[Body composition in small for gestational age newborns]

OBJECTIVES

Aim of the present study was to test the hypothesis that the body composition of small for gestational age preterm infants, assessed at term equivalent age, was different as compared to that of small for gestational age full-term newborns.

METHODS

Growth parameters and body composition, assessed by means of an air displacement pediatric plethysmography system, was measured in 120 newborns (67 preterm and 53 full-term).

RESULTS

Similar weight was found in preterm and full-term newborns at term equivalent age and at birth, respectively. On the contrary, percentage of total body fat mass was significantly higher in preterm newborns as compared to full-term newborns (14.3 +/- 4.7% vs. 5.7 +/- 3.8% respectively, P < 0.05). In the preterm group gestational age was negatively associated with total fat mass at term equivalent age. CONCLUSIONS. The preterm newborns, especially if born small for gestational age, appear to be at risk for developing an altered body composition, which is a risk factor for the development of the metabolic syndrome in adult life. Preterm infants, born small for gestational age, appear to develop a quantity of fat mass higher than the adipose tissue they would have accumulated if they had completed their intrauterine gestation. The gestational age and the nutritional management in the early postnatal life could play a key role in affecting the body composition in these vulnerable infants.

Increasing appropriateness of hospital admissions in the Emilia-Romagna region of Italy

Objectives:

The Emilia-Romagna region of Italy has reduced the number of available hospital beds and introduced financial incentives to curb hospital use. The goal of this study was to assess the impact of these policies on changes over time in the number of acute hospital admissions classified in diagnosis related groups (DRGs) that could be treated safely and effectively in alternative, less costly settings.

Methods:

The assessment of the appropriate site of care was based on analysis of hospital discharge data for all hospitals for the selected diagnosis related groups in the Emilia-Romagna region for 2001 to 2005. The necessity for acute hospital admission was based on the severity of a patient's principal diagnosis, co-morbid diseases and, for surgical admissions, procedure performed.

Results:

From 2001 to 2005, potentially inappropriate medical admissions of more than one day decreased from 20,076 to 11,580, a 42% decrease. Inappropriate admissions decreased in both public and private hospitals but there remained a higher rate of inappropriate admissions to private hospitals. Potentially inappropriate medical admissions accounted for 128,319 bed-days in 2001 and 68,968 bed-days in 2005, a reduction of 59,351 bed-days. Potentially inappropriate surgical admissions decreased from 7383 in 2001 to 4349 in 2005, a 41% decrease. Bed-days consumed by inappropriate surgical admissions decreased from 23,181 in 2001 to 13,660 in 2005.

Conclusions:

The Emilia-Romagna region has succeeded in reducing the use of acute hospital beds for patients in selected diagnosis related groups. However, there are still substantial numbers of admissions that could potentially be treated in less costly settings.

[Quality of growth in preterm infants assessed at term equivalent age: a pilot study]

BACKGROUND

The American Academy of Pediatrics (AAP) recommends that preterm infants' growth duplicates fetal growth rates and that body composition replicates in utero body composition. Aim ofthe study was to compare the total body fat mass between preterm infants assessed at term and full-term newborns.

METHODS

A prospective observational study was conducted. Forty-five preterm infants (mean (SD) gestational age: 30,1 (2.3) weeks; birth weight: 1125 (280) g), and 40 full term (mean (SD) 38.5 (1.2) weeks, 3203 (385) g, breast fed infants underwent assessment of growth and body composition by means of an air displacement system at term adjusted-age and on day 3 of life, respectively. A T test was used to compare % fat mass between preterm and term infants.

RESULTS

Weight, length and head circumference were smaller in the preterm group assessed at term adjusted-age as compared to the term group. Mean (SD) percentage of fat mass in preterm infants was significantly higher as compared to term infants [14.5 (4.3) vs 7,6 (3.6), P < 0.0001].

CONCLUSIONS

Our data demonstrate that preterm infants are at risk of developing an increased adiposity in addition to postnatal growth retardation.

