Hospital Patients’ migration among Italian Regions

Background

At the beginning of the 2000s the federalization of the Italian National Health Service gave to the Regions greater financial and political responsibility: 21 Regional Health Services were set up with administrative and planning independence. They are in a potential competitive regime, since the citizens are free to choose their place of treatment. The aim of our research was to analyze fulfillment of needs for hospital services on site and Patients' migration to hospitals of other Regions.

Methods

We conducted an observational cross sectional study on Hospital Discharge Cards provided by the Ministry of Health, upon specific request, from 2013 to 2017. The subjects of the analysis (catchment areas) were the hospital networks of Italian Regions. Interregional flows were carried out from data of Residents, Attractions and Escapes, which were developed through Attraction and Escape Indexes. Graphic representation was produced with Gandy's Nomogram.

Results

In the studied period, we observed an important decrease in hospitalizations and a simultaneous increase in interregional mobility. At the same time, admissions to hospital managed by Local Health Authorities and to Private Clinics increased. According to the Major Diagnostic Categories the main causes of hospitalizations in mobility were Musculoskeletal System And Connective Tissue Diseases (MDC 8), Cardiovascular System Diseases (MDC 5), Nervous System Diseases (MDC 1) and Digestive System Diseases (MDC 6). There were discrepancies between the Regions of Northern/Central Italy (higher Attraction Indexes) and Southern Italy (higher Escape Indexes). According to Gandy's Nomogram only nine Regions showed a good public hospital planning: Lombardy, A.P. of Bolzano, Veneto, Friuli V.G., E. Romagna, Tuscany, Umbria, Latium and Molise.

Conclusions

The North/Centre Regions have a public hospital planning able to be better to meet the care needs of their citizens and to attract Patients than the South ones.

Key messages

The study of Patients’ mobility is relevant in order to evaluate equity and quality of care provided by different Italian Regions. Patients' mobility has also an important economic implications.

Economic crisis, epidemiology and resilience in Italian Regions

Introduction

Avoidable Mortality is an indicator of the effectiveness of Health Services. We know that Gross Domestic Product (GDP) and other macroeconomic indicators are related to health indicators. The aim was to study the impact of economic indicators on Avoidable Mortality, in Italy, with attention to the periods following the economic crisis and COVID-19 epidemic.

Methods

GDP, Gini Coefficient (GC) and other economic and epidemiologic data were collected from the beginning of the Century up to the present from the Italian National Institute of Statistics database (ISTAT) and the Italian National Institute of Health (ISS). Mortality data (597 causes coded by ICD-9) was divided in Preventable, Amenable and Avoidable categories. Spearman's rank Correlation Coefficient was carried out with STATA software. The analysis was performed, also using JOINPOINT software, on the entire Italian territory and then specifically on the 20 Regions.

Results

GDP trend showed two decreasing phases occurred between 2008-2009 and 2012-2013. A negative correlation (p.<0.05) has been demonstrated in 7 Regions between GDP values and Avoidable Mortality, 5 Regions for Preventable and Amenable Mortality. GC showed a fluctuating but growing trend without any correlation with all categories of Avoidable Mortality. In 2020, after the start of the COVID-19 pandemic (in February 2020 in Italy), GDP and Employment Rate (ER) declined rapidly, but not always homogeneously.

Conclusions

The upward trend of the GC reflects an increase in inequality in the period following the economic crisis. GDP trend reflects the phases of the economic crisis impacting on epidemiological indicators with a latency of about 4 years. The negative correlation between GDP and Avoidable Mortality can not be observed in all Regions. This may be explained by heterogeneous administrative policies and different levels of resilience among Regions: another description of the “european microcosm” represented by Italy.

Key messages

The impact of the economic crisis on Avoidable Mortality has about 4 years of latency. COVID-19 pandemic has a faster impact on GDP and ER.

Italian Regions show different levels of resilience.

Food and lifestyle education in Tuscan schoolchildren: 2018-2019 follow-up of a long-term campaign

Background

Nutritional profile, physical activity level and sedentary behaviours, in preteen age, are determinants able to influence both short and long-term state of health, therefore succeeding in health education campaigns addressed to this age group is critical for the interested population. Is currently underway the multiannual follow-up of the Italian “sCOOL FOOD - Per un Futuro di tutto Rispetto” project of Monte dei Paschi Foundation of Siena, Tuscany, which offers year-round cycles of classes and workshops about the themes listed above. Our objective was to assess whether this intervention could significantly influence over time healthy, and unhealthy, behaviours of the participants.

Methods

We structured the follow-up as a prospective cohort study with one-group pretest-posttest design. We used the CAWI technique, building a questionnaire based on the Italian “OKkio alla Salute” survey, and collected data from the whole population of students enrolled in the project (in the school year 2018-2019 they were 3787, aged from 7 to 12) before and after the intervention. Afterwards, we conducted paired data analysis on the frequencies of specific behaviours.

Results

We analysed paired data from 310 respondents. Improvements were gained in: afternoon TV watching (OR 0.54; 0.34 - 0.84; p &lt; 0.01), consumption of sweet (OR 0.39; 0.16 - 0.88; p &lt; 0.05) and salty (0.42; 0.18 - 0.90; p &lt; 0.05) snacks, attitude to play outdoors after school (OR 2.6; 1.21 - 6.04; p &lt; 0.01), sedentary behaviour in leisure time (OR 0.27; 0.16 - 0.44; p &lt; 0.0001), mean weekly sport activity (+0.14 days; +0.02 - +0.27; p &lt; 0.05). No variable has deteriorated.

Conclusions

The improved compliance with healthy behaviours in the participants at this project suggests its viability as a health promotion campaign. Further parallel surveys on control groups are pending, in order to control potential confounders such as the seasonality of some habits and the awareness of the participants on the addressed subjects.

Key messages

A coordinated and cross-disciplinary food and lifestyle year-round education campaign at school can affect health determinants of children. School can correct unfavourable eating and lifestyle behaviours determined by family habits.

Surveillance for severe acute respiratory infections in the 2019/2020 season in Tuscany, Italy

Background

Influenza is a major public health burden. In Italy there were 7.6 million symptomatic case of influenza in the 2019/2020 influenza season. In Italy, the influenza season lasts from October to April of the following year. We analysed influenza A and B viruses from hospitalized patients with Severe Acute Respiratory Infections (SARI) to carry out epidemiological and virological surveillance.

