Analysis of the excess mortality and factors associated with deaths from COVID-19 versus other causes in Central Tuscany (Italy) in 2020.

OBJECTIVES: to assess the extent of the excess mortality from all causes in 2020 compared to 2015-2019 in Central Tuscany (Italy) as a proxy to estimate COVID-19-related excess mortality and to identify demographic and clinical differences between subjects who died from COVID-19 and those who died from other causes in 2020. DESIGN: descriptive analysis of the temporal trend of general mortality. SETTING AND PARTICIPANTS: the study population is represented by the 1.6 million residents living in the territory of the Central Tuscany Healthcare Authority in Central Italy, i.e., little less than half of the population of Tuscany, in an area of just over one fifth of the entire region, where the provinces of Florence, Pistoia, and Prato are comprised. MAIN OUTCOME MEASURES: using the Italian National Resident Population Registry (ANPR) as a source of mortality data, standardized mortality ratios with 95% confidence intervals were calculated to compare the number of deaths in 2020 with the number of deaths expected on the basis of mortality data from 2015 to 2019. Furthermore, after record linkage with data from the integrated surveillance of cases of SARS-CoV-2 virus infection and with the MaCro dataset of comorbidities, the characteristics of subjects who died from COVID-19 were compared with those of patients who died from other causes using a multivariate logistic regression model; odds ratios with 95% confidence intervals were calculated. RESULTS: a statistically significant excess mortality was observed during the first pandemic wave in March and April, and during the second wave in the fall; it ranged between +9% in March and +51% in November. On the contrary, in January, February, and May, all-cause mortality was significantly lower than in previous years. The male gender, dyslipidaemia, and dementia were positively associated with death from COVID-19 rather than from all other causes. On the contrary, heart failure and recent tumours were more represented among deaths from other causes. CONCLUSIONS: much of the over-mortality observed in spring is attributable to the harvesting effect COVID-19 exerted on a segment of population with serious underlying chronic conditions and who in the previous months had survived a mild winter and a flu season of medium intensity. In the second pandemic wave, in autumn, the impact of both direct and indirect effects of COVID-19 was substantially higher. Consistently with the available evidence, death from COVID-19 was related to the male gender and to clinical conditions such as dyslipidaemia and dementia.

[Impacts of geocoding quality in environmental epidemiology studies: two case-studies in Tuscany Region (Central Italy)]. / L'impatto della qualità della georeferenziazione negli studi di epidemiologia ambientale: due casi studio in Toscana.

OBJECTIVES: Geographical Information Systems (GIS) are widely used in environmental epidemiology studies to locate study population by geocoding addresses and to evaluate exposures and relationship with health outcomes. Despite this, Italian environmental epidemiologists poorly discuss quality of address geocoding results. DESIGN: two case-studies have been carried out in Tuscany Region (Central Italy): one in the mountain area in the Municipality of Piancastagnaio (Siena Province) and one in the urban area around the airport of Florence. Three geocoding systems have been compared: the geographical database produced by Tuscany Region and two commercial systems (Google and Bing-Microsoft); 1,549 addresses in Piancastagnaio and 2,946 addresses in Florence have been tested. RESULTS: Tuscan geographical database showed better performance than the two commercial systems, with bigger differences in Piancastagnaio. In this area, mean difference between regional system and Google service is more than 300 mt, with peaks of 7-8 km. Bing- Microsoft system does not provide any information on addresses in Piancastagnaio: all input addresses were geocoded in the centroid of the municipality or in the centre of a few principal streets. Lowest differences among the three methods were observed in the urban area of Florence: mean difference between Tuscany and Goggle systems was 150 mt, with less than 2 km peaks; between Tuscany and Bing-Microsoft mean difference was 100 mt with 3 km peaks. In both case-studies, but especially in Piancastagnaio area, these differences gave rise to great misclassification in the evaluation of individual exposure and health outcome. CONCLUSION: the study highlighted the impacts of address geocoding process in exposure assessment in environmental health research and pointed out the need of specifically evaluate the quality of cartographic data.

[Alcohol dependence in the Italian general population: diagnostic criteria according to general practitioners and to the Composite International Diagnostic Interview (CIDI)]. / L'alcoldipendenza nella popolazione generale: i criteri di diagnosi secondo i medici di medicina generale e secondo l'intervista Composite International Diagnostic Interview (CIDI).

