Size at birth by gestational age and hospital mortality in very preterm infants: results of the area-based ACTION project.

BACKGROUND: Size at birth is an important predictor of neonatal outcomes, but there are inconsistencies on the definitions and optimal cut-offs. AIMS: The aim of this study is to compute birth size percentiles for Italian very preterm singleton infants and assess relationship with hospital mortality. STUDY DESIGN: Prospective area-based cohort study. SUBJECTS: All singleton Italian infants with gestational age 22-31 weeks admitted to neonatal care in 6 Italian regions (Friuli Venezia-Giulia, Lombardia, Marche, Tuscany, Lazio and Calabria) (n. 1605). OUTCOME MEASURE: Hospital mortality. METHODS: Anthropometric reference charts were derived, separately for males and females, using the lambda (λ) mu (µ) and sigma (σ) method (LMS). Logistic regression analysis was used to estimate mortality rates by gestational age and birth weight centile class, adjusting for sex, congenital anomalies and region. RESULTS: At any gestational age, mortality decreased as birth weight centile increased, with lowest values observed between the 50th and the 89th centiles interval. Using the 75th-89th centile class as reference, adjusted mortality odds ratios were 7.94 (95% CI 4.18-15.08) below 10th centile; 3.04 (95% CI 1.63-5.65) between the 10th and 24th; 1.96 (95% CI 1.07-3.62) between the 25th and the 49th; 1.25 (95% CI 0.68-2.30) between the 50(h) and the 74th; and 2.07 (95% CI 1.01-4.25) at the 90th and above. CONCLUSIONS: Compared to the reference, we found significantly increasing adjusted risk of death up to the 49th centile, challenging the usual 10th centile criterion as risk indicator. Continuous measures such as the birthweight z-score may be more appropriate to explore the relationship between growth retardation and adverse perinatal outcomes.

[Epidemiology of work-related accidents in the Lazio Region of Italy]. / Epidemiologia degli infortuni sul lavoro nella Regione Lazio.

BACKGROUND: Prevention of work-related accidents requires an in-depth epidemiological assessment of the issue. In Italy the most used databases are from the national insurance (INAIL) and research (ISPESL) institutes. However, these data are only available several years after the time of accident. OBJECTIVES: To describe the characteristics of accidents and evaluate factors potentially associated with hospitalization using the Information System of Hospital Emergency Departments (SIES). METHODS: We analyzed 51.705 Emergency Department (ED) work-related accident admissions in the Lazio Region of Italy in 2008 among workers aged 16-65 years. Information on socio-demographics, diagnosis, triage codes, and outcome of ED admissions were gathered. We performed a logistic regression model to estimate association between these factors and risk of hospitalization after ED admission. RESULTS: The subjects' mean age was 39.1 (SD 11.0); 71.5% woere men, 12.7% were foreigners, 5.9% arrived by ambulance, 4.5% with triage red/yellow tags, 2.7% were hospitalized. Diagnosis was trauma in 85.1%, orthopaedic lesions in 8.3%. We found a higher risk of hospitalization in subjects with: one year of age increase (OR=1.02; 95% CIs: 1.01-1.03), males (OR=1.68; 95% CIs: 1.44-1.97), foreigners coming from countries with high emigration rates (OR=1.55; 95% CIs: 1.31-1.82), ED triage red/yellow tags (OR=84.47; 95% CIs: 47.06-151.60). CONCLUSIONS: It was confirmed that data fr-om an emergency health care information system can be a useful complement to information gathered by national insurance and research institutes, thus resolving the limit posed by the delay in availability for analysis of these data after the occurrence of accidents. We also identified some factors potentially associated with more serious accidents, which constitute a basis for planning and implementing specific public health preventive interventions.

[A cross-sectional survey on childhood immunization coverage and reasons of non-compliance in Lazio Region, Italy (2007)]. / Indagine campionaria sulle coperture vaccinali in età pe- diatrica e sui motivi di mancata vaccinazione nella regione Lazio (2007).

During 2007, Laziosanità conducted a cross-sectional survey on childhood immunization coverage in Lazio Region. The survey, implemented in collaboration with the 12 LHUs of the Region, aimed at assessing immunization coverage among children, with 24 months of age or older, at regional and district level. In addition, the survey assessed reliability of the routine surveillance system and immunization records at peripheral level. Finally, delay in immunization schedule, and major reasons for non-compliance, as reported by the mothers, were analyzed. The survey results allowed to identify weakness in the routine surveillance system, low coverage levels for specific LHUs, and strategies for improvement of immunization coverage.