Methods

68 oropharyngeal swabs were taken from the patients with SARI at Le Scotte University Hospital in Siena and they were given a questionnaire to record their underlying disease and vaccination status. Total RNA was extracted from the swabs by means of the QIAamp Viral RNA Mini kit and RT-PCR was carried out. After, biodirectional DNA sequencing reactions were performed. All statistical analyses were performed by means of GraphPad Prism 6 software.

Results

The median age of subject was 82 years and 52.9% were female. The subjects showed fever (89.7%), fatigue (77%), headache (47%), cough (75%), sore throat (70.5%), breathlessness (63.2%).We found that 20.5% of 68 subject were positive (13% for A H3N2 and 7% for A H1N1). Out of the 68 subject, 25% received seasonal influenza vaccination (91.6% trivalent vaccine and 8.4% quadrivalent vaccine). The most common underlying disease found in the positive subjects were cardiovascular diseases (50%), renal diseases (50%), lung diseases (42.8%), diabetes (35.7%), cancer (35%).

Conclusions

Epidemiological and virological surveillance remains an essential tool for monitoring virus circulation and possible mismatches with seasonal vaccine strains, and providing information that can be used to improve the composition of influenza vaccines. Our data support the importance of seasonal vaccination in subjects with chronic diseases to reduce hospitalisation and mortality.

Key messages

Virological surveillance is important for determining the spread of influenza viruses. Seasonal vaccination is considered as the most effective way to prevent influenza and its complications.

Efficacy of nearuv-a to inactive microbial growth

Background

Microbes are less able to develop resistance towards antimicrobial blue light (aBL), at 405nm, towards disinfectants/antibiotics. In addition, Near UV-A light (nUV) is less harmful to host cell compared to UV-C irradiation. This study aimed to assess the efficiency aBL in reducing microbial growth on surfaces.

Methods

This cross-sectional study, run between July-October 2020. Petri dishes were contaminated with P. Aeruginosa, E. Coli, S. Aureus, S. Typhimurium, K. Pneumoniae at a concentration of 1.5x104 CFU/mL and were placed at 2 and 3m of distances from the light source having an irradiance of 967,39 and 497,33 µW/cm2 for 12 hours. The air confined the room was sampled for two weeks with two air samplers (SAS), before and after the exposition to the nUV light source to estimate the reduction of the environmental microbial contamination. The analysis was conducted using Stata software. Final results were expressed as logarithmic reduction mean with 95% confidence interval.

Results

The highest microbial reduction was reached 2m directly under the light. Significant (p &lt; 0.05) log-reduction were achieved for S. Typhimurium, 2.93 (IC 2.44-3.40), K.Pneumoniae, 2.30 (IC 2.14-2.46), S.Aureus, 3.98 (IC 3.78-4.12), E.Coli, 3.83 (IC 3.17-4.50), P. Aeruginosa, 3.86 (IC 3.22-4.48). At 3m of distance from the light source, it was observed a significant logarithmic reduction for S. Aureus, 3.49 (IC 3.34-3.65), and P. Aeruginosa, 3.80 (IC 3.11-4.47). In the air tests, we observed a mean percentage microbial reduction of about 70% after 12 h of exposure to nUV light.

Conclusions

nUV has proven to contrast microbial growth on the plates. It is possible to implement this technology in the environment for controlling microbial presence in “ad hoc” scenario but also in common areas. Mitigating the energy, it is possible to use this technology in presence of persons.

Key messages

In this experimental study, nearUV-A has proven to be efficient to reduce the microbial growth and to disinfect air and surface. NearUV light (nUV) can be use as an innovative technology for decreasing bacterial contamination, also in presence of people.

How the health-related quality of life in geriatric patients is influenced?

Background

Health requires a multi-dimensional approach and not just a cure for illness. Health can be assessed from the point of view of the objective state, but also from its perception which influences the quality of life (QoL). Several tools have been used to measure QoL in many clinical contexts such as five-level EuroQol-5 dimension questionnaire (EQ-5D-5L). The aim of the study is to evaluate the perceived QoL in geriatric patients.

Methods

We conducted a cross-sectional study, using EQ-5D-5L from January to December 2019. EQ-5D-5L was self-administered to a sample of 187 geriatric patients from a private clinical (100 beds). We performed a descriptive and statistical analyses using the five dimensions: mobility (M), self-care (SC), usual activities (UA), pain/discomfort (PD), anxiety/depression (AD) in association with BMI, age, sex, length of stay (LoS). The analyses (Spearman correlation coefficient) was carried out with STATA software.

Results

In our sample the 66,8% was female, the mean age was 78,35 ±10,9, the LoS had an average of 22,37 ± 37,72. Only 170 patients responded to EQ-5D-5L. The mean score of the five dimension of EQ-5D-5L was 3 excepted for the AD that was 2. The mean of EQ index was 0.44 ± 0.29, and it is realted to LoS (p = 0,01; Rho=-0,18). Only UA was associated to BMI (p &lt; 0.05; Rho= -0,21). The age and LoS were associated to M, SC and UA (p &lt; 0,03 Rho&lt;0,25). The gender appeared related to the M (p &lt; 0,02) with a worse perception in the female.

Conclusions

Our sample perceived a low quality of life that appeared to be related to the length of stay. Among the 5 dimensions mobility, self-care and usual activities were more influenced by our variables. A higher BMI doesn't appear as a limit to the habitual daily activities.

Key messages

Health requires a multi-dimensional approach and not just a cure for illness beacause it could influence the quality of life. The length of the stay seems to condition the quality of life of patiens and also a higher BMI seems not impacted the habitual daily activities.

There is no planet B: masks UVC disinfection to rise to the environmental challenge during COVID-19

Background

Since the outbreak of Sars-CoV-2 public health measures have been adopted globally, most notably the use of face masks has become essential and often mandatory. As a result, about 3.4 billion single-use face masks are estimated to be discarded daily worldwide. Due to waste mismanagement, the COVID-19 pandemic is severely impacting the environment, the ecosystem and therefore human health. We aimed to assess if UV-C light is an efficient tool for proper mask disinfection, to guarantee their safe reuse and reduce their waste.

