Analysis of survival in a sample of elderly patients from Ragusa, Italy on the basis of a primary care level multidimensional evaluation

The detection of frail elderly people is a crucial point in planning health care services. The aim of this study is to assess the effectiveness of a multidimensional evaluation instrument in order to identify frail elderly people, in a primary care setting. In 1994, a 15-20-min multidimensional questionnaire, called Geriatric Functional Evaluation (GFE), was administered to 3060 over 65-year-old citizens of Ragusa (Italy), who live in their own home. The sample was subdivided in three groups (independent, moderately impaired, and severely impaired) on the basis of the Final Synthetic Score (FSS) originated by the answers to the questionnaire. A follow up was carried out in 1999 with survival and institutionalization as the end-point. The lost to follow-up rate was 1.2%. After 5 years, the Kaplan-Meyer survival analysis showed that the survival rate of the three groups was 42%, 68%, and 88%, respectively. The Cox Proportional Survival analysis showed that the risk of death was doubled in the moderately impaired group and tripled in the severely impaired group compared with higher FSS group. The multivariate analysis showed that the use of services was increased by 40% and therefore indirectly their need, shifting from the lowest to the highest score. The FGE questionnaire had a strong predictivity of both mortality and need of services. The use of FGE in a primary care setting could make it possible to detect the frail population in order to address the community based services.

Iron deficiency anemia and feeding practices in Albanian children

Iron deficiency is the most prevalent nutritional problem of humans. In northern Albania, nutritional deficiencies are widespread among children but there is a lack of biochemical data. The aim of this study was to assess the prevalence rate of the iron deficiency anemia in a sample of northern Albanian children. A group of 112 children aged 6-60 months, recruited during the routine vaccinations, was enrolled in a cross-sectional health examination survey that included venou blood measurements of iron status. The survey was conducted during 2000 in Lezha District. The mean age was 17.1 +/- 10 months, the majority of the children were living in rural areas (61%), 47.8% were female. The mean level of hemoglobin was lower than the reference value (10.3 +/- 1.1). Iron deficiency Anemia occurred in 47 children (47%) and more likely during the first year of the life (51%). Fifty seven children were fed with whole cow's milk, among them 44 were IDA. The risk value to be anemic or iron deficient for infants aged 6 to 12 months that were fed with whole cow's milk before the fourth months of life was high (OR = 6.2 (C.L.1.0-38)). In conclusion, the high prevalence of IDA and the relationship with early feeding of whole cow's milk suggest to consider iron deficiency in infancy and childhood in Albania as an important nutritional public health problem and to implement strategies for his detection, treatment and prevention.

A large infantile gastroenteritis outbreak in Albania caused by multiple emerging rotavirus genotypes

By the end of December 2000, the epidemiological system 'Alert' of the Public Health Institute in Tirane reported an outbreak of acute gastroenteritis. The outbreak involved children in Tirane and in the rural area. In total, 2722 children were seen in Tirane Hospital and 982 (56.4%) were treated for acute gastroenteritis. The age group with the highest morbidity was 0-5 years (89.7%), followed by the 6-9 (6.2%) and 10-15 years age groups (4.1%). The distribution of acute gastroenteritis cases, which occurred along the same water distribution system, suggests a waterborne origin. The nucleic acid amplification confirmed the co-circulation of different genotypes of rotavirus, mainly P[8]G9 and P[8]G3, responsible for the outbreak. Other enteric viruses such as astrovirus serotype 1, adenovirus and Norovirus, genogroups I and II were detected. Co-infections with different rotavirus genotypes and even with different enteric viruses were detected in several samples.