Termination of pregnancy among very preterm births and its impact on very preterm mortality: results from ten European population-based cohorts in the MOSAIC study.

OBJECTIVE: To study the impact of terminations of pregnancy (TOP) on very preterm mortality in Europe. DESIGN: European prospective population-based cohort study. SETTING: Ten regions from nine European countries participating in the MOSAIC (Models of OrganiSing Access to Intensive Care for very preterm babies) study. These regions had different policies on screening for congenital anomalies (CAs) and on pregnancy termination. POPULATION OR SAMPLE: Births 22-31 weeks gestational age. METHODS: The analysis compares the proportion of TOP among very preterm births and assesses differences in mortality between the regions. MAIN OUTCOME MEASURES: Pregnancy outcomes (termination, antepartum death, intrapartum death and live birth) and reasons for termination, presence of CAs and causes of death for stillbirths and live births in 2003. RESULTS: Pregnancy terminations constituted between 1 and 21.5% of all very preterm births and between 4 and 53% of stillbirths. Most terminations were for CAs, although some were for obstetric indications (severe pre-eclampsia, growth restriction, premature rupture of membranes). TOP contributed substantially to overall fetal mortality rates in the two regions with late second-trimester screening. There was no clear association between policies governing screening and pregnancy termination and the proportion of CAs among stillbirths and live births, except in Poland, where neonatal deaths associated with CAs were more frequent, reflecting restrictive pregnancy termination policies. CONCLUSION: Proportions of TOP among very preterm births varied widely between European regions. Information on terminations should be reported when very preterm live births and stillbirths are compared internationally since national policies related to screening for CAs and the legality and timing of medical terminations differ.

An urban Italian study on emergency room utilisation by immigrants suffering from mental disorders in Rome, 2000-2004.

PURPOSE: To compare Emergency Room (ER) utilisation by subjects diagnosed as suffering from a mental disorder, who were born in Strong Migratory Pressure Countries (SMPC) or in Italy. To evaluate the predictors of admission to psychiatric and to non-psychiatric wards. METHOD: Data collected from Information System of Emergency Rooms were analysed. ER contacts in the years 2000-2004 pertaining to subjects who received a psychiatric diagnosis (ICD9-CM codes), and who were born in SMPC or in Italy were examined. "Contacts" included a total of 68,867 assessments made in the ER of all general hospitals in Rome having an acute psychiatric ward. Gender, age and clinical information on SMPC-born and Italian-born patients were compared. A multinomial logistic regression analysis was performed in order to determine risk factors for admission to a psychiatric or to a non-psychiatric ward. RESULTS: At the end of follow-up, 11.7% of ER contacts concerned patients born in SMPC. Compared to the Italian-born group, these patients were younger and received more frequently a diagnosis of "Alcohol and substance abuse and dependencies", while admissions to a psychiatric ward were significantly less common. CONCLUSION: Monitoring health service utilisation may provide relevant information for the delivery of culturally sensitive mental health services.

Hospitalizations for pediatric anaphylaxis.

The aim of the study is to examine the epidemiology of anaphylaxis in hospitalized children in Lazio (Central Italy) and to evaluate the incidence and case fatality rate. We also verified the concordance of diagnosis between the Emergency Department and Ordinary hospitalizations. In order to obtain these results, we reviewed all ICD-9 codes indicative of anaphylaxis in all primary and secondary diagnoses from 2000 to 2003 in all Emergency Departments, Ordinary Hospitalizations and Day Hospitals in Lazio. We then identified 203 ICD-9 diagnoses of anaphylaxis in children aged between 0 and 17 years. Anaphylactic shock (995.0) accounted for 109 (53.7%) of cases. Food anaphylaxis (995.60 onwards) accounted for 87 (43.0%) of cases. Food anaphylaxis was more frequent in the first years of life. In fact, it decreased from 12.5/100,000 resident children/year in the first year of life to 6.1/100,000 resident children/year in the first two years of life, and less than 3/100,000 resident children/year after the seventh year (p <0.001). Only 12.5% of cases of anaphylaxis diagnosed in Ordinary Hospitalizations were subsequently diagnosed by the Emergency Department as anaphylaxis. Moreover, only 42.3% of the diagnoses of anaphylaxis made in the Emergency Department were later confirmed during ordinary hospitalization. In the four years of study, one child died from anaphylaxis. Thus, mortality was 0.038 cases/100,000 resident children/year. In conclusion, the incidence of hospitalization was highest in the first years of life, during which food anaphylaxis accounted for most hospitalizations. The inconsistency of diagnoses between Emergency Departments and Ordinary Hospitalizations suggests the need to increase awareness of anaphylaxis among health workers.

