[Synchronies and asynchronies in the development of COVID-19 pandemic in Italy]. / Sincronie e asincronie negli sviluppi della pandemia di COVID-19 sul territorio.

BACKGROUND: the study of the possible determinants of the rise and fall of infections can be of great relevance, as was experienced during the COVID-19 pandemic. One of the methods to understand whether determinants are simultaneous or develop through contiguity between different areas is the study of the diagnostic replication index RDt among regions. OBJECTIVES: to introduce the analysis of RDt variability and the subsequent application of a recently introduced functional clustering method as highly useful procedures for recognizing the presence of clusters with similar trends in epidemic curves. DESIGN: within the considered period, trends in regional RDt are analyzed in detail over four different time intervals. SETTING AND PARTICIPANTS: to exemplify this methodology, the study of variability in the period from the end of 2021 to the beginning of 2022 may be of interest. MAIN OUTCOMES MEASURES: the variability in the regional RDt indices is assessed by means of the correlation coefficient weighted with respect to the populations of the individual regions. The clustering procedure is applied to the time series of absolute RDt values. RESULTS: it emerges that the periods of increasing variability in the RDt correspond to the initial growth or decrease in the number of infections, while functional clustering identifies macro-areas in which the epidemic curves have had similar trends. What caused contagions to increase seems to relate to a factor that is not specific to certain areas, with the contribution in some cases of a contagion dynamic between adjacent areas. CONCLUSIONS: the variability in the trend of regional diagnostic replication indices, which are calculated with only a few days delay, is a further indicator for the early detection of major changes in the trend of epidemic curves. The clustering of epidemic index curves may be useful to determine whether determinants act simultaneously or by contiguity between adjacent areas.

[The wave train of COVID-19 infections]. / COVID-19: il treno di onde dei contagi.

The present work studies the epidemic curve of COVID-19 in Italy between September 2020 and mid-June 2021 in terms of poussées, that is successive waves. There is obviously only one pandemic, although the virus has spread in the form of several variants, but the daily incidence trend can also be read in terms of overlapping of events that are different from each other or, in any case, induced by various phenomena. It can be hypothesized that in this way a succession of various waves was generated, which are modelled here using appropriate adaptation curves used in the study of epidemic data. Each curve corresponds approximately to the situation that would have occurred if no element had intervened to prevent the decrease of infections after the relative peak, while their overlap is considered to describe the subsequent increases. This interpolation has no predictive purpose, being purely descriptive over the time window under consideration. The discrepancies between the superposition of the modelling curves and the real epidemic curve are therefore also highlighted, especially in the transition periods between the various poussées. Finally, the analysis carried out allows to match the trend of the epidemic in the period considered with, on one hand, the series of events and, on the other, with the containment measures adopted which may have determined the succession of increases and decreases in the incidence of infections.

[Rt or RDt, that is the question!] / Rt or RDt, that is the question!

The article compares two of the most followed indices in the monitoring of COVID-19 epidemic cases: the Rt and the RDt indices. The first was disseminated by the Italian National Institute of Health (ISS) and the second, which is more usable due to the lower difficulty of calculation and the availability of data, was adopted by various regional and local institutions.The rationale for the Rt index refers to that for the R0 index, the basic reproduction number, which is used by infectivologists as a measure of contagiousness of a given infectious agent in a completely susceptible population. The RDt index, on the other hand, is borrowed from the techniques of time series analysis for the trend of an event measurement that develops as a function of time. The RDt index does not take into account the time of infection, but the date of the diagnosis of positivity and for this reason it is defined as diagnostic replication index, as it aims to describe the intensity of the development of frequency for cases recognized as positive in the population.The comparison between different possible applications of the methods and the use of different types of monitoring data was limited to four areas for which complete individual data were available in March and April 2020. The main problems in the use of Rt, which is based on the date of symptoms onset, arise from the lack of completeness of this information due both to the difficulty in the recording and to the absence in asymptomatic subjects.The general trend of RDt, at least at an intermediate lag of 6 or 7 days, is very similar to that of Rt, as confirmed by the very high value of the correlation index between the two indices. The maximum correlation between Rt and RDt is reached at lag 7 with a value of R exceeding 0.97 (R2=0.944).The two indices, albeit formally distinct, are both valid; they show specific aspects of the phenomenon, but provide basically similar information to the public health decision-maker. Their distinction lies not so much in the method of calculation, rather in the use of different information, i.e., the beginning of symptoms and the swabs outcome.Therefore, it is not appropriate to make a judgment of preference for one of the two indices, but only to invite people to understand their different potentials so that they can choose the one they consider the most appropriate for the purpose they want to use it for.

[Equity of access to percutaneous transluminal coronary angioplasty (PTCA) among patients with acute myocardial infarction in Tuscany Region (Central Italy), 2001-2008]. / Equità nell'accesso all'angioplastica coronarica transluminale percutanea (ACTP) nei pazienti con infarto miocardico acuto in Toscana, 2001-2008.