Waterborne gastroenteritis outbreak in Albania

Three different studies are reported concerning the environmental pollution caused by viruses in Albania. The first study describes an outbreak of gastroenteritis in the capital city, involving 2,722 children attending the Paediatric Unit of Tirana Hospital. The age group with the highest morbidity was 0-5 years, with 89.5%; no fatalities were recorded during the outbreak. Rotavirus was detected in 26/28 faecal samples by RT-PCR, although astrovirus, adenovirus and calicivirus were also present. The second study describes an outbreak of hepatitis A virus involving the city of Lac. Two hundred cases were recorded, with the highest incidence in the age-group 5-9 years. Phylogenetic analysis of the VP1/2A region showed the presence of a unique sequence: genotype IA. Rotavirus was identified in drinking-water samples collected during the outbreak. The third study describes the prevalence of HAV and HEV in 202 sera randomly collected from 12 different cities in Albania. HAV showed a high incidence (66.2%), whereas none was positive for HEV. The genomic analysis of the VP1/2A junction revealed the presence of only one genotype (IA) with few point mutations and just two amino acid substitutions at codons 22 and 34. Additionally, two potential antigenic variants were detected, the first at position 46 of VP3 and the second at position 23 of VP1.

[Multidimensional functional evaluation of social and health care needs of an elderly population in Rome]

The aim of this study is to analyse the condition of the elderly of Rome through a multidimensional instrument to determine their assistance needs. To this purpose a sample composed by 693 over 65 subjects was selected (430 women and 263 men). The Geriatric Functional Rating Scale of Grauer was administered to them. The questionnaire is divided into 7 sections (physical health, mental health, functional skills, support to the collectivity, type of housing, social relationships and economic situation); they enable to evaluate the dependency level of each subject. On the base of each area score a total score is obtained which divides the elderly into three categories according to their assistance need. The whole information collected in the single areas led to a definition of non self-sufficiency for 4.9% of the interviewed people and of partial self-sufficiency for 5.3%, the rest of the sample turned out composed by subjects able to live in an autonomous way. This sample of elderly (about 10%) is that on which it is possible to intervene with social and/or health home care plans in order to limit institutionalization.

[Social and health services needs in a sample of elderly people in Catanzaro]

The aim of this study is to analyze the general health state conditions of older people living in Catanzaro, using a multidimensional assessment instrument to determine their social and health needs. To this purpose, a sample of 544 individuals (344 women and 210 men) older than 65 years of age (mean age = 75.3) was selected from the general population. All subjects were administered the OARS (Older Americans Resources and Services) questionnaire that evaluates five areas: physical health, mental health, social resources, economic resources and Activities of Daily Living (ADL). The percentage of subjects with score 3 or more in each area, and therefore identified as partially or totally dependent, is higher in the area of physical health (17.9%) and ADL (16.6%). About 65% of the sample is not disabled in any of the different areas, while 8% is dependent in 3 or more areas. These subjects are partially or totally dependent elderly people, who stay at their own house in precarious conditions, and are able to remain there only because they are helped by informal caregivers. Probably these people are those for whom any domiciliary help is necessary and more urgent in order to support the existing stability and to avoid institutionalization.

Tirane, Albania: survey on drinking water quality and facilities

To develop a realistic model of the situation, a study was carried out in four different socioeconomic and hygienic areas of Tirane, namely in the modern and historical centre as well as in the intermediate and peripheral areas. In each area interviewers from the city's Public Health Directorate, contacted randomly, door-to-door, the residents, submitting a questionnaire and collecting water samples at the same time. Our data show relevant differences regarding distribution and quality of drinking water between the centre and peripheral areas. One third of water samples revealed the presence of microorganisms, whereas one fifth had no residual chlorine. Altogether more than 200,000 people in the peripheral areas of Tirane live under low level hygienic conditions. The recent outbreaks of cholera, poliomyelitis and the hyperendemic hepatitis A disease are the dramatic results of the low quality drinking water.

Child malnutrition in north Albania: results from an anthropometric survey

In order to assess child malnutrition, an anthropometric cross-sectional survey of children aged 0-36 months was conducted in selected rural, urban and mountainous areas of Northern Albania in May 1997. The results showed a high prevalence of low anthropometric indices in rural and mountainous areas with a trend of similar magnitude in northern rural areas. In Northern Albania child malnutrition is a public health priority. As the main risk factor for underweight we found a recent history of diarrhoea (OR = 2.45) together with female gender (OR = 2.28), rural (OR = 2.09) or mountain (OR = 1.61) residency. Absence of sanitation, marker of poor housing conditions, also showed a significant association (OR = 1.55) with underweight. Low birthweight (OR = 1.12) was confirmed as an important risk factor for underweight condition. In conclusion these findings underline the importance of support appropriate mother and child health and nutritional programmes in rural areas of Northern Albania.