OBJECTIVES: to identify the criteria used by general practitioners (GPs) for the diagnosis of alcohol dependence (AD) and to compare them with the criteria of the Composite International Diagnostic Interview (CIDI). DESIGN: cross-sectional correlational study. SETTING AND PARTICIPANTS: the 55 GPs of Friuli Venezia Giulia Region (Northern Italy) and Tuscany Region (Central Italy) who took part in the research conducted a clinical evaluation of the first 40 patients who came for a medical examination. MAIN OUTCOME MEASURES: prevalence of AD diagnosed by GPs and CIDI and their association with sociodemographic variables, other diseases, and alcohol consumption. RESULTS: AD prevalence assessed by the GPs was 5.4%, while AD prevalence assessed by the CIDI was 4.4%, with an overlap of about 26%. Patients identified as AD by the GPs were older and more frequently suffering from liver disease and hypertension than patients identified by the CIDI. CONCLUSIONS: the limited overlap between diagnoses of AD made by GPs and the one made by the CIDI is problematic. GPs appear to identify mainly more severe forms of AD, in which excessive consumption of alcohol is associated with the presence of liver disease, while the CIDI could identify younger patients who have not yet developed diseases. GPs' recognition of AD could be increased by using their expertise along with standardised questionnaires which measure alcohol consumption.

[Trends in occurrence, treatment, and outcomes of acute myocardial infarction in Tuscany Region (Central Italy), 1997-2010]. / Trend temporali di occorrenza, trattamento ed esiti dell'infarto miocardico acuto in Toscana, 1997-2010.

OBJECTIVES: to describe trends in attack rate, treatment, and outcomes of acute myocardial infarction (AMI) in Tuscany Region (Central Italy). DESIGN: population-based epidemiological study using the Tuscany Acute Myocardial Infarction Registry. SETTING AND PARTICIPANTS: cases have been identified by record linkage between the hospital discharge database and the mortality registry, and divided into hospitalised AMI (1997-2012) and out-of-hospital coronary deaths (1997-2010). Details on hospitalised cases based on the presence/absence of ST-segment elevation (STEMI / NSTEMI) can be detected for the period 2001-2012. MAIN OUTCOMEMEASURES: distribution by calendar time, gender, and type of event of absolute frequencies, age-standardised attack rates (per 100,000; standard Tuscany population, 2001) and percentages (standard: total hospitalised cases in 2011) of invasive cardiac procedures and 28-day case fatality in hospitalised cases. RESULTS: a reduction in both out-of-hospital coronary deaths and STEMI hospitalisations (attack rates, respectively, - 2.3% and -3.9% in males, -3.3% and -4.1% in females) and an increase in NSTEMI hospitalisations (+13.1% in males and +13.3% in females) were shown. The use of invasive cardiac procedures (PCI, coronary angiography) in hospitalised cases shows a considerable increase over time both in STEMI and in NSTEMI. The proportion, however, always remains lower in the whole period after the age of 70 and in women. The short term prognosis in hospitalised AMI cases shows an improvement over time, which, however, disappears when stratified by type of AMI. This trend is mainly related to the different weight that STEMI and NSTEMI have on incidence over time (increase in attack rates for NSTEMI and reduction for STEMI, with worst prognosis). CONCLUSIONS: results confirm the important changes in epidemiology, clinical presentation, and treatment of acute coronary disease in Tuscany, previously identified in the international literature. Differences in coronary reperfusion treatment of hospitalised cases still persist by age and gender. Additional efforts are needed to ensure equity in access to the best treatment for AMI.

Oral bisphosphonates do not increase the risk of severe upper gastrointestinal complications: a nested case-control study.

BACKGROUND: Data on the effect of oral bisphosphonates (BPs) on risk of upper gastrointestinal complications (UGIC) are conflicting. We conducted a large population-based study from a network of Italian healthcare utilization databases aimed to assess the UGIC risk associated with use of BPs in the setting of secondary prevention of osteoporotic fractures. METHODS: A nested case-control study was carried out within a cohort of 68,970 patients aged 45 years or older, who have been hospitalized for osteoporotic fracture from 2003 until 2005. Cases were the 804 patients who experienced hospitalization for UGIC until 2007. Up to 20 controls were randomly selected for each case. Conditional logistic regression model was used to estimate odds ratio (OR) associated with current and past use of BPs (i.e. for drug dispensation within 30 days and over 31 days prior the outcome onset, respectively) after adjusting for several covariates. RESULTS: Compared with patients who did not use BPs, current and past users had OR (and 95% confidence interval) of 0.86 (0.60 to 1.22) and 1.07 (0.80 to 1.44) respectively. There was no difference in the ORs estimated according with BPs type (alendronate or risedronate) and regimen (daily or weekly), nor with co-therapies and comorbidities. CONCLUSIONS: Further evidence that BPs dispensed for secondary prevention of osteoporotic fractures are not associated with increased risk of severe gastrointestinal complications is supplied from this study. Further research is required to clarify the role BPs and other drugs of co-medication in inducing UGIC.