Decision theoretic properties of forensic identification: underlying logic and argumentative implications

The field of forensic science has profited from recent advances in the elicitation of various kinds probabilistic data. These provide the basis for implementing probabilistic inference procedures (e.g., in terms of likelihood ratios) that address the task of discriminating among competing target propositions. There is ongoing discussion, however, whether forensic identification, that is, a conclusion that associates a potential source (such as an individual or object) with a given item of scientific evidence (e.g., a biological stain or a tool mark), can, if ever, be based on purely probabilistic argument. With regard to this issue, the present paper proposes to analyze the process of forensic identification from a decision theoretic point of view. Existing probabilistic inference procedures are used therein as an integral part. The idea underlying the proposed analyses is that inference and decision are connected in the sense that the former is the point of departure for the latter. As such the approach forms a coordinated whole, that is a framework also known in the context as 'full Bayesian (decision) approach'. This study points out that, as a logical extension to purely probabilistic reasoning, a decision theoretic conceptualization of forensic identification allows the content and structure of arguments to be examined from a reasonably distinct perspective and common fallacious interpretations to be avoided.

Prevalence of long-term care acquired infections in nursing and residential homes in the Emilia-Romagna Region

BACKGROUND

Hardly any data on the occurrence of infection in Italian nursing homes have been published; yet Italy has the second oldest population in the world. The objective of the study was to assess the frequency of infections in a sample of Italian nursing homes.

MATERIALS AND METHODS

A 1-day prevalence survey was conducted in three local health authorities (LHAs) of the Emilia-Romagna region in Italy, aimed at describing the prevalence of patients with long-term care facilityassociated infections and their associated factors among residents of nursing and residential facilities. All nursing homes (NHs) and a stratified random sample of residential homes (RHs) in the three LHAs were included in the study, for a total of 1,926 elderly people in 49 facilities. The following data were recorded: infections, medical condition, activities of daily living (ADL), use of antibiotics. The main outcome of the study was infection prevalence.

RESULTS

The prevalence of patients with long-term care facility-associated infection was 8.4/100 residents overall (CI 95% 7.9-9.0), 14.6/100 in NHs and 7.5/100 in RHs (CI 95% 6.8-8.1). The prevalence of infection significantly varied with LHA and facility. It was associated with level of dependency and exposure to invasive procedures, such as urinary catheterization and parenteral procedures. Six percent of residents received a systemic antimicrobial on the day of the study, and in 22% of cases there was no evidence of suspected or diagnosed infections.

CONCLUSION

The prevalence study identified a high prevalence of infected patients in nursing homes in Italy, consistent with observation in other geographic areas.

[Proposal for a protocol for the staging of incontinentia pigmenti in pediatric age]

Incontinentia Pigmenti (IP) is an X-linked dominant disorder of skin with neurologic and ophthalmologic involvement. IP predominantly affects females because the mutations are usually lethal in males in utero. IP is characterized by abnormalities of neuroectodermal tissues. IP is caused by mutations in a gene called NEMO, which is required to activate the NF-kB pathway. We present a diagnostic protocol for IP and a meta-analysis of the clinical spectrum of IP in 82 patients cited by MEDLINE in the European literature from 2000 to 2006.

Effect of hospital ownership status and payment structure on the adoption and use of drug-eluting stents for percutaneous coronary interventions

BACKGROUND

The impact of the use of drug-eluting stents in percutaneous coronary intervention (PCI) on cardiac care is still uncertain. We examined the influence of systemic factors, such as hospital ownership status, organizational characteristics and payment structure, on the use of drug-eluting stents in PCI and the effect on cardiac surgery volume.

METHODS

We conducted a cross-sectional analysis of drug-eluting stent use in 12 993 patients undergoing PCI with stenting (drug-eluting or bare-metal) and time-series regression analyses of the monthly number of cardiac surgery and PCI procedures performed using data collected from 1998 to 2004 at 13 public and private hospitals in the Emilia-Romagna region of Italy.