Genomic characterization of human and environmental polioviruses isolated in Albania

Between April and December 1996, a serious outbreak of poliomyelitis occurred in Albania; almost 140 subjects were involved, and the episode presented an unusually high mortality rate (12%). During the outbreak, water samples from the Lana River in Tirana, Albania, and stool samples from two cases of paralytic poliomyelitis were collected and analyzed for the presence of polioviruses. Six polioviruses were isolated from the environmental and human samples, according to standard methods. All the samples were characterized by partial genomic sequencing of 330 bases across the 5' untranslated region (5'-UTR) (nucleotide positions 200 to 530) and of 300 bases across the VP1 region (nucleotide positions 2474 to 2774). Comparison of these sequences with those present in data banks permitted the identification of environmental isolates Lana A and Lana B as, respectively, a Sabin-like type 2 poliovirus and an intertypic recombinant poliovirus (Sabin-like type 2/wild type 1), both bearing a G instead of an A at nucleotide position 481. The two other environmental polioviruses were similar to the isolates from the paralytic cases. They were characterized by a peculiar 5'-UTR and by a VP1 region showing 98% homology with the Albanian epidemic type 1 isolates reported by other authors. This study confirms the environmental circulation in Albania of recombinant poliovirus strains, likely sustained by a massive vaccination effort and by the presence in the environment of a type 1 poliovirus, as isolated from the Lana River in Tirana about 2 months before the first case of symptomatic acute flaccid paralysis was reported in this town.

[The general practitioner faced with the choice of hospitalization: an analysis of the data from the Follow-Up System computerized network]

The Project "Informatization of the General Practitioner" aimed at networking the work stations of a randomized set of 150 general practitioners equipped with the "Follow-Up System" software, for the collection of information related to the activity carried out, to be electronically transferred to a central unit was developed in the frame of the finalized Project of the National Research Council: "Prevention and Control of the Disease Factors". During the project activity, a study on prescribed hospitalizations was carried out. The contents of items regarding hospitalization diagnosis show that diagnoses concerning diseases included in chapter ICD-9: "Symptoms, signs and morbid conditions not well defined" represent 30.3% of the total; most of these undefined syndromes can be identified under the item "abdominal pain" with 18.2% of cases. Obviously in the case of appendicitis (12.1% of hospitalizations) the hospitalization carried out by the physician resulted to be necessary, in the case of biliary lithiasis (8 cases, 7.4%), the physician could have treated the patient without hospitalization. The interest of such data is to induce a sort of provocation in order to observe, within 8% of hospitalizations following abdominal pain, what rate of hospitalization could be avoided, giving the adequate support to the general practitioner in order to decide the behaviour to have.

Surveillance of infections in hospital: agents and antibiotic-resistance

The surveillance system for Hospital Acquired Infections (HAI) implemented in the S. Eugenio hospital of Rome allows to monitor the distribution of the micro-organisms by service and their resistance to antibiotics. It is based upon the data collected by the Central Analysis Laboratory of the hospital. The data of four high-risk departments (Surgical service, Intensive Care Unit, Haematology, Burn Unit) are reported. In the period October 1992-September 1993, 3909 samples have been analyzed; 1603 (43.1%) were found positive to the microbiologic analysis. The results of the antibiotic resistance concerning four micro-organisms, agents of HAI are reported and discussed. Surveillance systems are necessary to limit the frequency of HAI.

A sentinel network of general practitioners for epidemiologic surveillance in Italy

A Computer Network of General Practitioners (GP's) has been established connecting 110 general practitioners representing a statistically selected national sample, homogeneously distributed all over Italy. The purpose of the network is to increase the epidemiologic surveillance on the health status of the Italian community, to collect useful data on the routine activity of the GP's, to promote computer use among them, and to organize some "ad hoc" investigations on specific subjects (case-control studies). To this purpose, a specific software was developed both to meet the requirements of epidemiological research and to manage general practitioners' clinical files. A working prototype of health card using micro-computer technology is also being experimented on a subset of the GP's.