Effectiveness of oral bisphosphonates for primary prevention of osteoporotic fractures: evidence from the AIFA-BEST observational study.

PURPOSE: Osteoporosis is a chronic disease of the bone, whose incidence increases progressively with aging. The main consequences of osteoporosis are fragility fractures, which have considerable medical, social, and economic implications. Adequate treatment of osteoporosis must be considered as a compelling public health intervention. Bisphosphonates (BPs) represent the most significant advance in this field in the past decade, and they are widely used in the treatment of osteoporosis. However, evidence for their effectiveness is limited to secondary prevention, whereas their effect in primary prevention is uncertain and needs further investigation. METHODS: Using administrative data collected in the "Biphosphonates Efficacy-Safety Tradeoff" (BEST) study, a nested case-control study was conducted by including 56,058 participants, aged 55 years who were started on oral BPs from 2003 to 2005. Cases were the 1,710 participants who were hospitalized for osteoporotic fractures until 2007. Up to 20 controls were randomly selected for each case. Conditional logistic regression model was used to estimate odds ratio of fracture associated with categories of treatment duration. RESULTS: Compared with participants assuming BPs for less than 1 year, those who remained on therapy for at least 2 years had a 21% (95% confidence interval (CI) 7 to 33%) fracture risk reduction. CONCLUSION: This study provides evidence that BPs, dispensed for primary prevention of osteoporotic fractures, are associated with a reduced risk of osteoporotic fractures after at least 2 years of treatment.

User-only design to assess drug effectiveness in clinical practice: application to bisphosphonates and secondary prevention of fractures.

PURPOSE: Different strategies applicable to control for confounding by indication in observational studies were compared in a large population-based study regarding the effect of bisphosphonates (BPs) for secondary prevention of fractures. METHODS: The cohort was drawn from healthcare utilization databases of 13 Italian territorial units. Patients aged 55 years or more who were hospitalized for fracture during 2003-2005 entered into the cohort. A nested case-control design was used to compare BPs use in cohort members who did (cases) and who did not experience (controls) a new fracture until 2007 (outcome). Three designs were employed: conventional-matching (D1 ), propensity score-matching (D2 ), and user-only (D3 ) designs. They differed for (i) cohort composition, restricted to patients who received BPs straight after cohort entry (D3 ); (ii) using propensity score for case-control matching (D2 ); and (iii) compared groups of BPs users versus no users (D1 and D2 ) and long-term versus short-term users (D3 ). RESULTS: Bisphosphonate users had odds ratios (95% confidence interval) of 1.20 (1.01 to 1.44) and 0.95 (0.74 to 1.24) by applying D1 and D2 designs, respectively. Statistical evidence that long-term BPs use protects the outcome onset with respect to short-term use was observed for user-only design (D3 ) being the corresponding odds ratio (95% confidence interval) 0.64 (0.44 to 0.93). CONCLUSIONS: User-only design yielded closer results to those seen in RCTs. This approach is one possible strategy to account for confounding by indication.

Trends in consumption of alcoholic beverages and policy interventions in Europe: an uncertainty "associated" perspective.

Having qualitatively investigated, both the temporal curves of alcoholic beverage consumption trends and the introduction of preventive alcohol policy measures in six European countries during the 1960s-2000s, drinking control policy measures often appeared to operate as co-factors of change, while during some periods of time they were not even present even if effective consumption changes were occurring. Study limitations are noted.

Italy between drinking culture and control policies for alcoholic beverages.

This paper focuses on whether the on-going dramatic decrease in alcohol consumption in Italy, especially of wine, during 1961-2008, was associated with which parallel sociodemographic and economic changes and with alcohol control policies. The study, using both time series (TS) and artificial neural network (ANN)-based analyses documents that its selected sociodemographic and economic factors, and particularly urbanization, had a definite connection with wine consumption decrease, spirits decrease, and the increase in beer consumption over time. On the other hand, control policies showed no effect on the decline in alcohol consumption, since no alcohol control policy existed in Italy between 1960 and 1987. A few policies introduced since 1988 (BAC and sale restrictions during mass events) may have contributed to reducing or to maintaining the on-going reduction. Study limitations are noted and future needed research is suggested.

Ozone short-term exposure and acute coronary events: a multicities study in Tuscany (Italy).