RESULTS

Public hospitals used drug-eluting stents more selectively than private hospitals, targeting the new device to patients at high risk of adverse events. The time-series regression analyses showed that the number of PCI procedures performed per year increased during this period, both in public (slope coefficient 36.4, 95% confidence interval [CI] 30.2 to 43.1) and private centres (slope coefficient 6.4, 95% CI 3.1 to 9.2 ). Concurrently, there was a reduction in the number of isolated coronary artery bypass graft (CABG) surgeries, although the degree of change was higher in public than in private hospitals (coefficient -16.1 v. -6.2 respectively ). The number of CABG procedures associated with valve surgery decreased in public hospitals (coefficient -5.0, 95% CI -6.1 to -3.8) but increased in private hospitals (coefficient 4.1, 95% CI 2.0 to 6.1).

INTERPRETATION

Public and private hospitals behaved differently in adopting drug-eluting stents and in using PCI with drug-eluting stents as a substitute for surgical revascularization.

Quantitative characterization of morphological polymorphism of handwritten characters loops

A methodology based on Fourier descriptors that was previously validated has been applied to 13 writers in order to quantify the polymorphism degree of the shape of the loops of the handwritten characters a, d, o and q. In a first step, the discriminating power of the parameters extracted from these letters was investigated. The loop of the letter d appeared to be the most discriminant with a correct classification rate of 82.4%, whereas the least discriminant one was the loop of the letter o (69.7%). The second aim of the study was to extract grouping characteristics which make it possible to discriminate between writer sets, whatever the letter. Trends in the writing of loops could effectively be shown: the 13 writers of the study were separated into five main groups according to the shape and surface of their loops. The most discriminating features between the writer groups were the importance of the loops elongation and the surface of the loops. Finally, the differences between writers belonging to distinct groups could be characterized more precisely, and differences between writers belonging to the same group were revealed; the individual writings were distinguished by the variability of the parameters of shape and surface of their loops and the morphological distances between its different letters. The correct classification rates reached in this study suggest that carrying out an expertise of fragmentary samples of handwriting comprising only some loops is completely possible.

A probabilistic approach to the joint evaluation of firearm evidence and gunshot residues

The present paper addresses issues that affect both the separate as well as the joint evaluation of firearm evidence (i.e., marks) and gunshot residues (GSR). Mark evidence will be used as a basis to discriminate among barrels through which a bullet in question might have been shot whereas GSR will be used to draw inferences about the distance of firing. Particular attention is drawn to the coherent handling of uncertainties associated with the various parameters considered within each item of evidence. The proposed analysis relies on a probabilistic viewpoint that uses graphical models (i.e., Bayesian networks) as an aid to cope with the complexity induced by the number of variables considered. The paper discusses how an approach based on a probabilistic network environment can be used for the formal analysis and construction of arguments. Emphasis is made on the gain of insight into structural dependencies that may be uncovered when the evaluative process is extended beyond single items of scientific evidence.

Managing the introduction of expensive medical procedures: use of a registry

OBJECTIVES

To explore how the adoption of medical innovations challenges tax-financed health systems, drawing from the case of sirolimus eluting stents, a promising and costly innovation for percutaneous coronary interventions.

METHODS

The coverage decisions for the new stents adopted in Emilia-Romagna, an Italian region, are described. The innovation was adopted through a process combining the development of clinical guidelines targeting their use to selected clinical indications, negotiation with the manufacturer for reducing price, and the organization of a registry for monitoring its patterns of utilization and assessing its effectiveness.

RESULTS

Overall, 17% of the 6276 patients included in the registry over a 12-month period had the new stent. Wide differences between published trials on sirolimus eluting stents and actual clinical practice emerged. The new stents were frequently (23%) used in combination with traditional bare metal stents, and for indications (acute myocardial infarction and multivessel coronary disease) never included in clinical experiments (25% and 8% of the cases, respectively). Patients' outcomes were also different, the overall rate of major adverse cardiac events being relatively higher (12%) than that shown in clinical trials.

CONCLUSIONS

The actions undertaken for the new stents allowed a timely, and at the same time targeted and monitored, adoption of the innovation. This experience highlights how policy decisions related to new medical products could benefit from the availability of clinical databases providing key information on how innovations are actually used and on their impact on clinical practice.