Disability and the need for rehabilitative facilities in the young Albanian population of the Lezha district

In order to implement a community-based rehabilitation programme in the rural district of Lezha (Albania), a systematic survey to assess disabilities and related care needs of people under 18 years of age was carried out. The aim of the survey was to evaluate the prevalence rates and severity of disabilities, detected by means of a questionnaire issued by the WHO Community-Based Rehabilitation Programme. The prevalence of disabled people under 18 years of age was 5.86 per 1000 (180 subjects out of the estimated population of 30,712). The most frequent diagnosis was sequelae of infantile cerebral palsy (1.8 per 1000), followed by mental retardation and deafness. The results of the survey stress that the severe non-self sufficiency of these subjects could be improved by means of an appropriate programme to increase their autonomy, including rehabilitation treatment and early school attendance.

Family history of cardiovascular diseases and risk factors in children

A sample of 861 Roman children, aged 7 to 14 years, was investigated in order to evaluate the association between some cardiovascular risk factors such as high systolic (SBP) and diastolic (DBP) blood pressure levels, body mass index (BMI), arm fat area (AFA) and a history of diabetes, stroke, angina pectoris, myocardial infarction, hypertension and overweight in their parents. The sample investigated was subdivided into three subgroups, based on whether the children had just one parent, both parents or no parent with a positive history. For all the variables considered, the highest values were found in the group of children with a positive history for both parents and the lowest ones in children with a negative history for both parents. The analysis of significance, based on the mean values for the three groups, revealed statistically significant differences for SBP, DBP, BMI and AFA between the group of children with a positive history for both parents and that of children with a negative history for both parents. Significant differences also emerged for DBP, BMI and AFA between the mean values of children positive for one parent and those negative for both parents and for BMI and AFA between the means of children positive for one parent and those positive for both parents. The odds ratio of high systolic and/or diastolic BP, BMI and AFA levels was consistently higher in children with one or two parents with a positive history compared to children with both parents with a negative history, and even higher considering only children with both parents with a positive history vs children with both parents with a negative history.

Blood pressure and anthropometry in parents and children of a southern Italian village

In an investigation on hypertension risk factors, the entire school population was examined in Trecchina, a southern Italian village. The reported findings refer to those children examined together with at least one parent, for a total of 134 mother-child pairs and 128 father-child pairs. For these groups of children, fathers and mothers, systolic (SBP) and diastolic (DBP) blood pressure, weight (W), height (H) and triceps skinfold (TS) were detected and body mass index (BMI) was calculated in order to evaluate the prevalence of high blood pressure (BP) values and if overweight. Of 19.3% children, 26.9% fathers and 15.8% mothers showed high BP values; 28.9% of children, 14.0% of fathers and 19.3% of mothers were overweight. In children, the analysis of correlations, after adjustment for height, showed a significant association between BP and W, BMI and TS. Using multiple regression analysis, with BP as the dependent variable, SBP was significantly associated with BMI and age in mother and fathers. For DBP the only variable entered in the model was BMI for mothers and fathers. When controlling for the children's age, H, W and BMI of children were significantly related to H, W and BMI of mothers and fathers. These results confirm that overweight and a parental history of obesity are predictive and possibly causal factors for essential hypertension.

Differentiation of glioblastoma multiforme from astrocytomas by in vitro 1H MRS analysis of human brain tumors

In vitro high resolution 1H NMR spectroscopy allows non-invasive metabolic evaluation of specimens derived from surgically biopsied or resected brain tumors, with the aim of identifying potential markers of different malignancy grading, and improving diagnostic and therapeutic strategies. In the present study we evaluated 36 patients affected by different brain gliomas (7 well differentiated astrocytomas, 7 anaplastic astrocytomas, 16 glioblastomas, 6 oligodendrogliomas). These analyses allowed discrimination between well differentiated and anaplastic astrocytomas (AII + AA) and glioblastoma multiforme (GM) samples on the basis of the ratio between the integrated choline-containing resonance (b"Cho") and the creatine peaks (creatine (Cr) + Phosphocreatine (PCr)). While no definite difference was found between AII and AA, significantly higher values were observed for this ratio in GM. Other signals, derived from different metabolites, such as Glycine (Gly) and N-acetyl-aspartate (NAA), may also assume relevance in differential tumor diagnosis. In this study an increased [Gly]/[Cr + PCr] ratio was observed in GM with respect to AII and AA. The NAA levels observed in our tumor specimens may be explained on the basis of tumor cell infiltration into brain adjacent tissue. Interesting, but inconclusive, are the data concerning oligodendrogliomas, which, also in well differentiated forms, exhibit increased levels of b"Cho"/(Cr + PCr) ratio. The present study confirms the role of MRS in the biochemical characterization of neoplastic brain tissue and its potential contribution to a better selection of multidisciplinary treatment strategies.