OBJECTIVE: assessing the equity in the access to the percutaneous transluminal coronary angioplasty (PTCA) and in its time trend among patients with ST-elevation acute myocardial infarction. DESIGN: observational study based on regional administrative data: Hospital Discharge Registry, Health Registry, and 2001 Census data. Two indexes were used as deprivation measure: deprivation status at small area level (as proxy of the individual deprivation) and deprivation status at Local Health Agency level. The residence in a mountain municipality was used as extra measure of contextual deprivation. SETTING AND PARTICIPANTS: patients with first emergency hospital admission for acute myocardial infarction (AMI) with ST-elevation, resident in Tuscany Region (Central Italy) and hospitalized during the period 2001-2008. MAIN OUTCOME MEASURES: relative risk (RR) of the PTCA utilization. RESULTS: multivariate analysis by multilevel multiple logistic regression showed a significant lower PTCA utilization in females (RR: 0.91, p <0.0001), in patients with high deprivation status at Local Health Agency level (RR: 0.71, p <0.0001), in residents in a mountain municipality (RR: 0.90, p <0.0001), and in patients with comorbidity (RR: 0.98, p =0.006; RR: 0.87, p <0.0001; RR: 0.69, p <0.0001 for Charlson comorbidity index equal to 1, 2, ≥3, respectively). The PTCA utilization over time has grown significantly (p <0.0001), from 26.6% in 2001 to 57.4% in 2008. This increase was more pronounced in patients with high deprivation status at Local Health Agency level (RR: 4.01, p <0.0001 for year 2008 vs. 2001), with consequent reduction of the initial differential with respect to patients with low deprivation status at Local Health Agency level (RR: 0.40, p <0.0001 in 2001 and RR: 0.93, p =0.114 in 2008). However, the differential associated with gender and residence in a mountain municipality persisted over time. DISCUSSION: In Tuscany during the period 2001-2008 a significant reduction of the differential in the PTCA utilization associated with the deprivation status at Local Health Agency level was observed. This finding could be explained by the diffusion and organization of suitable invasive cardiology units in the region, the organizational models of care, the different propensity to the PTCA utilization by the referral hospitals.

Indirect impact of the COVID-19 pandemic and its containment measures on social inequalities in hospital utilisation in Italy.

BACKGROUND: The pandemic may undermine the equity of access to and utilisation of health services for conditions other than COVID-19. The objective of the study is to evaluate the indirect impact of COVID-19 and lockdown measures on sociodemographic inequalities in healthcare utilisation in seven Italian areas. METHODS: In this multicentre retrospective study, we evaluated whether COVID-19 modified the association between educational level or deprivation and indicators of hospital utilisation and quality of care. We also assessed variations in gradients by sex and age class. We estimated age-standardised rates and prevalence and their relative per cent changes comparing pandemic (2020) and pre-pandemic (2018-2019) periods, and the Relative Index of Inequalities (RIIs) fitting multivariable Poisson models with an interaction between socioeconomic position and period. RESULTS: Compared with 2018-2019, hospital utilisation and, to a lesser extent, timeliness of procedures indicators fell during the first months of 2020. Larger declines were registered among women, the elderly and the low educated resulting in a shrinkage (or widening if RII <1) of the educational gradients for most of the indicators. Timeliness of procedures indicators did not show any educational gradient neither before nor during the pandemic. Inequalities by deprivation were nuanced and did not substantially change in 2020. CONCLUSIONS: The socially patterned reduction of hospital utilisation may lead to a potential exacerbation of health inequalities among groups who were already vulnerable before the pandemic. The healthcare service can contribute to contrast health disparities worsened by COVID-19 through more efficient communication and locally appropriate interventions.

Cost evaluation in a colorectal cancer screening programme by faecal occult blood test in the District of Florence.

OBJECTIVES: To evaluate the direct costs of first and repeat colorectal cancer screening by immunochemical faecal occult blood testing (I-FOBT). METHODS: Florence district residents aged 50-70 were invited to undergo one-time I-FOBT every two years. Full colonoscopy was recommended for FOBT-positive subjects. Direct cost analysis was carried out separately for the first and repeat screening. All relevant resources consumed by the programme were calculated. RESULTS: Among 25,428 or 62,369 subjects invited to the first or repeat screening, respectively, the corresponding participation rate was 47.8% or 52.3%, and the positivity rate was 4.4% and 3.3%. Corresponding detection rates and positive predictive values for cancer and advanced adenoma were 11.3% or 8.9% and 32.4% or 32.8%, respectively. The assessment phase accounted for the major cost, as compared with recruitment and screening. All cost indicators were slightly higher in the first screening compared with repeat screening. Cost per cancer and advanced adenoma detected was similar in the first or repeat screening. A higher than observed participation rate would have substantially reduced screening cost. CONCLUSION: Analysis of I-FOBT-organized population-based screening cost demonstrates lower cost at repeat compared with first screening and provides reference for decision-making in screening implementation.

[Sialoendoscopy: a new alternative for the treatment of salivary pathology. Our experience]. / Sialoendoscopia: una nueva alternativa en el tratamiento de la patología salival. Nuestra experiencia.