Methods

In October 2020 we conducted a cross sectional study on KN95 masks. Various operators wore the masks during their shift in the laboratory for 8, 16 and 24h. Contact plates were used to measure microbial contamination on both surfaces of the masks at time T(0). Then, masks were placed into a UV-C box (volume of 0.012 m3, 40 UVC LED at 270nm at 3mW) for a treatment of 3 minutes. We repeated the sampling at time T(1). We incubated all plates at 36 °C and read them after 48h. We performed descriptive and inferential (Wilcoxon matched pair test) analysis with Stata. Significance level was set at p < 0.05.

Results

We always observed greater contamination on internal surfaces than external ones. At T(0) the medians of CFU on samples of internal surface were 212.7 (CI 95% 0-480.2) at 8h, 311.7 (0-683.1) at 16h and 404.7 (0-736.1) at 24h; at T(1), CFU reduced (p < 0.05) and were respectively 3.2 (0-6.2), 2 (0-5.9) and 50.6 (0-164.7). At T(0) the medians of CFU on external surface were 23.7 (0-48.4), 53.2 (0-143) and 24.3 (0-71.8); at T(1) they respectively reduced (p < 0.05) to 8.7 (0-25.2), 18.2 (0-70), 2.3 (0-6.1).

Conclusions

Results showed that UV-C is effective in mask disinfection although an uncomplete abatement of the microbial load. It could be due to the limited UV-C dose or to its difficulty to penetrate among the meshes of the mask. Further investigation is needed to find a sustainable solution for mask use.

Key messages

UV-C seems a valid disinfection tool for used KN95 masks.

The development of strategies for proper disinfection of masks should be carried out to guarantee reusability and reduce waste production.

Carbapenem-resistant enterobacteriaceae: don’t trust your neighbour

Background

The spread of carbapenem-resistant enterobacteriaceae (CRE) outbreaks consists not only of germs producing KPC and OXA-48, endemic already, but also metallo-beta-lactamase such as NDM or VIM. In Tuscany, Italy, a multidisciplinary regional task force has extended, since NDM alert spread out, from 1st Oct 2019 the CRE screening programme, via molecular testing, to newly admitted patients in high risk settings (medical, intensive care, oncology, transplant, infectious diseases, cardiac surgery units) to fight cross-contamination. The aim of the study is to assess levels and types of CRE in an italian teaching hospital (615 beds) after the programme became effective.

Methods

The surveillance team began recording daily all the CRE positive cases, defined as laboratory confirmed colonizations/infections with CRE. Our retrospective, descriptive study covers the time span between 30th Sep - 16th Dec 2019. Cases were classified by infected apparatus and by resistance phenotype, and we calculated descriptive statistics.

Results

In total we identified 97 cases (male 60.82%, mean (+/-SD) age 71.58+/-17.34 years, 74.23% in medical wards); 5 patients had two body districts infected and 9 carried two different phenotypes. Out of 102 positive samples, 92.16% were bowel colonization, 1.96% BSI, 3.92% urinary and 1.96% respiratory. Among these, 21 were NDM (19.81%), 29 KPC (27.36%), 4 OXA-48 (3.77%), 52 VIM (49.06%). The most detected germ was Klebsiella pneumoniae (30.19%), followed by Escherichia coli (2.83%), Enterobacter cloacae (2.83%), Citrobacter freundii and braakii (2.83%), Klebsiella oxytoca (1.89%). 61 agents were unspecified (57.55%). Among the 21 NDM, 76.19% were K. pneumoniae, only one was a BSI.

Conclusions

CREs continue to be present despite constant surveillance. Although high levels of KPC-producing agents persist, the new spread of VIM phenotype is significant, highlighting, however, that the pathogen wasn't detected in over 50% of the samples.

Key messages

Despite increased surveillance, there is still a consistent portion of patients colonized with unidentified CRE. A surveillance mainly focused on NDM-producing CREs had incidentally highlighted an unexpected spread of VIM phenotype.

Promoting sport and physical activity in Italy: a cost-effectiveness analysis of seven innovative public health policies

BACKGROUND

Inactive lifestyles are a key risk factor underpinning the development of many chronic diseases, yet more than half of the Italian population does not meet WHO thresholds for at least moderate physical activity. This study aims to make the economic case to upscale investments in policy actions to promote exercise and physical activity.

STUDY DESIGN

Modelling-based cost-effectiveness analysis in Italy.

METHODS

The study assesses the impact on health and healthcare expenditure of seven public health policies to promote exercise and physical activity against a business as usual scenario. Assessed policies include: promotion of active transport, workplace sedentarily interventions, investments in sports and recreation, mass media campaigns, prescription of physical activity in primary care, school-based interventions and mobile apps.

RESULTS

Public policies to promote exercise have the potential to improve population health and produce savings in healthcare expenditure. Assessed policies can avoid hundreds of cases of cardiovascular diseases and diabetes per year and tens of cases of cancer resulting in gains in DALYs in the order of thousands per year. In the medium-term, the vast majority of policies show excellent cost-effectiveness ratio, below internationally recognized thresholds.

CONCLUSIONS

Investing in policies to promote active lifestyles is a good investment for Italy.

Can the timing of hospitalization influence the outcomes of childbirth?

Background

The timing of hospitalization of pregnant females could influence the outcomes of both mother and the baby. The aim of this study was to analyze impact of coming to hospital too early on outcomes of childbirth.

Methods

A cross-sectional study was conducted in the birth center of Siena University hospital (Italy), all women that gave birth between 2017 and 2019 were included. Examined variables were: age, parity, gestational age: GA(weeks), Bishop score at admission: BS (0-13; &gt;9 high possibility of spontaneous delivery), time to delivery:TTD (min), labor duration:LD (min), n°of interventions (induction, amniorhexis, augmentation):NI, type of birth (vaginal/caesarean section: CS/operational birth: OB), laceration, episiotomy, hematic loss: HL (ml), skin to skin:StS and initiation of breastfeeding: BR (yes/no). The females that came too early were identified if TTD &gt;75° percentile. Analysis was performed with Stata 12.