OBJECTIVE: Many studies have investigated the potential role of ozone exposure in cardiovascular mortality and morbidity. The effects on specific cardiovascular outcome and the role of individual susceptibility are less studied. This paper focuses on the short-term effects of ozone on acute coronary events and it investigates comorbidities as indicators of personal susceptibility. SETTING AND PATIENTS: This study was conducted in five urban areas of the Tuscany region (Italy) covering the period January 2002-December 2005. Air quality and meteorological data from urban background monitoring sites were collected. Hospital admissions for acute myocardial infarction and out-of-hospital coronary deaths were extracted from administrative database. DESIGN: Both time series and case-crossover designs were applied. The confounding effects of some time-dependent variables, such as temperature, were taken into account. Some potential susceptibility factors were investigated. Pooled estimates were derived from random-effect meta-analysis. RESULTS: During the warm season 4555 hospitalized acute myocardial infarctions and 1931 out-of-hospital coronary deaths occurred. Authors estimated a 6.3% (95% confidence interval, 1.2%, 11.7%) increase in out-of-hospital coronary deaths for a 10 µg/m3 increase in ozone (lag 0-5). Results also suggested higher risks for females, elderly, and patients previously hospitalized for cerebrovascular and artery diseases. CONCLUSIONS: This study adds further evidence to the relation between cardiovascular diseases and ozone exposure, showing an adverse effect on out-of-hospital coronary deaths, but not on hospitalized acute myocardial infarctions. Some susceptible subgroups, such as females, elderly, and patients affected by some chronic diseases, are likely to be at major risk.

[The study "Social health need of elderly people in Tuscany (Italy)": an example of epidemiology inside a regional programming cycle]. / Lo studio "Bisogno sociosanitario degli anziani in Toscana": un esempio di epidemiologia integrata in un ciclo di programmazione regionale.

OBJECTIVE: in 2008,Tuscany Region (Italy) allocated the "Regional Fund for Disabled Elderly People" to support a dedicated local welfare system mainly characterised by universal access and resource allocation proportional to assessed individuals' personal care needs. To assure sustainability, reliable estimates of disabled elderly people living in the Region, stratified by level of personal care needs, were needed. For such a purpose, in 2009, the Regional Health Agency of Tuscany conducted a survey called Bi.S.S. DESIGN: cross-sectional survey inside the resident population over 65 years. A structured questionnaire was used for detection: it contains the same multidimensional evaluation instruments used by Multidisciplinary Evaluation Units of the region. SETTING AND PARTICIPANTS: sample of Tuscany population over 65 years; stratified sampling by gender, age and residence zone (No. 2.551). Cases were extracted from the inhabitants registry of Tuscany. Evaluation data were collected only for the elderly who lived at home. MAIN OUTCOMEMEASURES: prevalence estimation and current and forecasted expected cases (by gender and age) of home resident disabled elderly people (according to inability to perform basic activities of daily living), by level of personal care needs (according to a pre-defined scale ranging 1-5, based on the level of dependence in performing basic activities of daily living, cognitive impairments and behaviour disorders). Expected cases were calculated on demographic data supplied by the Italian National Institute of Statistic (ISTAT). RESULTS: about 67,000 home resident disabled elderly people (49,000 women and 18,000 men) are currently expected to live in Tuscany, equal to 7.8% of the population aged 65 years and over. Of these, about 13,000 are classified at level of personal care needs 1; 7,500 at level 2; 15,500 at level 3; 24,000 at level 4; and 7,000 at level 5. By 2015, disabled elderly people living in Tuscany are expected to increase up to 80,500. CONCLUSIONS: on the basis of the available resources and of these results, amount of resources to be allocated for the personal care of the individual disabled people according to his/her level of care needs have been decided. Therefore, Bi.S.S. has been a good example of an epidemiological survey fully integrated in a regional programming plan. The expected increase in the next future of elderly disabled people calls for urgent prevention programmes and organization of cost-effective personal care services.

[A screening and comprehensive assessment programme aimed at secondary prevention of disability in community-dwelling frail older subjects: a pilot study]. / Screening della fragilità e valutazione multidimensionale degli anziani residenti a domicilio per la prevenzione secondaria della disabilità: risultati di uno studio pilota.

OBJECTIVE: to test a screening and comprehensive assessment procedures for frail elderly in Tuscany (Central Italy) in the perspective of interventions to prevent disability. DESIGN: two-phases feasibility study: a) screening phase, using a postal questionnaire and b) comprehensive assessment phase, aimed at identifying risk factors for disability that might be targeted by specific interventions. SETTING AND PARTICIPANTS: 11,589 individuals aged over 70, living at home, identified from residents registry of 2 health care districts in Tuscany, excluding subjects with recognized disability and those living in nursing home. Participants were sent a 7-item postal questionnaire (modified Sherbrooke Postal Questionnaire). Respondents with a score =3, suggestive of frailty, were offered an in-home comprehensive assessment performed by a nurse or social worker, oriented to ascertain independence in activities of daily living, lower limbs extremity function, mood status, malnutrition risk, cognitive level, visual acuity, hearing function, environmental risk and medications number. General practitioners, social workers or specific health care services were thereafter informed about results of the assessment with recommendations for specific interventions. RESULTS: among 6,629 respondents to the questionnaire, 52% (No. 3,432) scored =3, triggering the comprehensive assessment, which was performed in 66% of cases (No. 2,276). Out of them, 38% showed already a disability in basic activities of daily living. Of the remaining 1,411, 38% showed a disability in instrumental activities of daily living, 30% a reduced lower limb extremity function, 18% depressive symptoms, and 11% a cognitive impairment. Human resources used for the project were limited in relation to the extent of the involved population. CONCLUSIONS: postal screening of frailty in older subjects is feasible and is able to identify patients who might benefit from further assessment to address interventions for specific risk factors.

