometric tests, bronchial hyperresponsiveness was evaluated by methacholine test, atopic status was evaluated by skin prick testing, and a blood sample was collected to determine Pi phenotype. Urinary cotinine and creatinine concentrations were determined and assessment of exposure was made from questionnaire data and urinary cotinine concentrations. The results were analysed by multiple regression analysis. RESULTS: Sixty one subjects (6.1%) were found to be Pi heterozygotes. Lung function did not differ between homozygotes and heterozygotes. There was a reduction in lung function in subjects exposed to parental smoking in the overall sample: FEV(1)/FVC ratio (-0.78%), FEF(25-75) (-0.11 litres), and FEF(75) (-0.13 litres). Interaction terms between parental smoking and Pi status were significant with regard to FEV(1)/FVC ratio (p=0.035) and FEF(50) (p=0.023). In subjects exposed to parental smoking the decrement in lung function in Pi heterozygotes tended to be greater (FEV(1)/FVC ratio = -2.57, FEF(25-75) = -0.30, FEF(50) = -0.43, and FEF(75) = -0.29) than in PiM homozygotes. These results did not change significantly when the urinary cotinine concentration was used as an exposure variable. CONCLUSIONS: The detrimental effect of environmental tobacco smoke on lung function in schoolchildren is confirmed. This harmful effect is greater in Pi heterozygotes than in PiM homozygotes.

[The quality of medical records: a retrospective study in Lazio Region, Italy]. / La qualità della cartella clinica negli ospedali del Lazio.

INTRODUCTION: Medical records have an important role in the communication among different care providers and in forensic medicine. In Italy, information on completeness and correctness of medical records is scanty, whereas future hospital accreditation could take into account their quality as a proxy of good medical practice. PURPOSE: We performed a retrospective study in order to assess the quality of medical records in the Lazio region. METHODS: From all 37009 hospital discharges for five different diseases in 123 hospitals (acute myocardial infarction (AMI), coronary artery bypass surgery, pneumonia, cerebrovascular disorders, breast surgery), registered in the Regional Hospital Information System, we selected a random sample of 2022 (5.5% of the total). Ten physicians, previously trained, reviewed the relative medical charts and filled in "ad hoc" questionnaires. RESULTS: A total of 1960 (97% of the target) charts were reviewed. Organization and structure of data recording strongly varied. Important differences were found across the diseases for various items: presence of anamnesis 98.1% (range: from 95.6% for breast surgery to 100% for AMI); presence of physical examination 92.7% (range: from 88.1% for breast surgery to 98.5% for AMI), completeness of the daily medical records was good in 70.8% (range: from 34.2% for pneumonia to 93.9% for cerebrovascular disorders). Variability among different type of hospitals was also observed, being teaching hospitals and some private hospitals more accurate. CONCLUSIONS: Quality of medical records tended to vary across different type of hospitals and different diseases. Actions for improving the quality should be undertaken as a priority. Efforts have to be done in restructuring charts, creating guidelines and training caregivers. The development and application of computer based health information systems should help solving these problems.

Snoring in 9- to 15-year-old children: risk factors and clinical relevance.

OBJECTIVE: Our objective was to investigate the occurrence of snoring in a general population sample of children and to evaluate the association with anthropometric data and clinical findings of oropharynx and nasal airways. METHODS: A cross-sectional study was conducted with children from primary and secondary schools in Civitavecchia and Viterbo in the Latium region in central Italy. The total sample of the survey included 2439 schoolchildren. A total of 2209 children who were ages 10 to 15 years were selected (response rate: 90.5%) according to their snoring frequency during sleep: never, only with colds, occasionally apart from with colds, often. Children in the last category were defined as habitual snorers. Data were collected by means of questionnaires and clinical examination. A blood sample was collected to determine the concentration of hemoglobin in the blood. Logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals. RESULTS: The prevalence of habitual snorers was 5.6%. Boys who were older than 15 years and had a body mass index greater than the 90th percentile were significantly more likely to be snorers. Habitual snoring was strongly associated with decreased nasal patency (rhinitis OR: 2.13; septal deviation OR: 2.75; nasal obstruction OR: 2.20). Children who had undergone adenoidectomy or had markedly enlarged tonsils were at greater risk of being habitual snorers (OR: 4.28 and 5.07, respectively). Last, habitual snorers had a significantly higher concentration of hemoglobin in the blood compared with other children. CONCLUSION: Body weight and nasal and pharynx patency seem to be the main determinants of snoring. The finding of higher values of blood hemoglobin concentration in snorers than in nonsnorers suggests that these children could be experiencing oxyhemoglobin desaturation during sleep. Taking into consideration the relationship between these different risk factors could lead to a better clinical approach to the snoring child.