Results

A total of 758 females were analyzed (32.0±5.2years), 55.5% multiparous, average GA was 39.6±1weeks, average BS was 7.2±2.5; 63% had BS &lt;9. Average TTD was 376.7±318.5min; 23% came too early (TTD 865.6±244), more likely primiparous (OR 3.9) and those with higher GA (OR 1.2). A negative correlation between BS and TTD was observed (Rho=-0.6), females with BS &lt;9 had higher probability to have prolonged TTD (OR10.8). Ninety-three% had vaginal birth, 6%CS, 1%OB Average LD was 169.1±145 min, average NI was 0.64±0.93, 78% had lacerations, 7.2% episiotomy. Average HL was 299.3±282.7ml. Females with prolonged TTD had higher NI (1.2 ±1 vs 0.4±0.6), higher probability of CS (OR 3), OB (OR4.5) and episiotomy (OR3.6), lower probability of StS and BR (OR 0.9), prolonged LD (299±184 vs. 120±102) and major HL (347.2±301.8 vs 284.9±275.4).

Conclusions

Our study showed an association between too early arrival to hospital and adverse maternal and fetal outcomes in terms of higher use of medical interventions that can interfere with physiological processes.

Key messages

The risk of arriving too early in hospital for labor was higher in primiparous and in those with higher gestational age. The too early arrival in hospital for labor was associated within increased use of medical interventions, interfering with physiological processes.

Sliding doors: how their opening affects particulate matter levels?

Background

The operating theatres (OTs) have adequate conditions to perform safe operations and to prevent surgical site infections. Opening doors can compromise these situations. Measurement of particulate contamination is a key point to check the effectiveness of preventive measures in the OTs. We analysed how openings impact in different type of OTs.

Methods

Between January/February 2020 a transversal study was conducted in 5 different types of OTs in a university hospital. Two had laminar flows, with 55 and 60 air changes/h; three had turbulent flows: OT-A (18 air changes/h, with 4 inlets from the ceiling), OT-B (23 air changes/h and air flow from the ceiling plenum), OT-C (16 air changes/h, air flow directed from one wall to the opposite wall and the main door laterally to the flow). Particulate matter (PM) measurements were carried out in 7 different points in each OT, alternating two conditions: a) doors closed; b) opening/closing the main door twice per minute. For each spot, in each condition, we recorded for several minutes the following parameters: particles (0.3, 0.5, 1, 3, 5, 10µ), room temperature (Ta), Relative Humidity (Rh), airspeed (Va). Comparison with the Wilcoxon test were made using STATA 14.

Results

In laminar flow, classified with better ISO levels (4), opening and closing the door the PM, for any size, increased not significantly (p &gt; 0.05). The OTs with turbulent flows (ISO 5-6) had a higher particulate level than the laminar ones and greater variations with door openings. OT-A worsened significantly for all particles (p &lt; 0.05) closing/opening the door. In contrast, OT-B and OT-C had a significant reduction of PM (p &lt; 0.05). All 5 OTs had pressure falling to 0 at door opening; Ta, Rh and Va may be affected by different type air flows and design.

Conclusions

OTs parameters during door openings are influenced by different ventilation systems and room design. Laminar flows OTs are less affected, but innovative turbulent flows OTs can be just as effective.

Key messages

The operating rooms are affected by the door opening. Laminar flows operating rooms are less influenced by door openings than turbulent flows ones. Turbulent flow rooms have different performance depending on their construction characteristics.

The venom bites in pregnant women: systematic review

Background

The snakebite in pregnancy are rarely reported in literature; they cause mortality and morbidity, the symptoms may be many, such as circulatory collapse, respiratory failure, bleeding, renal failure. The antivenom is the standard treatment, but it can be a potential cause of anaphylaxis and serum diseases; its effects on the fetus are unknown, so doctors may hesitate to apply it. We conducted this study because there are many cases not described in the literature also in Italy. The aim of systematic review is to evaluate the outcomes of the bites for women and newborns and the antivenom treatments in pregnant women, to understand the best behaviour to adopt.

Methods

In January-February 2020, we searched studies in Medline using the key MeSH Terms “snake bites” and “pregnant woman”. We included all case-control studies and letter to editor in English.

Results

The research yielded 22 publications: after title, abstract and full text's analysis, 12 manuscripts were included in this review. The studies were conducted from 2006 to 2019 in Japan, Taiwan, India, Pakistan, Thailand, Burkina Faso, USA, Israel and included a total of 14 pregnant women (1-3 women per study). The mean age was 30.47± 7.34, the average of pregnancy week was 21.50±11.25, 93.33% of mothers was alive as well as 60% of fetuses. The antivenom was given in 66.67% of cases, of these, all mothers were alive and only four newborns were dead (the deaths in studies don't seem to be related to the use of antivenom).

Conclusions

Snakebite during pregnancy could lead to serious complications for mother and fetus. The use of antivenom does not appear to be related to fetal or maternal death, and it should always be species-specific for the type of snake, so as to reduce the risk of adverse effects caused by antivenom or its improper use. It is necessary to implement guidelines for the correct management of therapy and to ensure good maternal and fetal outcomes.

Key messages

It is important to diagnose snakebite in pregnant women quickly in order to begin supportive therapy and identify the species of snake for the administration of the correct antivenom. An improvement of the guidelines is needed for better management of therapy in pregnant women.

A simulation model of microbe overlapping for the correct estimation of UV-C device log-reduction

Background

Candida auris is an emerging pathogen responsible for several outbreaks within healthcare facilities. It can be found on hospital surfaces and patient care devices. UV- C sanitisation may constitute an effective adjunct to routine room cleaning to prevent the spreading of this yeast. Previous findings with this technology suggest to investigate different sources of variability in the study of the biocidal effect of UV devices on C. auris. In this study we develop a computer simulation of surface distribution of microorganisms on a stainless steel carrier, to optimize UV-device experiments.

Methods

Based on the literature about C. auris studies and its estimated average size (about 5 μm diameter), several Matlab simulations have been performed to include as many microorganisms as possible to be ideally placed on a 20 cm2 stainless steel support, avoiding cell overlapping. This was done in order to maximize the effectiveness of UV exposure.

Results

Two initial simulations were performed to evaluate a random arrangement of a very large number of microorganisms (8x107 CFU) on the steel support, widely overlapped. In this case, due to the poor UV-C penetrability, we would not exceed two log10 reduction. By randomly distributing 1x106 CFU, the probability of overlapping was about 1.3%, but even a partial overlap limits the log10 reduction. By randomly distributing 1x105 CFU, the overlaps were at least 10 times less likely.

