[Access to the Emergency Department in the time of COVID-19: an analysis of the first three months in the Lazio Region (Central Italy)]. / L'accesso al pronto soccorso ai tempi del COVID-19: un'analisi dei primi tre mesi nella regione Lazio.

OBJECTIVES: to evaluate the impact of the SARS-CoV-2 epidemic on the access to the emergency services of the Lazio Region (Central Italy) for time-dependent pathologies, for suspected SARS-CoV-2 symptoms, and for potentially inappropriate conditions. DESIGN: observational study. SETTING AND PARTICIPANTS: accesses to the emergency departments (EDs) of Lazio Region hospitals in the first three months of 2017, 2018, 2019, and 2020. MAIN OUTCOME MEASURES: total number of accesses to the emergency room and number of specific accesses for cardio and cerebrovascular diseases, for severe trauma, for symptoms, signs, and ill-defined conditions, and for symptoms related to pneumonia. RESULTS: in the first 3 months of 2019, there were 429,972 accesses to the EDs of Lazio Region; in the same period of 2020, accesses arise to 353,806, (reduction of 21.5%), with a 73% reduction in the last three weeks of march 2020 as compared with the corresponding period of 2019. Comparing the first 3 months of the 2017-2019 with 2020, the accesses for acute coronary syndrome and acute cerebrovascular disease decreased since the 10th week up to more than 57% and 50%, respectively. The accesses due to symptoms, signs, and ill-defined conditions, proxy of potentially inappropriate conditions, decreased since the 8th week, with a maximum reduction of 70%. Access to severe trauma decreased by up to 70% in the 11th week. The accesses for pneumonia increased up to a 70% increment in the 12th week. CONCLUSIONS: the evaluation of accesses to emergency services during the SARS-CoV-2 epidemic can provide useful elements for the promotion and improvement of the planning, for the management of critical situations, and for the reprogramming of the healthcare offer based on clinical and organizational appropriateness.

Use of emergency department services by women victims of violence in Lazio region, Italy.

BACKGROUND: Violence against women is a significant health problem and a hidden phenomenon, in Italy that about 31% of the women have been victims of violence once in life. Aims of this study are to describe characteristics of women victims of violence (VV) attending the EDs in the Lazio region in 2008 and to illustrate the frequency and characteristics of previous ED visits. METHODS: Using the Emergency Information System, visits of women, (15-49 years), in the 60 EDs, for a violent trauma have been analysed. For each VV identified, we considered the last episode and searched for ED attendances in a six year period (2003-08) in order to identify other visits. We performed descriptive analyses of socio-demographic and clinical factors of VV and we analyzed the impact previous ED visits. We compared ED utilization of women VV with a random sample of women with the same age distribution who gave birth in 2008. RESULTS: In 2008, 7,725 ED attendances of women VV were found (1.1% of the ED visits) corresponding to 6,936 women (prevalence = 52.0x10,000). The mean number of ED visits for each woman in five years was 5.0 (1-190). Prevalent diagnoses were contusions (45.8%), neurotic disorders (5.4%) complications of medical care (6.3%). The women were young, approximately 70% were residents in Rome or the surrounding areas. Foreign women were three times more likely to visit the ED for intentional injuries than were Italian women (114.1 vs 44.4 per 10.000). CONCLUSIONS: This study shows high prevalence of violence against women in Lazio region, Italy. Most of the women have been visited by the ED several times before the violent episode, often with traumas. ED medical and nursing staff should be prepared and trained to successfully manage victims of violence.

Perinatal outcomes among immigrant mothers over two periods in a region of central Italy.