Case-Control Study on the Routes of Transmission of SARS-CoV-2 after the Third Pandemic Wave in Tuscany, Central Italy.

The emergence of hyper-transmissible SARS-CoV-2 variants that rapidly became prevalent throughout the world in 2022 made it clear that extensive vaccination campaigns cannot represent the sole measure to stop COVID-19. However, the effectiveness of control and mitigation strategies, such as the closure of non-essential businesses and services, is debated. To assess the individual behaviours mostly associated with SARS-CoV-2 infection, a questionnaire-based case-control study was carried out in Tuscany, Central Italy, from May to October 2021. At the testing sites, individuals were invited to answer an online questionnaire after being notified regarding the test result. The questionnaire collected information about test result, general characteristics of the respondents, and behaviours and places attended in the week prior to the test/symptoms onset. We analysed 440 questionnaires. Behavioural differences between positive and negative subjects were assessed through logistic regression models, adjusting for a fixed set of confounders. A ridge regression model was also specified. Attending nightclubs, open-air bars or restaurants and crowded clubs, outdoor sporting events, crowded public transportation, and working in healthcare were associated with an increased infection risk. A negative association with infection, besides face mask use, was observed for attending open-air shows and sporting events in indoor spaces, visiting and hosting friends, attending courses in indoor spaces, performing sport activities (both indoor and outdoor), attending private parties, religious ceremonies, libraries, and indoor restaurants. These results might suggest that during the study period people maintained a particularly responsible and prudent approach when engaging in everyday activities to avoid spreading the virus.

[State of health of populations residing in geothermal areas of Tuscany]. / Stato di salute delle popolazioni residenti nelle aree geotermiche della Toscana.