Conclusions

The simulation results allowed us to evaluate the most appropriate microorganism distribution model able to optimize the biocidal effects of UV-C devices. The overlapping of microorganisms reduces UV-C penetrability. Our simulated study is consistent with literature results where we observed a lower log-reduction by increasing the concentration of microorganisms and therefore the probability of overlapping. The resulting model would simulate any log-reduction scenario, at any distance and any concentration, with and without overlapping.

Key messages

The complete or partial microorganism overlapping plays a relevant role in the outcome of UV-C biocidal experiments. To identify the exponential CFU reduction curve and estimate accurately the inactivation rate constant, simulated experiments should be performed to assess the real effectiveness of UV devices.

Factors associated to functional outcome after total hip and knee arthroplasty

Background

An individual rehabilitation plan should guarantee a personalized approach to each patient. Identifying patients at risk of slower progression could help to implement a targeted approach. Aim of this study was to analyse patients characteristics associated to worse Functional Outcome (FO).

Methods

A cross sectional study of patients after Total Hip Arthoplasty (THA) or Total Knee Artroplasty (TKA) recovered in a Rehabilitation Clinic from January 2017 to December 2018 was performed. Patients characteristic: Age, Gender, Body Mass Index (BMI), Pain at admission (expressed in Numeric Pain Rating Scale: NRS), Cumulative Illness Rating Scale (CIRS) and Length of Stay in surgical facility (SLOS). Outcome tested: Active Flexion (AF), Barthel index (BI), Tinetti scale (TS), Pain at Discharge (PD). Patients were divided into two groups in relation to the achievement of target values in eight day of rehabilitation (AF = 84°, BI = 90, TS = 19 and PD ≥ 5). Statistical analysis was realized using Stata12.

Results

In total 1857 patients, 58% females, 56% after THA. Average age was 70.5±10.4, higher for females (72±9.7 vs. 68.3±11), average BMI 27.2±4.3, average SLOS 5.2±2.8. Regarding AF: 48% did not reach target value (38%THA; 55%TKA), for THA more likely older (OR 1.01) and females (OR 1.5) and for both THA and TKA higher NRS (OR 1.2). As for the BI target value was not reached by 24% patients (24.4%THA; 23.4%TKA); more likely older patients (OR 1.05), females (THA OR 2.1; TKA OR1.5), those with higher NRS (OR 1.13) and higher SLOS (THA OR 1.16; TKA OR 1.14). As for TS, 7% did not reached target (6.5%THA; 6.8%TKA), association with age (TKA OR 1.08; THA OR 1.04) and for THA also with SLOS (OR 1.13), pain (OR 1.16) and female sex (OR 2.16) was observed. As for the PD 17% not reached target (9.78%THA; 25.59%TKA), for TKA an association with BMI was observed (OR 1.08).

Conclusions

Worse FO was associated to not modifiable variables as age and gender but also with NRS, BMI and SLOS.

Key messages

Analysing patients characteristics associated to worse Functional Outcome allow to identify patients at risk of slower progression. The aim is to implement a targeted and personalized approach. The worse FO was associated to not modifiable variables as age and sex but also to higher NRS, prolonged SLOS and high BMI. Those conclusions help to manage an Individual Rehabilitation plan.

Operating Rooms efficiency: leveraging data to improve management of elective surgery

Background

Careful scheduling of elective surgery Operating Rooms (ORs) is crucial for their efficient use, to avoid low/over utilization and staff overtime. Accurate estimation of procedures duration is essential to improve ORs scheduling. Therefore analysis of historical data about surgical times is fundamental to ORs management. We analyzed the effect, in a real setting, of an ORs scheduling model based on estimated optimum surgical time in improving ORs efficiency and decreasing the risk of overtime.

Methods

We studied all the 2014-2019 elective surgery sessions (3,758 sessions, 12,449 interventions) of a district general hospital in Siena's Province, Italy. The hospital had3 ORs open 5 days/week 08:00-14:00. Surgery specialties were general surgery, orthopedics, gynecology and urology. Based on a pilot study conducted in 2016, which estimated a 5 times greater risk of having an OR overtime for sessions with a surgical time (incision-suture)&gt;200 minutes, from 2017 all the ORs were scheduled using a maximum surgical time of 200 minutes calculated summing the mean surgical times for intervention and surgeon (obtained from 2014-2016 data). We carried out multivariate logistic regression to calculate the probability of ORs overtime (of 15 and 30 minutes) for the periods 2014-2016 and 2017-2019adjusting for raw ORs utilization.

Results

The 2017-2019 risk of an OR overtime of 15 minutes decreased by 25% compared to the 2014-2016 period (OR = 0.75, 95%CI=0.618-0.902, p = 0.003); the risk of a OR overtime of 30 minutes decreased by 33% (OR = 0.67, 95%CI= 0.543-0.831, p &lt; 0.001). Mean raw OR utilization increase from 62% to 66% (p &lt; 0.001). Mean number of interventions per surgery sessions increased from 3.1 to 3.5 (p &lt; 0.001).

Conclusions

This study has shown that an analysis of historical data and an estimate of the optimal surgical time per surgical session could be helpful to avoid both a low and excessive use of the ORs and therefore to increase the efficiency of the ORs.

Key messages

An accurate analysis of surgical procedures duration is crucial to optimize operating room utilization. A data-based approach can improve OR management efficiency without extra resources.

The impact of mortality for infectious diseases on life expectancy at birth in Tuscany, Italy

Introduction

The epidemiologic transition describes the reduction of mortality for infectious diseases (ID), followed by an increase in prevalence of non-communicable diseases. During recent years the situation has changed; an increase in mortality for sepsis was observed. Italy is amongst the countries with the highest prevalence of microorganisms resistant to antimicrobial therapy in Europe. The aim of the present work was to evaluate the impact of mortality for ID on life expectancy (LE) in the Tuscany region(Italy).

Methods

Mortality data relative to residents that died during the period 2000/2002- 2013/2015 were provided by the Tuscan Regional Mortality Registry. At first the analysis was performed for whole territory, then for geographic area (Nord-Est:NE, Centrum:C, South-East:SE). The analysis was realized with software Epidat,using the Pollard's method of decomposition of variations in LE for age and cause

of death.