[Oral health of elderly occupants in residential homes]. / Salute orale degli anziani ospiti delle Residenze Sanitarie Assistenziali.

Institutionalised elderly often report oral and dental problems which reduce nutrition ability and compromise significantly quality of life. The main objective of this study was to assess the prevalence of oral diseases in a group of residential homes elderly and to evaluate the association between degree of edentulism and some individual characteristics. From November 2004 to April 2005 448 subjects living in 10 residential homes of the city of Rome were enrolled in a special dental health programme in Lazio (Central Italy). The median age was 83.2 yrs, 47.3% of the subjects were edentulous, while 24.8% had 1 to 9 teeth, 63.1% of whom didn't have denture. 57.1% of subjects reported one or more oral disorders. Multivariate analysis showed a significant association between edentulism and the following factors: age > or = 75 yrs (Odds Ratio [OR] = 3.16 CI 95% 2.11-4.74) permanence of stay in the residential home > or = 3 yrs (OR = 1.96 CI 95% 1.13-3.40), lack of routine dental visits (OR = 1.71 CI 95% 1.14-2.58). The study findings confirmed that institutionalised elderly subjects, together with several chronic diseases, also show a poor oral health. Consequently greater attention should be paid to improve actively oral health services in this care setting.

[Italian Registry of Dialysis and Transplantation: 1996-2001 experience]. / Registro Italiano Dialisi e Trapianto. Esperienza 1996-2001.

The Italian Registry of Dialysis and Transplantation (RIDT) was born in 1996 under the aegis of the Italian Society of Nephrology, and it is organized as a federation of regional registries. This study aimed to completely revise the epidemiological data collected during the first 5 yrs (1996-2001) of RIDT activity to evaluate the trends of the main epidemiological features. During this period, regional registries were not always able to assure complete and exhaustive information according to RIDT requirements, owing to different levels of organization and functioning. To avoid any possible error in data analysis, information inadequately assessed was refused. The incidence of end-stage renal disease (ESRD) patients on renal replacement therapy (RRT) in Italy has increased from 114 pmp in 1996 to 139 pmp in 2001, that means an increase of 3.5%/yr, corresponding to 5718 patients during 1996 and 8000 patients during 2001. Primary renal diseases (according to the EDTA) in incident ESRD patients are vascular and diabetic nephropathy. Main dialysis modality in incident patients was hemodialysis (HD) (85%), while peritoneal dialysis (PD) was only 15%; pre-emptive transplantation was a very unusual modality. The prevalence of ESRD patients at 31 December was 693 pmp in 1996 and 827 pmp in 2001; among dialysis patients, the corresponding rates were 575 pmp and 657 pmp, respectively. Consequently, the number of dialyzed patients increased, respectively, from 28892 to 37919. The prevalent dialysis modality was bicarbonate dialysis in 74% of cases, followed by hemodiafiltration (HDF) in 15%, continuous ambulatory peritoneal dialysis (CAPD) in 7% and APD in 3%. The gross mortality rate in dialyzed patients was stable during this period, at approximately 14%, the main causes of death being cardiovascular diseases and cachexia.

Home breastfeeding support by health professionals: findings of a randomized controlled trial in a population of Italian women.

AIM: We conducted a randomized controlled trial to assess the effectiveness of a support intervention delivered by health professionals to increase the rate and duration of breastfeeding. METHODS: A randomized controlled intervention study was conducted in the period 2000-2001 among 605 mothers who had given birth in a public maternity ward located in the city of Rome, Italy. The intervention consisted of a home visit by a midwife from the maternity ward of the hospital. The outcome of the study was the infant's feeding habits, assessed by a 24-h recall. The effect of the intervention on the duration of breastfeeding was estimated by the Kaplan-Meier method and by the Cox multivariate regression model. RESULTS: According to intention-to-treat analysis, there was no significant difference between the intervention and the control group, after controlling for confounding factors (hazard ratio (HR) 1.04; 95% confidence interval (95% CI): 0.85-1.26). The duration of breastfeeding was shorter (HR 1.61; 95% CI: 1.13-2.31) for women in the intervention group who refused the obstetric visit. CONCLUSION: Our study shows that an early home support programme delivered by health professionals was not effective in increasing breastfeeding initiation and duration.