Predicting stroke inpatient rehabilitation outcome: the prominent role of neuropsychological disorders

This study was designed to determine the role of demographic, medical and cognitive factors in the results of rehabilitation in first stroke patients. In a prospective study on 273 consecutive patients admitted to a rehabilitation hospital for sequelae of first stroke, we used multiple regressions to assess the relationship between 11 independent variables and a battery of outcome measures: mortality, length of hospital stay, Barthel Index (BI) and Rivermead Mobility Index (RMI) scores at discharge and their effectiveness. Severity of stroke at admission and hemineglect were the strongest prognostic factors. In a logistic model, cognitive impairment was a significant independent predictor (OR = 4.10) also after adjusting for age and severity of stroke. Patients with hemineglect had a significantly higher relative risk of poor autonomy [RR = 7.30, 95% confidence interval (CI) 4.04-13.18] and impaired mobility (RR = 9.25, CI 4.63-18.45). Global aphasic patients had similar risks for both autonomy (RR = 4.51, CI 2.74-7.41) and mobility (RR = 4.71, CI 2.79-7.97). This study underlines the crucial role of cognitive disorders as predictors of poor functional outcome in stroke survivors and confirms the need for early neuropsychological screening.

[Dental health and the state of oral hygiene in an elderly population in Rome]

The purpose of this study was to investigate dental conditions and oral hygiene in a population of 369 elderly people residing in Rome--293 females and 76 males--aged between 60 and 99 years (mean 81.9 +/- 8.1). The sample was interviewed following a dental examination. Clinical tests revealed that 40% were totally edentulous, whereas subjects with natural teeth had a mean of 11.4, teeth, of which 1.5 were decayed. Oral hygiene habits were investigated by means of questions on use of dental tools (toothbrush, mouth-wash, dental floss), which were not much used. Moreover, many elderly people reported they had not been to the dentist's recently (86.2% during the last year) because they did not feel it necessary. From this study a rather low level of oral health has emerged, along with a limited knowledge of prevention for dental and periodontal diseases. These results show the need of dental treatment and prevention for the elderly population.

Care requirements of people with ARC/AIDS in Rome: non-hospital services

In Italy, care for people with AIDS (PWA) is centred on hospital services. However, other services are beginning to develop, both in the form of residential facilities and of home care. It seems, therefore, important to define the type of non-hospital services that should be supplied on the basis of AIDS patients' real needs. The aim of this paper is to contribute to the definition of care requirements by administration to 92 persons with ARC/AIDS of a questionnaire on Functional Multidimensional Evaluation to assess the demand for services in relation to the state of health and socio-economic situation of those interviewed. The pattern that emerged was one of severe socio-economic difficulties (most of the patients were drug addicts) and of major functional impairment (about 60% of those interviewed were not self-sufficient as far as Instrumental Activities of Daily Living were concerned). Among the main problems: difficulties of finding accommodation (almost 9% of those interviewed have no fixed abode) and economic difficulties; the demand for services was characterized by a lack of self-sufficiency. The most frequently required social services were help with preparation of meals, household chores and assistance with transport; the most frequently required health service was physiotherapy, which is also the least available. The study supplies useful information for the planning of non-hospital services in Italy and in other western countries with similar epidemiological situations.