OBJECTIVE: The limited scientific knowledge on relationship between exposure and health effects in relation to geothermal activity motivated an epidemiologic investigation in Tuscan geothermal area. The study aims to describe the health status of populations living in Tuscany municipalities where concessions for exploitation of geothermal resources were granted. DESIGN: This is an ecological study, so it is not useful to produce evidence to sustain a judgment on the cause-effect link. The major limits of this type of study are the use of the residence at municipal level as a proxy of exposure to both environmental and socioeconomic factors and the use of aggregated data of health outcomes that can lead to the well-known ecological fallacy. SETTING AND PARTICIPANTS: Sixteen municipalities were included in the study area: eight are part of the so-called "traditional" geothermal area, defined as Northern Geothermal Area (NGA) and eight located in the Amiata Mountain defined as Southern Geothermal Area (SGA). In 2000-2006, the average resident population in the overall area was approximately 43,000 inhabitants. Thirty-one geothermal power plants were active, with a production capacity of 811 MW, 5 of them with 88 MW located in the SGA. Statistical analyses on the entire geothermal area, NGA and SGA subareas, and the sixteen municipalities were performed. MAIN OUTCOME MEASURES: Mortality data were obtained from Tuscany Regional Mortality Registry for the 1971-2006 period, analysing 60 causes of death, of interest for population health status or consistent with "Project SENTIERI" criteria. Hospital discharge records of residents in Tuscany Region in 2004-2006, anywhere admitted to hospital, were analyzed considering only the main diagnosis, excluding repeated admissions for the same cause. The causes taken into account are the same analysed for mortality were considered. Age-standardized mortality rates (TSDM) and the temporal trends of TSDM for four periods (1971-1979, 1980-1989, 1990-1999, 2000-2006) were computed. Age-standardized mortality/hospitalization ratios (SMR/SHR), with and without adjustment for the deprivation index based on 2001 census data, were calculated: mortality in the years 2000-2006 and hospitalization in 2004-2006. The expected number of events were computed using rates of residents in neighbouring municipalities (municipalities included in 50 km radius circle centred on the study area). Bayesian estimates of mortality/hospitalization ratios (BMR/BHR) at municipal level only and relating maps of the Bayesian risk estimators were elaborated. Congenital malformations (MC) were analysed using data from Tuscan Registry of Birth Defect in 1992-2006 period, relative to outcomes of pregnancies in women resident in the municipalities of study area, wherever the birth or termination of pregnancy occurred. The ratio between observed and expected cases (O/A), with expected defined according to regional rate, were calculated and O/A Bayesian estimates (BMR) are showed only at municipal level. The low weight and the males/females ratio at birth were analysed using data from Tuscany Birth Certificates, covering period 2001-2007, excluding births occurred in facilities outside Tuscany Region. For Low birth weight (< 2,500 grams), very low birth weight (< 1,500 grams), low birth weight in women with normal gestational age or greater than 36 weeks, gestational age less than 36 weeks, and the frequency of males, the observed/expected ratio was calculated, with the expected number defined according to regional rate. RESULTS: ENVIRONMENTAL BACKGROUND: High levels of arsenic in drinking water distribution emerges as a critical element, so that several municipalities resorted to granting exemptions for the parameters laid down by the Legislative Decree in force (D.Lgs 31/01). However, during the final phase of the study, new blast systems activated in the SGA decreased the arsenic levels in the water supply, reaching values not requiring derogations, which, instead, are still effective in some NGA municipalities. Air quality data, from Tuscany Regional Agency for Environmental Protection-ARPAT, show that geothermal activities are able to affect air quality, especially with hydrogen sulphide in NGA, and hydrogen sulphide and mercury in SGA. A significant contribution to the presence of mercury in air is due to previous metallurgical sites. Although mercury levels are below WHO guideline values, in SGA nearby Siena, values were significantly higher than in other geothermal areas, because of power plant PC2 (turned off in July 2011) in Piancastagnaio municipality. The hydrogen sulphide concentration levels were generally lower than WHO reference values, with occasional excesses over guideline value for health protection (150 µg/m3 as average of the 24 hours). Olfactory pollution was more critic with values exceeding 7-10 µg/m3 range even in areas without geothermal plants. RESULTS: POPULATION'S HEALTH STATUS: This study evaluated health status of resident population in geothermal areas analysing geographic and temporal distribution of mortality, hospitalization and reproductive health outcomes (congenital malformations, low birth weight, sex ratio among newborns). In both geothermal areas mortality rates steadily declined from 1971 to 2006, in males and females, in line with the regional trends. In 2000-2006 period, in the overall geothermal area a significant mortality excess was observed for all causes among males (2,312 deaths, 2,146 expected), but not among females, using as reference residents in neighbouring municipalities. The mortality excess among males was more evident for infectious diseases (25 deaths, 10 expected), especially tuberculosis (8 deaths, 2 expected), for respiratory diseases (218 deaths, 170 expected), in particular pneumoconiosis, including deaths from silicosis (51 deaths, 14 expected), and for nervous system diseases (72 deaths, 56 expected). Among females significant mortality excess for liver cirrhosis (35 deaths, 25 expected) emerged, while mortality from cardiovascular diseases and ischemic heart diseases were significantly lower than expected. In the NGA, mortality among men was lower than expected for all cancers (-15%), in particular for lung cancer (- 25%), while values significantly in excesses were observed for infectious diseases (11 observed, 4 expected) and respiratory diseases (90 observed, 73 expected), expecially pneumoconiosis (20 observed, 6 expected). Among females, significant mortality excesses for ovarian cancer (17 observed, 10 expected) and for circulatory disorders of brain (170 observed, 140 expected) resulted. In the SGA, mortality was more critical, accounting for majority of the excesses detected in overall Geothermal Area. In fact, only infectious diseases and pneumoconiosis were detected in excess in both the geothermal areas. In the SGA, excess of general mortality among males (1,431 deaths; 1,245 expected) but not among females emerged. Even for all cancers, an excess among males (505 deaths, 419 expected) was observed, in particular for cancer of stomach (53 deaths, 44 expected, not statistically significant after adjusting for DI), liver (39 deaths, 23 expected) and lung (124 deaths, 102 expected) cancer. Mortality in SGA was also in excess for respiratory diseases only among men (128 deaths, 97 expected), mostly due to silicosis (31 deaths, 8 expected), although steadily decreasing since 1971 as observed at regional level. Also tuberculosis resulted in excess in SGA (7 deaths, 1 expected). Among females acute respiratory disease mortality was significantly in excess (41 observed, 29 expected). Temporal trend showed a decline from the 70s to the 90s, with a rising trend in recent years in line with Tuscany region. It should be considered that pneumonia was the commonest cause of death of acute respiratory diseases, which allow for lower reliability of death certificate, especially among the elderly (> 64 years). Among females resident in SGA a mortality excess from digestive system diseases was observed (72 observed, 55 expected). The hospitalization in the overall Geothermal Area did not show any excess for all causes and all tumours in both genders. Statistically significant excesses for hospital admission from stomach cancer among males (49 observed, 38 expected) and females (42 observed, 28 expected), and from lymphohematopoietic tumours among females, particularly from lymphatic leukaemia (15 observed, 5 expected), were observed. As mortality analysis highlighted, also hospital admissions by geothermal areas and gender showed a worst picture in SGA than in NGA. In the latter, a significant excess of hospital admissions from all causes among females (1,357 observed, 1,284 expected) but not among males (1,193 observed, 1,141 expected) and an excess - close to statistical significance - from all tumours only among females (297 observed; 272 expected) were observed. Furthermore, statistically significant excesses of hospital admissions from digestive system diseases in both genders (M: 392 observed, 350 expected; F: 300 observed, 268 expected), from dementias (16 observed, 8 expected) and from lympho hematopoietic cancers among females, particularly from lymphatic leukaemia (9 observed, 2 expected), were observed. In the SGA, statistically significant excesses of hospital admissions for stomach cancer (M: 32 observed, 21 expected, not significant after adjusting by DI; F: 29 observed, 18 expected), for respiratory diseases (M: 408 observed, 351 expected; F: 339 observed, 277 expected) and for renal failure (M: 61 observed, 41 expected; F: 52 observed, 34 expected) were observed in both genders. (ABSTRACT TRUNCATED)