Results

The overall gain in LE was 2.9 years for males and 2.6 years for females. The increase in mortality for ID was responsible for the loss of 0.11 years of LE for males vs. 0.16 years for females. The loss was observed in males aged 45-89, for females from 69 years onwards, with the highest loss between 79-89 years. After analysis for area, geographical differences emerged, for both males and females the highest loss of LE was observed for NE (-0.23 years vs.-0.19), followed by C (-0.15 years vs. -0.16) and SE (-0.12 vs. -0.11).

Conclusions

The result can be partially explained by the transition from ICD-9 to ICD-10 (in 2010), which improved the sensitivity of codification, but also by diffusion of pathogens resistant to antimicrobial therapy. The highest impact of ID was observed in elderly, probably due to the existence of predisposing clinical condition. The ID deserve major attention; the programmes of hospital infection control and antimicrobial stewardship have to be potentiated in order to contain the phenomenon.

Key messages

During the study period an increase in mortality for infectious diseases comported the loss in terms of LE years. The growing diffusion of microorganisms resistent to antimicrobial therapy could have contributed to the higher mortality rates observed during the last period.

Increasing efficiency for reducing elective surgery waiting times: a multi-interventions approach

Background

Elective surgery long waiting times are a common problem in publicly funded health systems. They have been tackled allocating additional resources or using existing resources more efficiently but results are patchy. We studied the effectiveness of a multi-interventions project based on the reorganization of existing capacity.

Methods

In a district general hospital (Siena's Province, Italy) with 150 beds, 4 elective surgery operating rooms (ORs) opened 6 hours/day 5 days/week (surgery specialties: general surgery, orthopedics, gynecology and urology) in October 2018 a project for reducing surgery waiting times was implemented based on 3 key points: i) separation of the Day Surgery (DS) flow from that of the ordinary activity; ii) increase of available operating time through reorganization of personnel: 30 additional hours/week were made available; iii) allocation of operating sessions flexibly in proportion to the waiting list: the made-available hours were redistributed through an algorithm able to estimate the optimal allocation of surgical time blocks to minimize the length of waiting lists, taking account of the interventions priority class. The waiting time of the out from 1/10/2019 to 31/12/2019 (N = 635) was compared with that of the interventions carried out from 1/10/2018 to 31/12/2018 (N = 634) using t-test.

Results

Waiting times for non-urgent cases (that can be operated beyond 30 days) were significantly reduced for all specialties (p &lt; 0.01) except urology. For general surgery, orthopedics and gynecology, DS interventions' mean waiting time decreases from 198 to 100 days (-50%) that one of ordinary interventions from 213 to 134 days (-37%). Waiting time for urgent cases (to be operated within 30 days) was also reduced.

Conclusions

A multi-interventions project based on using existing capacity (personnel and structures) more efficiently and improving planning methodologies resulted to be strongly effective in reducing waiting times for elective surgery.

Key messages

To effectively reduce surgical waiting times, a strategy is needed that involve the entire process: from surgical planning, to staff and structures organization. The flexible OR time allocation on the base of the waiting list is a key point to improve surgery planning and reduce waiting list.

How much general practitioners empathize with patients?

Introduction

Thanks to the privileged relationship that the general practitioner establishes with patients, he well knows their personal background and assesses the disorders as a whole, without focusing only on unique pathology. The aim of the work were: I) to assess the level of concordance between the health profile (HP) of the patient measured by the doctor and that measured by the patient, and II) to and assess which variables influence the perception.

Methods

A cross-sectional study was conducted between Aug 2019-Jan 2020 in a primary care setting. To assess health-related quality of life we administered the EuroQol 5d-5L to patients (EQ-p). Simultaneously, we asked the doctors to fill in the questionnaire 'from the patient's point of view' (EQ-d), also based on data collected in the computerized clinical diary. Data was collected anonymously and the statistical analysis was carried out using Stata 14 (Cohen's kappa; Fisher test).

Results

The sample consisted of 223 patients (46% men). The mean age was 56.5±19.6 (min 18-max95). The mean BMI was 25.5±5 (28% overweight; 18% obese). Significant differences by gender were found in Pain and Anxiety/Depression dimensions (44% of men had not pain vs 33% of women (p = 0.03) and 56% of men had no Anxiety/Depression vs 36% of women (p &lt; 0.01)). These differences were not detected by doctors; As regards the concordance between EQ-p and EQ-d, it was moderate for Mobility (k = 0.45; p &lt; 0.01) and Self-Care (k = 0.46; p &lt; 0.01). The agreement was fair for usual activities (k = 0.39; p &lt; 0.01) and it was poor for Pain/Discomfort (k = 0.14; p &lt; 0.01), Anxiety/Depression (K = 0.19; p &lt; 0.01) and EQ Index (k = 0.11 p &lt; 0.01).

Conclusions

Our analysis shows a greater concordance especially for the dimensions that appear more objective (Mobility and self-care) than the subjective ones (Pain, Anxiety). The physicians do not seem to take into account the differences in perception between men and women when they empathize with patients.

Key messages

The general practitioner knows the personal history of his patients and assesses the disorders as a whole, without focusing only on the specific pathology. In the exercise of the identification, he seems to understand mainly dimensions that appear more objective without grasping the differences in perception between men and women.

Every cockroach is beautilful to the eyes of his mother? Parent’s perception of child’s BMI

Background

Childhood obesity is becoming a social health problem in the western world and an important goal is to analyze and correct risk factors. Part of the problem could be determined by a different perception of the weight. We aim to determine the association between children's BMI and the parent's perception of their Health Status.

Methods

In October 2019 we conduced a cross sectional study in which a questionaire was administrated to the parents of primary and secondary schools children in South-East Tuscany, Italy. Eating habits, lifestyle and biometric data were collected from children and their parents. 4324 persons were included. We used Stata for descriptive and inferential analysis. Cohen's Kappa was used to find the correlation between variables.

Results

Analysis was carried out on 1421 complete questionnaires. We found that most of parents have a wrong perception of weight's children. 88.3% of parents who have obese children belive that his child is normal weight or only “a little overweight” and only 11.7% have a perception of their child's obesity. 67.6% of parents who have overweight children, belive that their child is normal weight. While among underweight children, 74.3% of parents belive that their child is normal weight. Cohen's kappa show poor agreement between real and perceived BMI (K = 0.26; p = 0.0001).