[Collaborative study on peritoneal dialysis (PD) as first dialysis treatment in an Italian region: 1994-2000]. / Studio collaborativo sulla dialisi peritoneale (DP) come primo trattamento nel Lazio: 1994-2000.

BACKGROUND: In Lazio, only about 5% of uremic patients are on peritoneal dialysis (PD). The present study focuses on the parameters of PD selection, the treatment schedules, and the clinical outcomes of PD patients in the nine public facilities offering a PD program. A cohort of 249 first-time PD patients, from July 1, 1994 to December 31, 2000, was retrospectively considered. METHODS: For the enrollment of the patients, the Regional Dialysis Registry databank was consulted. On December 31, 2000, a systematic review of patient charts was performed to extract the reasons for the PD choice, details of PD schedule, peritonitis episodes, reasons for drop-out, and patient survival rates. In regard to technique success-defined as the probability of having a patient alive on PD-change of modality and death were considered as final events. In regard to patient survival, only death, even in the first 2 months after a shift to hemodialysis, was considered the end point. RESULT: The main PD selection reasons were patient and/or nephrologist preference in 90% of cases. One-hundred eighty-nine patients (76%) had been started on CAPD. During the follow-up, 38.2% dialysis schedules had been modified at least once. At the end of follow-up, 41.2% patients were on APD. The peritonitis rate was one episode per 30 patient-months (1 per 27 patient-months in CAPD; 1 per 37 patient-months in APD; p = 0.08). The technique success rate was 66.3% after 2 years and 49.8% after 3 years. The patient survival rate was 81.1% after 2 years and 68.7% after 3 years. CONCLUSIONS: Patients chose PD as a first dialysis treatment mainly because of reasons unrelated to their clinical status. The technique's success, patient mortality rates, and the peritonitis rate do not explain the low PD diffusion in the region. The peritonitis rate meets the target criteria for excellence recommended by the Italian Society of Nephrology. The observed outcomes may have been favored by the selection of motivated patients and by the increased use of APD.

[Socioeconomic inequalities in health care efficacy. Three examples in Lazio region]. / Diseguaglianze socioeconomiche nell'efficacia dei trattamenti sanitari. Tre esempi nel Lazio.

There has been a limited number of studies in Italy investigating the relationship between socioeconomic inequalities and efficacy of treatments. This paper reviews three case studies on the association between socioeconomic status and disease outcome in the Lazio Region, Italy. The studies investigated: a) the probability of renal transplantation among patients with endstage renal disease; b) the survival of AIDS patients before and after the introduction of the new antiretroviral therapies; c) the 30-day mortality of patients who underwent coronary artery bypass graft surgery. The three studies demonstrate the complex relationship between socioeconomic status and both access to, and efficacy of, important health interventions.

End stage renal disease among ceramic workers exposed to silica.

OBJECTIVES: To evaluate whether ceramic workers exposed to silica experience an excess of end stage renal disease. METHODS: On the basis of a health surveillance programme, a cohort of 2980 male ceramic workers has been enrolled during the period 1974-91 in Civitacastellana, Lazio, Italy. For each worker, employment history, smoking data, and x ray film readings were available. The vital status was ascertained for all cohort members. All 2820 people still alive and resident in the Lazio region as in June 1994 were searched for a match in the regional end stage renal diseases registry, which records (since June, 1994) all patients undergoing dialysis treatment in public and private facilities of the region. Expected numbers of prevalent cases from the cohort were computed by applying the rate of patients on dialysis treatment by the age distribution of the cohort. RESULTS: A total of six cases was detected when 1.87 were expected (observed/expected (O/E) = 3.21; 95% confidence interval (95% CI) 1.17 to 6.98). The excess risk was present among non-smokers (O = 2; O/E = 4.34) and smokers (O = 4; O/E = 2.83), as well as among workers without silicosis (O = 4; O/E = 2.78) and workers with silicosis (O = 2; O/E = 4.54). The risk was higher among subjects with < 20 years since first employment (O = 4; O/E = 4.65) than among those employed > 20 years. CONCLUSION: These results provide further evidence that exposure to silica dust among ceramic workers is associated with nephrotoxic effects.

Determinants of psychiatric inpatient admission to general hospital psychiatric wards: an epidemiological study in a region of central Italy.