Bayesian networks and probabilistic reasoning about scientific evidence when there is a lack of data

Bayesian networks (BNs) are a kind of graphical model that formally combines elements of graph and probability theory. BNs are a mathematically and statistically rigorous technique allowing their user to define a pictorial representation of assumed dependencies and influences among a set of variables deemed to be relevant for a particular inferential problem. The formalism allows one to process newly acquired evidence according to the rules of probability calculus. Applications of BNs have been reported in various forensic disciplines. However, there seems to be some reluctance to consider BNs as a more general framework for representing and evaluating sources of uncertainties associated with scientific evidence. Notably, BNs are widely thought of as an essentially numerical method, requiring "exact" numbers with a high "accuracy". The present paper aims to draw the reader's attention to the point that the availability of hard numerical data is not a necessary requirement for using BNs in forensic science. An abstraction of quantitative BNs, known as qualitative probabilistic networks (QPNs), and sensitivity analyses are presented and their potential applications discussed. As a main difference to their quantitative counterpart, QPNs contain qualitative probabilistic relationships instead of numerical relations. Sensitivity analyses consist of varying the probabilities assigned to one or more variables and evaluating the effect on one or more other variables of interest. Both QPNs and sensitivity analyses appear to be useful concepts that permit one to work in contexts with acute lack of numerical data and where reasoning consistent with the laws of probability should nevertheless be performed.

The Italian health-care system

Italy's national health service is statutorily required to guarantee the uniform provision of comprehensive care throughout the country. However, this is complicated by the fact that, constitutionally, responsibility for health care is shared between the central government and the 20 regions. There are large and growing differences in regional health service organisation and provision. Public health-care expenditure has absorbed a relatively low share of gross domestic product, although in the last 25 years it has consistently exceeded central government forecasts. Changes in payment systems, particularly for hospital care, have helped to encourage organisational appropriateness and may have contributed to containing expenditure. Tax sources used to finance the Servizio Sanitario Nazionale (SSN) have become somewhat more regressive. The limited evidence on vertical equity suggests that the SSN ensures equal access to primary care but lower income groups face barriers to specialist care. The health status of Italians has improved and compares favourably with that in other countries, although regional disparities persist.

Forensic identification of urine samples: a comparison between nuclear and mitochondrial DNA markers

Urine samples from 20 male volunteers of European Caucasian origin were stored at 4 degrees C over a 4-month period in order to compare the identification potential of nuclear DNA (nDNA) and mitochondrial DNA (mtDNA) markers. The amount of nDNA recovered from urines dramatically declined over time. Consequently, nDNA likelihood ratios (LRs) greater than 1,000 were obtained for 100, 70 and 55% of the urines analysed after 6, 60 and 120 days, respectively. For the mtDNA, HVI and HVII sequences were obtained for all samples tested, whatever the period considered. Nevertheless, the highest mtDNA LR of 435 was relatively low compared to its nDNA equivalent. Indeed, LRs obtained with only three nDNA loci could easily exceed this value and are quite easier to obtain. Overall, the joint use of nDNA and mtDNA markers enabled the 20 urine samples to be identified, even after the 4-month period.

Quantification of the shape of handwritten characters: a step to objective discrimination between writers based on the study of the capital character O

In view of contributing to the scientific validation of the individuality of handwriting, the testing of the two so called fundamental laws of handwriting--1: no two people write exactly alike; 2: no one person writes the same word exactly the same way twice--was approached by analysing the shape of 445 handwritten capital characters O produced by three individuals. A methodology based on classical Fourier descriptors was applied to the characters contours, which were extracted through an automated procedure of image analysis. Precise individual characterization of the shape was possible through Fourier analysis. Within-writer variability of the shape of character O for the writers selected could be shown in an objective and quantitative way through the statistical analysis of the Fourier descriptors. It was demonstrated that this polymorphism differed between the three writers. Differentiation between writers was quantitatively demonstrated by discriminant analysis of the Fourier descriptors, and by the existence of marked morphological distances between the set of characters O of each writer. The degree of dissimilitude of the character O writings could, thus, be assessed. Because of relatively reduced within-writer variability and a pronounced differentiation between the writers, a morphological profile could be established and discrimination between writers could be obtained through the quantification of the shape of one handwritten character.