Conclusions

Our results show, among the overweight children, there is a misperception in the weight of the child by the parents, uniformly with the data present in the literature. Acquisition of healty behavior during childhood is extremely important for the state of health in adulthood and for avoiding the onset of associated diseases. Therefore, food education becomes a crucial objective for the future of our country: an essential goal is to create prevention programs addressed to children and parents to increase consciousness of the correct weight and the diseases that can result from bad nutrition.

Key messages

Many parents have a misperception of the weight of their children. It is crucial to educate parents to control their children's weight to avoid the onset of metabolic diseases. Increase consciousness in children and parents of the correct weight should become extremely important to avoid the onset of disease in adulthood.

Know your enemy, fight the outbreak: an Italian experience

Issue

The New Delhi-Enterobateriaceae producing metallo-beta-lactamase NDM, resistant to carbapenems, are responsible of hospital outbreaks. The European Centre for disease prevention and control has published a report about the NDM outbreaks in Italy. Knowledge and application of all types of precautions is necessary to obtain adequate control.

Description

Between June and August 2019 an outbreak of Klebsiella pneumoniae producing NDM-1 occurred in an acute cardiac surgery setting from medium to high intensity, in a third level-hospital in Italy. Every patient with at least one positive typing test for NDM in clinical specimens was defined as a case. The infection control team sought patient 0, reviewed patients' daily records and created a timeline to control movements, verifying risk factors and time to positivity. The correct application of isolation and standard precautions was assessed. Auditing and training sessions were carried out. Our aim is to verify if these actions sufficed to control and halt the outbreak.

Results

Fourteen cases were identified, mean age=66.28 (SD = 13.55), 71.43% of them had a previous negative test. Positivity was found in samples from 13 rectal swabs (prevalence 12.38%), 7 lung aspirates, 3 urine cultures, 2 blood cultures and 2 wound swabs. Eight patients were positive in multiple body districts, 5 have been admitted to the same hospital within the year before, 3 came from other hospitals. The patient 0 has been moved in from a medical ward. After auditing, a training class was given to healthcare staff. The class concerned NDM phenotype, hand hygiene, isolation and personal protective equipment, with further observation in wards. In the following three months no new cases were registered.

Lessons

A continuous high-level adherence to standard precautions and hand hygiene by healthcare staff should be supported by adequate training. This is confirmed to be a strong action to prevent or stop cross-contamination.

Key messages

Colonization of multiresistant germs in healthcare due to cross-contamination has to be tackled promptly. Auditing and training actions should be taken into serious account in order to ensure an effective reaction from healthcare staff.

Cardiotocography monitoration in antepartum care: analysis of controls

Introduction

WHO does not recommend the routine prenatal cardiotocography (CTG) during pregnancy to improve maternal and perinatal outcomes. Instead, Italian guidelines consider CTG after the 41st week of pregnancy to be useful. The aim of this work was to identify the variables associated with CTG performed before the 40th week.

Materials and Methods

A retrospective study was conducted at the Hospital of Siena (Italy), all females that accessed to CTG from 2016 to 2018 was included. The variables were: nationality, pregnancy associated pathology(PAP), gestational age(GA), parity, type of access (urgent/programmed), n° of accesses, active fetal movements (AFM), amniotic fluid index (AFI) and necessity of recovery. The statistical analysis was carried out using Stata 12.

Results

The women included were 4010, mean age was 32.8±5.6 years (75% Italian; 62.4% primiparous). A mean GA was 38 ± 3 weeks; 47.5% had one access, 27% two accesses, 14% three accesses. The 22% were urgent accesses, 11.5% had PAP (70% diabetes mellitus). The 58% showed up before the 40th week, the probability was higher for non-Italian women (OR 1.3), multiparous (OR 1.32), women with urgent access (OR 7.9) and women with PAP (OR 3.4). In 5.4% the CTG was altered, 23% had absent AFM and 2% had alterated AFI. Females that came before 40th week were more likely to have absent AFM (OR 4.5) and AFI (OR 2). The 3% needed an immediate hospitalization, mainly in non-Italian (OR 1.7), urgent accesses (OR 4.4), those that came before 40th week (OR 2.44), absent AFM (OR 21.8), and altered AFI (OR 15.8),

Conclusions

Our analysis shows the association between precocious access to CTG and urgent medical condition and PAP as expected, but also with other variable as parity and nationality. The low GA without an indication of high risk at the moment of the access suggests the possible overmedicalization of pregnancy. It seems useful to review clinical practices to ensure obstetric care close to best practice.

Key messages

As literature reports, to avoid overmedication of pregnancy cardiotocography should not be performed before the 41st week of pregnancy. In some situations the CTG is anticipated and for this reason it seems useful to review the clinical practices implemented in order to ensure obstetric care close to best practice.

The applicability of methods for assessing comorbidities: The Cumulative Illness Rating Scale (CIRS)

Introduction

It is essential to compare the results of medical care in patients suffering from multiple, and complex diseases. CIRS is a risk adjustment tool useful for assessing patients’ comorbidities although it needs to be used with precision following guidelines. The aim of this research is to assess whether organised seminars, planned to motivate the clinicians for correct data compilation, have an effect on the concordance of scores on the CIRS scores.

Methods

A prospective, pilot study started in November 2018 on a sample of 49 patients admitted to a private clinic between December 2018 and February 2019. In the context of a seminar, an Resident Physician in Public Health (RP), distributed and explained the CIRS guidelines to the clinicians. CIRS scores were then calculated by the ward physicians and compared with those of the RP who successively analysed the same medical records. The inter-rater agreement was calculated through Cohen’s kappa coefficient (κ), using Stata 14.2.

Results

Concordance was excellent or almost perfect or substantial for 8 out of 14 categories: heart disease (k = 0.82), genitourinary disease (k = 0.90) blood pressure category (p = 0.72), sense organs (k = 0.75), upper gastrointestinal system (k = 0.70), lower gastrointestinal system (k = 0.76), musculoskeletal system and skin (k = 0.66), central nervous system (k = 0.69), endocrine system and breast (k = 0.63) and psychiatric diseases (k = 0.63). The agreement was moderate for the respiratory system (k = 0.48) and for the liver (k = 0.57), and was fair for Severity Index, Comorbidity Index and the vascular system (k = 0.24, k = 0.38 and k = 0.28 respectively).No Concordance in renal diseases (k = 0.00).

Conclusions

Overall, the agreement of the scores between RP and clinicians was good, and it was possible to analyse the main weaknesses and difficulties of the clinicians. Subsequent seminars will be done to increase over time the concordance of the surveys.