[The general practitioner and clinical records: a survey of the knowledge of users of a software package]

The FATMA project--subproject 6, Line of Research 2--aims at implementing a new computerized information network for general practitioners using the same kind of software and homogeneously located throughout Italy. Thus, patients' case form data can be collected for public health purposes. After a study of literature in order to check whether other countries had implemented similar projects and what they consisted of, a survey based on a computerized questionnaire was carried out on a group of g.p.s. who had already received a software for the management of their clinical and professional activities from Janssen Informedica. This survey aimed at judging some aspects of users in order to select potential monitors of the information network who would test a new software. The analysis regards both g.p.s' social and professional data and the use of a computer package with reference to the quality and quantity of the clinical data they input. 2,010 questionnaires were filled in all their parts and mailed back to Informedica. It came out that g.p.s. believe more and more they can improve the organization and management of their work by using a software equipped with routines and easy access procedures so that clinical data, diagnostic reports and treatment can be collected, placed on files and updated. Thus, a new software should be developed. While meeting g.p.s' needs, it must overcome the limits of packages now available concerning the possibility of carrying out epidemiological studies. The software can become a tool to collect clinical data of patients, diseases and diagnostic procedures through standard protocols directly from g.p.s records.

A new community-oriented network in Italy for the collection and processing of clinical and epidemiological information

This study illustrates a project to implement a clinical information system based on a general practitioner's network covering the national territory. The project is important because there are no other such systems in operation in Italy. Moreover, as is well known, both the quality and the quantity of health information made available by the National Health Service are far from optimal. This community-oriented network enables end-users to share software for the management of outpatient clinics that is produced by Informedica Janssen and distributed throughout Italy to over 16,000 physicians. The features of potential participants in the network as well as the software they have adopted are described.

[An evaluation of body adiposity in Roman schoolchildren]

The purpose of this study is to assess the body fat content of 871 Roman children, aged 7-14 years, by a simple method based on measurement of body density from skinfold thickness. Weight, height, triceps, biceps, subscapular and suprailiac skinfold were measured for every child and calculated body mass index and percentage of body fat. Girls tended to have more fat than boys and an increase of values with age; boys presented an increase of fat until 11 years, than a decrease more considerable at 14 years. Body fat percentage has a higher correlation with age than BMI and therefore is added to other body mass indices, based on weight and height, for a careful assessment of body composition.

[Skinfold thickness in a group of Roman schoolchildren]

Triceps, biceps, subscapular and supra-iliac skinfold measurements were taken on 871 children, aged 7-14, in three Roman schools. Girls have larger skinfolds than boys; the values at every site increase with age. Boys present an increase in skinfold measurements until 11 years, then a decrease, more marked at 14 years. Skinfold measurements are a method to assess the amount of fat in the body. Age reference curves, prepared from many Authors, in various parts of the world, show differences between different populations. Skinfold reference data for Italian population therefore are necessary.

[Factors correlated with arterial blood pressure. Follow-up of a young population in Rome]

In order to find out whether there is any relationship between blood pressure, body mass index, weight, heart rate in youth and arterial hypertension later on in life, 212 subjects (16-26 years of age) were re-examined 2 years later. Previous blood pressure level were very significantly associated with present blood pressure levels A relationship was also discovered with the other parameters measured 2 years earlier: weight, body mass index and heart rate. These findings confirm the fact that it is possible to detect future hypertensives early in life and to take effective preventive measures.

[Proposal for changing the ministerial instructions for antirabies prophylaxis in the light of the experience of the Centro Antirabbico di Roma]

Records of clinical assistance and of post-exposure antirabies prophylaxis from 4820 outpatients who attended the Antirabies Center of Rome following animal bites in 1986 were analysed. We observed a high proportion of people submitted to active immunization (44% received at least one shot of HDCV vaccine) in spite of the fact that rabies is absent from Central Italy since many decades in both wild and domestic animals. These considerations suggest the opportunity of a major revision of the official recommendations for rabies prevention, and we feel that different policies should be adopted in rabies enzootic areas (such as Northern Italy) compared to those where the risk is only potential. Immunization should be avoided after bites by rodents; passive immunization should be added to the vaccine after bites by wild animals in enzootic areas, while bites by cats and dogs, even uncaptured, will not be necessarily followed by vaccination in non enzootic areas.

[Borderline arterial hypertension. Preliminary study of a young Roman population]

Blood pressure levels and related factors such as age, sex, body mass index, socioeconomic level and family were studied in a group of 398 young subjects. A high incidence of subjects with borderline hypertension was confirmed. The results analysed and discussed the conclusion being reached that the form of arterial hypertension may be considered as either the onset or at least a risk factor or stable hypertension.