Evaluation of the Anti-Spike (RDB) IgG Titer among Workers Employed at the University of Pisa Vaccinated with Different Types of SARS-CoV-2 Vaccines.

With the development of SARS-CoV-2 vaccines, many authors started evaluating the immunization efficacy of the available vaccines mainly through sero-positivity tests or by a quantitative assessment of the IgG against the spike protein of SARS-CoV-2 virus in vaccinated subjects. In this work, we compared the titers resulting from vaccination and tried to understand the potential factors affecting the immune response to the available SARS-CoV-2 vaccines. This study was conducted on 670 volunteers employed at the University of Pisa and undergoing a health surveillance program at the University Hospital of Pisa. For each participant, 10 mL of blood, information about contacts with confirmed cases of COVID-19, age, sex, SARS-CoV-2 vaccination status, previous SARS-CoV-2 infection and symptoms, type of vaccine and the date of administration were collected. In the multivariate analysis, the type of vaccine, the presence of symptoms in SARS-CoV-2 positive individuals, and the distance from the second dose significantly affected the antibody titer; the combined vaccination resulted in a faster decay over time compared with the other types of vaccination. No significant differences were observed between Spikevax and Comirnaty (p > 0.05), while the antibody levels remain more stable in subjects undergoing Vaxzevria vaccination (p < 0.01) compared with mRNA-based ones.

[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.

Alcohol and tobacco consumption among Albanian immigrants in Florence.

The aim of the present study was to obtain information about both drinking and smoking, as well as about alcohol consumption-related problems, among Albanians who have immigrated to Florence, Italy, after the collapse of the Communist regime in 1990. Between October 2001 and January 2002, an opportunistic sample of 141 Albanians living in the city of Florence were interviewed about their alcohol and tobacco use, as well as about their drinking pattern and health problems Interviewees were mainly (81%) males, of an average age of 28, who had been living in Italy for the last 4 years; 92.9% drank alcoholic beverages, the preferred beverages were wine and liquor, and the average daily consumption was 39.5 grams of pure alcohol-males consumed 48.1 grams per day, which was 3.5 times more than a comparable sample of Florentine males. Also Albanians overtook Florentines in terms of the rate of smokers (49.6% vs. 39.6%) and of contact with the emergency rooms (24.1% vs. 0.37%). Such high amounts of alcohol intake may contribute to the reported high rates of accidents and acts of violence involving Albanians in Florence. Some hypotheses were discussed to explain such a high level of alcohol consumption, including the sociocultural change due to emigration. The study's limitations are noted.

Epidemiological, demographic and clinical data on chronic viral hepatitis C in Tuscany.