OBJECTIVES: Sialoendoscopy is a procedure used to visualize the salivary ducts and their pathology. It can be used either as a diagnostic method to rule out inflammatory processes in the parotid and submandibular glands (diagnostic sialoendoscopy) or to treat pathological areas (stenosis, extract foreign bodies or sialolithiasis) through the use of appropriate instruments (interventionist sialoendoscopy). We attempt to prove a declining rate of salivary gland excision. PATIENTS AND METHOD: Sialoendoscopy was performed in 8 patients. RESULTS: Of these, 50 % of patients were diagnosed as having sialolithiasis and the other 50 % had chronic sialoadenitis. In patients with sialolithiasis, sialoendoscopy allowed the extraction of the calculus in two patients (50 %). In the remainder, sialoendoscopy provided confirmation of the diagnosis in all cases. CONCLUSIONS: Sialoendoscopy is a new technique for use in the diagnosis, treatment and post-operative management of sialolithiasis, sialoadenitis and other salivary gland pathologies.

Risk adjusted mortality after hip replacement surgery: a retrospective study.

INTRODUCTION: Hip replacement (HR) operations are increasing. Short term mortality is an indicator of quality; few studies include risk adjustment models to predict HR outcomes. We evaluated in-hospital and 30-day mortality in hospitalized patients for HR and compared the performance of two risk adjustment algorithms. MATERIALS AND METHODS: A retrospective cohort study on hospital discharge records of patients undergoing HR from 2000 to 2005 in Tuscany Region, Italy, applied All-Patient Refined Diagnosis Related Groups (APR-DRG) and Elixhauser Index (EI) risk adjustment models to predict outcomes. Logistic regression was used to analyse the performance of the two models; C statistic (C) was used to define their discriminating ability. RESULTS: 25 850 hospital discharge records were studied. In-hospital and 30-day crude mortality were 1.3% and 3%, respectively. Female gender was a significant (p < 0.001) protective factor under both models and had the following Odds Ratios (OR): 0.64 for in-hospital and 0.51 for 30-day mortality using APR-DRG and 0.55 and 0.48, respectively, with EI. Among EI comorbidities, heart failure and liver disease were associated with in-hospital (OR 9.29 and 5.60; p < 0.001) and 30-day (OR 6.36 and 3.26; p < 0.001) mortality. Increasing age and APR-DRG risk class were predictive of all the outcomes. Discriminating ability for in-hospital and 30-day mortality was reasonable with EI (C 0.79 and 0.68) and good with APR-DRG (C 0.86 and 0.82). CONCLUSIONS: Our study found that gender, age, EI comorbidities and APR-DRG risk of death are predictive factors of in-hospital and 30-day mortality outcomes in patients undergoing HR. At least one risk adjustment algorithm should always be implemented in patient management.

Sialoendoscopia: una nueva alternativa en el tratamiento de la patología salival. Nuestra experiencia / Sialoendoscopy: a new alternative for the treatment of salivary pathology. Our experience

Objetivos: La sialoendoscopia es un procedimiento cuya finalidad es visualizar los conductos salivales y sus procesos patológicos. Se utiliza como método diagnóstico, para descartar procesos inflamatorios de las glándulas (sialoendoscopia diagnóstica) y para tratar áreas patológicas (estenosis, retirar cuerpos extraños o cálculos), mediante instrumental (sialoendoscopia intervencionista). Queremos mostrar la disminución de extirpación glandular. Pacientes y método: Se estudia a 8 pacientes intervenidos con sialoendoscopia. Resultados: En el 50 % se trataba de sialolitiasis y en el otro 50 %, de sialodenitis crónica. En las sialolitiasis la sialoendoscopia intervencionista permitió extraer el cálculo en 2 (50 %) casos. En el resto la sialoendoscopia permitió confirmar el diagnóstico en todos los casos. Conclusiones: La sialoendoscopia es un nueva técnica que nos permite diagnosticar, tratar y hacer un adecuado seguimiento de las sialodenitis, sialolitiasis y otras afecciones glandulares

Objectives: Sialoendoscopy is a procedure used to visualize the salivary ducts and their pathology. It can be used either as a diagnostic method to rule out inflammatory processes in the parotid and submandibular glands (diagnostic sialoendoscopy) or to treat pathological areas (stenosis, extract foreign bodies or sialolithiasis) through the use of appropriate instruments (interventionist sialoendoscopy). We attempt to prove a declining rate of salivary gland excision. Patients and method: Sialoendoscopy was performed in 8 patients. Results: Of these, 50 % of patients were diagnosed as having sialolithiasis and the other 50 % had chronic sialoadenitis. In patients with sialolithiasis, sialoendoscopy allowed the extraction of the calculus in two patients (50 %). In the remainder, sialoendoscopy provided confirmation of the diagnosis in all cases. Conclusions: Sialoendoscopy is a new technique for use in the diagnosis, treatment and post-operative management of sialolithiasis, sialoadenitis and other salivary gland pathologies