BACKGROUND: The number of immigrants has increased in Italy in the last twenty years (7.2% of the Italian population), as have infants of foreign-born parents, but scanty evidence on perinatal outcomes is available. The aim of this study was to investigate whether infants of foreign-born mothers living in Italy have different odds of adverse perinatal outcomes compared to those of native-born mothers, and if such measures changed over two periods. METHODS: The source of this area-based study was the regional hospital discharge database that records perinatal information on all births in the Lazio region. We analysed 296,739 singleton births born between 1996-1998 and 2006-2008. The exposure variable was the mother's region of birth. We considered five outcomes of perinatal health. We estimated crude and adjusted odds ratios and 95% confidence intervals (CIs) to evaluate the association between mother's region of birth and perinatal outcomes. RESULTS: Perinatal outcomes were worse among infants of immigrant compared to Italian mothers, especially for sub-Saharan and west Africans, with the following crude ORs (in 1996-1998 and 2006-2008 respectively): 1.80 (95%CI:1.44-2.28) and 1.95 (95%CI:1.72-2.21) for very preterm births, and 1.32 (95%CI:1.16-1.50) and 1.32 (95%CI:1.25-1.39) for preterm births; 1.18 (95%CI:0.99-1.40) and 1.17 (95%CI:1.03-1.34) for a low Apgar score; 1.22 (95%CI:1.15-1.31) and 1.24 (95%CI:1.17-1.32) for the presence of respiratory diseases; 1.47 (95%CI:1.30-1.66) and 1.45 (95%CI:1.34-1.57) for the need for special or intensive neonatal care/in-hospital deaths; and 1.03 (95%CI:0.93-1.15) and 1.07 (95%CI:1.00-1.15) for congenital malformations. Overall, time did not affect the odds of outcomes differently between immigrant and Italian mothers and most outcomes improved over time among all infants. None of the risk factors considered confounded the associations. CONCLUSION: Our findings suggest that migrant status is a risk factor for adverse perinatal health. Moreover, they suggest that perinatal outcomes improved over time in some immigrant women. This could be due to a general improvement in immigrants' health in the past decade, or it may indicate successful application of policies that increase accessibility to mother-child health services during the periconception and prenatal periods for legal and illegal immigrant women in Italy.

Severe postpartum morbidity and mode of delivery: a retrospective cohort study.

The aim of this population-based study was to estimate the risk of postpartum maternal complications associated with mode of delivery in a population of low-risk pregnancies. Data from 324,883 full-term singleton births between 2001 and 2007 were retrieved from birth and hospital discharge databases of the Lazio Region, Central Italy. Women with breech presentation births and those with chronic/pregnancy-related diseases in the mother/fetus were excluded. The association between mode of delivery and maternal outcome was estimated for women by odds ratios (ORs), adjusted for potential confounders. Of nulliparous women 78.6% intended vaginal delivery, while for multiparous this was 68.6%. Elective cesarean section was associated with a higher risk of hysterectomy, obstetric shock and anesthetic complications compared with women in the intended vaginal delivery group. This suggests there is a need for a program to reduce unnecessary elective cesarean sections.

Primary paediatric care models and non-urgent emergency department utilization: an area-based cohort study.

BACKGROUND: The aim of this study was to evaluate the association between different primary paediatric practice models (individual, network -affiliated but in separate office-, and group practice) and non urgent utilization of the Emergency Department (ED). METHODS: The data sources were: the 2006 Regional Paediatric Patient files (0-6 years old), the Regional Community-based paediatrician (CBP) file and the 2006 Emergency Information System. We recorded and studied the ED visits of children, excluding planned ED visits, visits for trauma/poisoning and those that were assigned non deferrable/critical triage codes. A multivariate logistic regression was applied to estimate the adjusted odds ratio of an ED visit. The exposure was the type of paediatric practice that served the child: individual, network or group practice. Various characteristics of the child were considered. RESULTS: The cohort was composed of 293,662 children. In the 2006, 43,347 ED visits occurred (147.6 per 1000). Multivariate logistic models showed lower ED use for group paediatrician patients (OR 0.84; 95%CI 0.73-0.96) and for network paediatrician patients (OR 0.92; 95%CI 0.85-1.00) compared to patients served by an individual practice. CONCLUSIONS: This study shows that there is a weak association between the type of paediatrician primary practice and emergency department use. Our results highlight the necessity to continue to improve the organization of paediatrician primary practice, in order to increase patient access to primary paediatric care.

High risk of macrosomia in newborns of immigrant mothers.