BACKGROUND: Recent introduction of direct antiviral agents (DAAs) has completely changed the scenario regarding hepatitis C virus (HCV) treatment. Certain countries' economic health programs prioritize DAAs according to specific clinical features of HCV-infected patients. The aim of this study was to define epidemiological, demographic and clinical characteristics of HCV-infected patients in the Tuscany region of central Italy. METHODS: We enrolled HCV patients with chronic viral hepatitis who were referred to the outpatient services of 16 hospitals in Tuscany from 1 January 2015 to 31 December 2015. Case report forms contained patient information including main demographic data, blood chemistry data, viral hepatitis markers, instrumental evaluations (liver biopsy or transient elastometry, liver ultrasound), eligibility for DAAs, and liver transplantation or therapy already in progress. RESULTS: Of all patients considered, 2919 HCV patients were enrolled (mean age: 57.44 ± 15.15; 54% males, 46% females). All routes of transmission were well represented (intravenous drug use in 20.7%; nosocomial/dental care in 20.6%; and coagulation factors/blood transfusions in 13.3%). Diabetes was the highest represented comorbidity (20.8%), followed by metabolic syndrome (15.5%) and ischemic heart disease (6.2%). The most prevalent HCV genotypes were 1b (47.4%) and 2 (16.5%). In the whole cohort of patients, 32.8% were cirrhotic (40 patients were listed for liver transplantation). Signs of portal hypertension were present mostly in the group older than 45 years (92.3%). Extrahepatic HCV-related diseases were present in 13.3% of cases (cryoglobulinemic syndrome in 58.3% and B-cell non-Hodgkin's lymphoma in 10.5%). CONCLUSIONS: Our study provides evidence of a high prevalence of epidemiological changes in HCV infection with a major prevalence of advanced liver disease, such as portal hypertension, in this elderly cohort of patients.

Improved endothelial function after short-term therapy with evolocumab.

BACKGROUND: The reduction of cholesterol levels with cholesterol-lowering therapy may improve endothelial function. Lipid-lowering therapy has been greatly enhanced by the introduction of proprotein convertase subtilisin/kexin type 9 (PCSK9) antibodies. Less is known of the effect of PCSK9 inhibitors on endothelial function of subjects with hypercholesterolemia. OBJECTIVE: To assess whether treatment with PCSK9 inhibitors may improve endothelial function evaluated by brachial artery vasoreactivity test. METHODS: Brachial artery vasoreactivity test was performed in 14 consecutive patients with previous myocardial infarction before and after 2 months of therapy with evolocumab 140 mg twice in a month. Mean brachial artery diameter, velocity time integral, flow-mediated dilation (FMD) and low-density lipoprotein (LDL) cholesterol levels were also evaluated. RESULTS: After 2 months of treatment with evolocumab, mean total cholesterol levels decreased from 245 ± 41 to 128 ± 30 mg/dL (P < .001, -48%), and LDL levels from 176 ± 43 to 71 ± 26 mg/dL (P = .001, -59%); FMD conversely increased from 6.3 ± 4.1% to 8.8 ± 6.3% (P = .004, +40%). Improvement in FMD was proportional to reduction of LDL levels (r = 0.69, P = .006). Therapy with evolocumab increased brachial artery diameter during vasoreactivity test (peak values 0.39 ± 0.09 vs 0.36 ± 0.11 cm, P = .010; final values 0.36 ± 0.10 vs 0.34 ± 0.10 cm, P = .001), and velocity time integral (peak levels 96 ± 1 vs 85 ± 9 cm, P = .045). CONCLUSIONS: Two months of treatment with evolocumab 140 mg may improve endothelial function in subjects with increased cardiovascular risk. The improvement in endothelial function is proportional to LDL reduction.

Predictive value of very low frequency at spectral analysis among patients with unexplained syncope assessed by head-up tilt testing.

BACKGROUND: The role of heart rate variability (HRV) in the prediction of vasovagal syncope during head-up tilt testing (HUTt) is unclear. AIM: To evaluate the ability of the spectral components of HRV at rest to predict vasovagal syncope among patients with unexplained syncope referred for HUTt. METHODS: Twenty-six consecutive patients with unexplained syncope were enrolled in the study. All patients underwent HRV evaluation at rest (very low frequency [VLF], low frequency [LF], high frequency [HF] and LF/HF ratio) and during HUTt. HUTt was performed using the Westminster protocol. Continuous electrocardiogram and blood pressure monitoring were performed throughout the test. RESULTS: Eight (31%) patients developed syncope during HUTt. There were no baseline differences in terms of clinical features and HRV variables among patients who developed syncope and those who did not, except for VLF (2421 vs 896ms2; P<0.001). In the multivariable logistic regression analysis, including age and sex, VLF was the only independent variable associated with syncope during HUTt (odds ratio 1.002, 95% confidence interval 1.0003-1.0032; P=0.02). The area under the curve at rest was 0.889 for VLF, 0.674 for HF and 0.611 for LF. A value of VLF>2048ms2 was the optimal cut-off to predict syncope during HUTt (sensitivity 87.5%, specificity 72.2%). CONCLUSIONS: VLF at rest predicted the incidence of syncope during HUTt. Further studies are warranted to confirm these preliminary data.