OBJECTIVE: To determine which factors contribute to the decision to admit individuals to psychiatric wards in general hospitals. METHOD: Data on 1,379 individuals undergoing psychiatric evaluation in eight emergency rooms in a region of central Italy were collected. A logistic regression analysis was used to evaluate the likelihood of psychiatric admission considering the independent effects of demographic, social, and clinical factors and of the history of psychiatric treatment. RESULTS: The adjusted odds ratio for psychiatric admission significantly increased with the following variables: severity of symptoms; presence of paranoid states and schizophrenic psychoses, affective psychoses and acute psychotic conditions (with neurotic disorders used as reference); a history of outpatient treatment; the presence of a staff member of a community mental health facility upon presentation at the emergency room; and the availability of beds in the psychiatric ward. CONCLUSION: The independent effect played by the presence of a staff member of a community mental health facility is of particular interest, suggesting the existence of a collaborative relationship between inpatient and outpatient services.

Risk factors of hepatitis C virus infection in patients on hemodialysis: a multivariate analysis based on a dialysis register in Central Italy.

A seroprevalence survey of antibodies to HCV was carried out among 2788 hemodialysis (HD) patients in a region of central Italy. Anti-HCV seroprevalence was 28.6%. A multivariate analysis of risk factors showed a significant association with time on HD, history of blood transfusion and metropolitan area of residence. Our study clearly showed that HCV infection is common among HD patients and is partially associated with preventable factors.

[The descriptive epidemiology of patients with kidney failure on chronic dialysis treatment. The results of the Lazio Population Registry. The Lazio Dialysis Registry]. / Epidemiologia descrittiva dei pazienti con insufficienza renale in trattamento dialitico cronico. Risultati del Registro di Popolazione del Lazio. Il Registro Dialisi Lazio.

The study presents the methodology and selected results of the Lazio Dialysis Registry. The registry, begun in 1994, documents basic demographic data, minimal clinical information and vital status of all end-stage renal disease patients on dialysis treatment in Lazio region. At June 1994 the register included 2834 patients; during the next 12 months, 618 new patients had been notified. In one-year follow-up, among prevalent patients, 308 deaths and 90 renal transplants, and among new patients, 80 deaths and 9 renal transplants were observed. The mean age of the studied population was 59.6 (SD 15.1) for prevalent patients and 61.9 (SD 15.3) for new patients. Among prevalent patients 58.8% were males and 41.2% females, among new patients these figure were 62.1% and 37.9%, respectively. The prevalence rate was 55 per thousand population and the incidence rate was 12.0. The leading cause of renal failure was glomerulonephritis in prevalent patients (27.7%), among new patients the most representative group was nephropathies of unknown origin (27.0%). About 85% were on hemodialysis treatment, and about 4% on peritoneal dialysis. The cumulative survival rates during the one-year follow-up was 81.9%, among patients with age less than 65 years a better survival for males (94.9%) than females (90.1%) was observed. The results of the first year of activity show that a population-based registry of patients on chronic dialysis treatment can be an useful tool for service planning and epidemiological research.

Cesarean section rates by type of maternity unit and level of obstetric care: an area-based study in central Italy.

BACKGROUND: The rate of cesarean section in the Lazio region of Italy is one of the highest in the Western world, 26.5%. In order to evaluate the effects of nonmedical factors on cesarean section, we examined its relationship to the characteristics of maternity units in the region. METHODS: We collected data from the birth certificates of 91,557 infants born to women residing in Lazio in 1988-1989 and classified all maternity units in the region by method of financing (public, semiprivate with arrangements with the national health service, and completely private) and level of obstetric care (unclassified and levels I,II, and III). The rates of cesarean section were examined for primiparous and multiparous women, taking into account birthweight, gestational age, fetal presentation, maternal age, and day of delivery. RESULTS: The adjusted odds ratio for cesarean section (with public units of level I taken as reference) was 1.06 (primiparous) and 1.22 (multiparous) for semiprivate maternity units and 1.59 (primiparous) and 1.52 (multiparous) for private units; it increased to 1.59 (primiparous) and 1.61 (multiparous) for unclassified semiprivate units and to 2.06 (primiparous) and 1.87 (multiparous) for unclassified private units. CONCLUSIONS: The rate of cesarean section was associated in the Lazio region with private payment for hospital care and with inadequate level of obstetric care. The latter factor is of particular concern and should be investigated elsewhere.