BACKGROUND: In Italy live about 8.7% immigrants, which contribute to more than 15% of all deliveries taking place in Italy. We aimed to investigate whether newborns from high migratory pressure countries (HMPC) mothers have a different macrosomia and post-term pregnancy incidence compared to Italian newborns. METHODS: In this retrospective observational study, we analyzed data on 404.863 babies born between 2010 and 2017. Italian mothers delivered 309.658 (76.5%), HMPC mothers 88.179 (21.8%) and developed country (DC) mothers 7.026 (1.7%) babies. We analyzed the incidence of macrosomia and post term pregnancy. We estimated incidence rate (IR), unadjusted incidence rate ratio (IRR) and 95% confidence intervals (CIs) to evaluate the association between these perinatal parameters and the mother's region of birth. RESULTS: HMPC compared to Italian newborns showed a significantly higher incidence of birthweight > 4000 g (53.3‰ vs 39.1‰, p-value < 0.001; IRR 1.4, 95%CI = 1.36-1.45), birthweight ≥4500 g. (7.0‰ vs 3.8‰, p-value < 0.001; IRR 1.8, 95%CI = 1.67-2.0) and gestational age at birth > 41 weeks (19.9‰ vs 12.8‰, p-value < 0.001; IRR 1.55, 95%CI = 1.47-1.64). The macrosomia incidence between HPMC and Italian newborns was significantly increased at all gestational ages (Fig. 1), especially for mothers coming from Central Eastern Europe (121.79‰ vs 91.1‰, p-value< 0.001; IRR 1.34, 95%CI = 1.11-1.62). CONCLUSION: In Italy immigrant status represents a risk factor for macrosomia and post-term birth, which could be related to socio-economic status and unfavorable life conditions of immigrant mothers during pregnancy.

Neonatal respiratory morbidity and mode of delivery in a population-based study of low-risk pregnancies.

The aim of this study is to evaluate the association between the mode of delivery and the risk of neonatal respiratory complications in a cohort of term newborns in the Lazio region, Italy. Data on 139,379 term singleton infants born in 2003-2005 were retrieved from birth and hospital discharge database. Odds Ratios (ORs) adjusted by age, parity, birth weight, gestational age, and gender were calculated using logistic regression models. The rate of prelabor cesarean section (CS) was 26.2%. The rates of neonatal respiratory morbidity were 29.6/1,000 in infants delivered by prelabor CS and 17.4/1,000 in infants delivered vaginally or by CS in labor. The adjusted risk of neonatal respiratory morbidity associated with prelabor cesarean birth at 37 weeks is four times higher than in intended vaginal birth after 37 weeks. Prelabor cesarean delivery should be performed after at least 38 weeks' of gestation in order to minimize neonatal respiratory morbidity.

[Comparison of two methods for constructing birth weight charts in an Italian region. Years 2000-2003]. / Confronto tra due metodi per la costruzione delle curve del peso alla nascita per i neonati laziali. Anni 2000-2003.

OBJECTIVE: To apply two different statistical methods to the live births of Lazio region in the years 2000-2003 and calculate updated estimate of the curves of percentiles of birth weight for gestational age. DESIGN AND SETTING: The data analysed, including clinical-epidemiological and obstetric-neonatal information, have been extracted from birth certificates for the Italian region of Lazio for the period 2000-2003. Two methods of analysis, previously used in two Italian studies, have been applied. In the first method the observed distribution for each gestational week has been decomposed as a mixture of two normal distributions with homoscedastic components. The percentiles obtained, relative to the estimate of the component with the greater weight, have been then used in a third degree polynomial regression with gestational age as covariate, to estimate the final smoothed values. The second method assumes that, for a fixed gestational age, the position of the percentiles can be obtained as a polynomial function of Normal scores. Initially, for both sexes, the percentiles for every gestational age have been estimated using quantile regressions restricted to windows of three weeks. These have been subsequently smoothed by a polynomial model using the logarithm of the birth weight as the dependent variable and gestational age (up to the third degree), the z-score corresponding to the percentiles observed in the three week windows (up to the second degree), sex and the interaction between sex, gestational age and z-score as independent variables. RESULTS: data relating to 157,335 single live births to Italian women resident in the Lazio region have been analysed. The raw curves of the birth weight percentiles for the preterm babies are very irregular for the more extreme percentiles because of the very low number of deliveries of live pre-term babies. The two methods have produced similar results. However, the first method was less influenced by extreme and potentially anomalous values. The second method tended to estimate percentiles beyond 41a week of gestation inferior to those of the previous weeks. A comparison has been made with the curves obtained in the two previous Italian studies and the new estimated percentiles tend to be inferior for the very preterm live births. CONCLUSIONS: this study has produced new curves of birth weight for gestational age. The analysis has been based on two different techniques, which have produced substantially similar results. For the tenth percentile, our estimates are lower than those obtained in previous studies suggesting a reduction in the late foetal mortality of babies who are not only pre-term but also of low weight. These results could be used in order to define new standards for birth weights in Italy.