Key messages

Organized seminars, planned to motivate clinicians to correctly compile the CIRS scores, were effective. The inter-rater agreement was good. Subsequent seminars will be done to increase over time the concordance of the surveys.

Breastfeeding and Birth mode: comparative analysis between elective and in-labor caesarean section

Introduction

Evidence in literature suggests that the outcomes of children born by in-labor non-emergency caesarean section (CS) are better if compared to those born by programmed CS. The aim of this work was to evaluate impact of type of CS on neonatal outcomes and breastfeeding.

Materials and methods

The cross-sectional study was performed in the Siena province (hospital of Siena and Poggibonsi) during the period January-December 2015. All females that gave birth by CS were included, except those that had emergency CS from severe medical indication (pre-eclampsia/eclampsia, fetal distress, intrauterine growth retardation, etc) or due to multiple pregnancy.

The sample was divided in two groups (programmed CS/CS in the presence of labor). The outcome variables were: necessity of hospitalization in neonatal intensive therapy unit (NITU) or resuscitation; weight loss after birth (%), hours passed between birth and first attack to the breast, type of breastfeeding at discharge (exclusive/mixed). The statistical analysis was performed with Stata 12.

Results

In total 446 females were included (53.6% programmed CS). Any association between the type of CS and admission to NITU or resuscitation was observed.

Among the newborns born by CS in the presence of labor, there was a greater proportion of babies who attached to the breast immediately after birth (82% vs. 71%; p &lt; 0.05) and also those exclusively breastfed at the moment of discharge (71% vs. 60%; p &lt; 0.05).

The weight loss was lower in babies born by CS in the presence of labor (8%±1.8; 95% CI 7.7%-8.2% vs. 8.53%±1.7%; 95% CI: 8.3%-8.8%; p &lt; 0.05).

Conclusions

Our study confirmed the negative impact of the CS in the absence of labor on the breastfeeding initiation, probably due to incomplete activation of neuroendocrine mechanisms (release of oxytocin; etc). The CS in the presence of labor is more stressful from the organizational point of view, but it helps promotion of health through the facilitation of breastfeeding.

Key messages

In-labor non-emergency caesarean section is more physiological and helps to initiate and maintain breastfeeding. The CS in the presence of labor is more stressful from the organizational point of view, but it helps promotion of health through the facilitation of breastfeeding.

Finding alternative roles for Traditional Birth Attendants: an experience from the south of Angola

Background

Reduction of maternal mortality ratio (MMR), a key indicator contained in the Sustainable Development Goals (SDGs), is strictly related to maternal empowerment and to an increasing access to skilled care in pregnancy, childbirth and postpartum. The WHO recommends to define alternative roles for Traditional Birth Attendants (TBAs) in the transition from birth with TBAs to birth with Skilled Birth Attendants (SBAs), in particular in countries where maternal care services still do not meet recommended standards.

Objectives

In 2018, the Italian Non-Governmental Organization Doctors with Africa CUAMM and the District Health Department of Ombadja (a 350000 inhabitants district in Cunene province, south of Angola) started a three-year multifaceted project to support and strengthen local health services. Aim of this work is to describe the first six months of an implemented activity involving 120 local TBAs, identified and trained to perform basic educational talks in the district territory regarding topical issues of mother and child health. TBAs were also engaged in the referral of pregnant women to health facilities with SBAs.

Results

From June to November 2018, TBAs performed 2272 talks about maternal and child health issues: healthy pregnancy (551 talks, 24.3%), nutrition (404, 17.8%) and malaria (370, 16.3%) were the most debated topics. The total of women’s presences during these educational talks was 57504, and 15379 of them (26.7%) were pregnant. TBAs referred to health facilities 226 pregnant women for a delivery assisted by SBAs.

Conclusions

Angolan estimated MMR in 2015 was 477/100000 live births: therefore, more efforts should be made to contribute to the achievement of 2030 SDGs target of 70/100000 globally. Moreover, the country percentage of deliveries assisted by SBAs is less than 50%. Promoting alternative roles for TBAs into the mother and child health framework could represent an effective way to improve maternal and neonatal outcomes.

Key messages

According to the World Health Organization, defining alternative roles for traditional birth attendants could represent an effective way to support the health of women and children. Traditional Birth Attendants can play an important role in providing basic health education and in the “referral chain” of pregnant women to health facilities with skilled birth attendants.

The decomposition of life expectancy for age and cause of death in Tuscany, Italy

Introduction

Changing of life expectancy at birth (LE) over time reflects variations of mortality rates of a certain population. Italy is amongst the countries with the highest LE, Tuscany ranks fifth at the national level. The aim of the present work was to evaluate the impact of various causes of death in different age groups on the change in LE in the Tuscany region (Italy) during period 1987-2015.

Material and methods

Mortality data relative to residents that died during the period between 1987/1989 and 2013/2015 were provided by the Tuscan Regional Mortality Registry. The causes of death taken into consideration were cardiovascular (CVS), respiratory (RESP) and infective (INF) diseases and cancer (TUM). The decomposition of LE gain was realized with software Epidat, using the Pollard’s method.

Results

The overall LE gain during the period between two three-years periods was 6.7 years for males, with a major gain between 65-89, and 4.5 years for females, mainly improved between 75-89, &lt;1 year for both sexes. The major gain (2.6 years) was attributable to the reduction of mortality for CVS, followed by TUM (1.76 in males and 0.83 in females) and RESP (0.4 in males; 0.1 in females). The major loss of years of LE was attributable to INF (-0.15 in females; -0.07 in males) and lung cancer in females (-0.13), for which the opposite result was observed for males (gain of 0.62 years of LE).

Conclusions

During the study period (1987-2015) the gain in LE was major for males. To the reduction of mortality for CVS have contributed to the tempestuous treatment of acute CVS events and secondary CVS prevention. For TUM the result is attributable to the adherence of population to oncologic screening programmes. The excess of mortality for INF that lead to the loss of LE can be attributed to the passage from ICD-9 to ICD-10 in 2003 (higher sensibility of ICD-10) and to the diffusion of multi-drug resistant bacteria, which lead to elevated mortality in these years.

Key messages

The gain in LE during the period the 1987-2015 was higher in males. The major contribution to gain in LE was due to a reduction of mortality for CVS diseases.