The evaluation of evidence in the forensic investigation of fire incidents (Part I): an approach using Bayesian networks

The forensic investigation of the origin and cause of a fire incident is a particularly demanding area of expertise. As the available evidence is often incomplete or vague, uncertainty is a key element. The present study is an attempt to approach this through the use of Bayesian networks, which have been found useful in assisting human reasoning in a variety of disciplines in which uncertainty plays a central role. The present paper describes the construction of a Bayesian network (BN) and its use for drawing inferences about propositions of interest, based upon a single, possibly non replicable item of evidence: detected residual quantities of a flammable liquid in fire debris.

The evolution of health-policy making in Italy

An analysis of the dynamics of health care policy in Italy suggests that in recent years the pace of change in the health care system has accelerated. Although the basic features of universalism, comprehensiveness, and funding from general taxation have remained remarkably constant, the capacity to innovate policy tools and their settings and to take account of domestic and international experience seems to have increased. The political will and capacity to combat entrenched interests may also have increased, although implementation is still weak. The imperative to contain public expenditure has heavily conditioned health policy and will continue to do so. This has occurred mainly at the national level, but as the principal locus of health-policy making progressively shifts to the regions, so too will the constraining effect of this imperative move downward. If the decentralization process continues, problems could arise due to interregional differences in capacities to formulate and implement appropriate policies and to tackle special interest groups.

FMR1 gene premutation is a frequent genetic cause of late-onset sporadic cerebellar ataxia

In an Italian population of 275 unrelated men affected by adult-onset sporadic progressive cerebellar ataxia, the authors found six patients carrying an FMR1 gene premutation. Age at onset (range, 53 to 69 years) and clinical-neuropathologic findings were consistent with the fragile-X tremor ataxia syndrome (FXTAS), although tremor was not as common as previously described. FXTAS accounted for 4.2% of the cases diagnosed at >50 years, suggesting that it is a frequent genetic cause of late-onset sporadic ataxia.

A simple logical approach to questioned envelopes examination

This case report outlines research undertaken as the result of a document examination case in which two envelopes were involved. The combination of the circumstances of the case and the results of the examination allows a simple application of a logical approach to pre-assess the probability that an envelope (or a package) potentially recovered at a suspect's home comes from the same batch (same source) as questioned envelopes. This highlights that it is useful to examine envelopes.

The evaluation of evidence in the forensic investigation of fire incidents. Part II. Practical examples of the use of Bayesian networks

This paper extends a previous discussion of the use of Bayesian networks for evaluating evidence in the forensic investigation of fire incidents. Bayesian networks are proposed for two casework examples and the practical implications studied in detail. Such networks were found to provide precious support in addressing some of the wide range of issues that affect the coherent evaluation of evidence.

Empirical assessment of the impact of drug-eluting stents on the rate of use of coronary revascularization procedures

Objectives:To assess the impact of the availability of drug-eluting stents (DES) in April 2002 in Emilia-Romagna (a four-million resident Italian region), on the rate of use of revascularization procedures. DES are expected to influence the rate of use of coronary artery bypass graft (CABG) and percutaneous coronary interventions (PCI). However, to date, little empirical information is available on the actual impact of this innovation on clinical practice.

Methods:A time series regression analysis of the monthly number of procedures (PCI and CABG) performed between January 1998 and March 2003.

Results:DES availability was associated with statistically significant changes in the use of revascularization procedures, although the size of the effect was always small or moderate. PCI increased only by 0.36 more procedures per month (approximately four per year), whereas more evident was the concurrent reduction of isolated CABG (4.15 fewer per month, that is fifty fewer per year). Overall, considering all the surgical revascularizations (i.e., CAGB both isolated and associated with other interventions), there was a reduction of 2.52 procedures per month (thirty less per year).

Conclusions:Despite DES being at a very early stage of their diffusion process, our results indicate that they are already having an impact, although moderate, on the use of revascularization procedures. If these findings will be confirmed, they will have a substantial influence on the patterns of care for patients with coronary artery disease and relevant policy implications for health services.