Hospital admissions and mortality for STEMI and NSTEMI during COVID-19 outbreak: a meta-analysis

Background

During SARS-CoV-2 pandemic, various studies have shown a significant reduction of Emergency Department (ED) presentations for acute cardiac diseases requiring in-hospital management. The aim of our study was to quantify hospital admission and mortality, comparing pandemic period and pre-pandemic period in different countries.

Methods

We performed an updated meta-analysis of observational studies to quantify on a large basis the impact of the SARS-CoV-2 outbreak on patients admitted to the ED for STEMI and NSTEMI. The literature research was conducted on PubMed, EMBASE, Scopus, Science Direct, Web of Science and Cochrane database registry on 6 January 2022. We performed a random-effect model meta-analysis.

Results

A total of 61 studies were included: came from Italy, China, Germany, Israel, Turkey, France, Helvetic Confederation, India, Poland, Spain, US, UK, Albania, Austria, Egypt, Greece, Iran, Ireland, Japan, Pakistan, Portugal, Saudi Arabia and Canada. Hospital admissions for STEMI decreased in most country. The countries with the high levels of reduction were Italy (IRR = 0.68) and Germany (IRR = 0.69). Mortality rates for STEMI increased differently among countries analyzed: p = 0.003. The highest mortality rate was in Serbia (OR = 2.15), followed by Italy (OR = 1.97), Pakistan (OR = 1.69) and France (OR = 1.55). Among the High-Income countries, the highest mortality rate was in Italy (OR = 3.71), the highest among the Upper-Middle-Income was in Serbia (OR = 2.15) and the highest among Low- Middle-Income was in Pakistan (OR = 1.69). Regarding NSTEMI, hospital admissions showed that Italy had the lowest value for with IRR = 0.59. Among countries, the meta-regression subgroups analysis, showed statistical difference (p < 0.001).

Conclusions

Our meta-analysis may represent a robust snapshot that might help healthcare systems manage and assist an expected higher number of people coming to the hospitals for severe, post-acute cardiological issues in the future.

Key messages

• The study shows hospital admission and mortality, comparing pandemic period and pre-pandemic period in different countries.

• Epidemiological data suggests that one-fourth to one-third of MI patients, in large areas of the globe, during the COVID-19 pandemic in 2020, remained at home and did not have access to ED.

Carotid intima media-thickness is increased in obese children metabolically healthy, metabolically unhealthy, and with metabolic syndrome, compared to the non-obese controls

The prevalence of obesity continues to increase. Obesity is associated with cardiovascular risk factors: elevated blood pressure, dyslipidemia and glycemic alterations, causing metabolic syndrome. A subgroup of obese, Metabolically Healthy Obese (MHO), appears to be less prone to the development of metabolic disturbances. Carotid intima-media thickness (cIMT) is a non-invasive marker of subclinical atherosclerosis and it is associated with increased risk of CVD events. To investigate the cardiovascular risk, demonstrated through the increase of cIMT in obese subjects without Metabolic Syndrome (MetS), we have studied cIMT in MHO, metabolically unhealthy obese (MUO) and obese with MetS diagnosed with the IDEFICS criteria and compared to a control group. 224 obese children aged 6 to 21 years (13,50 ± 4.01 years) and 103 normal weight subjects aged 7 to 19 years (13.2 ± 4.1 years) were studied. The body mass index (BMI) of the obese children was ≥ the 95th percentile. Based on the IDEFICS criteria, we divided the obese subjects in three groups: MHO if no criteria were out of range, MUO if, at least, one of the criteria was out of range and MetS group if all the IDEFICS criteria were present. In all the subjects cIMT was measured with color Doppler by a vascular surgeon. Differences in the means of the variables were tested by ANOVA. Based on the IDEFICS criteria, 32 subjects were affected by MetS (14..3%), 66 were considered MUO (29.4%) and 126 MHO (56.3%). Comparison of mean cIMT highlighted a significant difference (p < 0.05) between the groups of obese children (MHO, MUO and MetS) and controls for both carotid arteries. We did not find significative difference in the value of cIMT in MHO, MUO and MetS subjects, and all groups showed cIMT value higher compared to cIMT of the controls.

Elastic fusion biopsy versus systematic biopsy for prostate cancer detection: Results of a multicentric study on 1,119 patients

OBJECTIVES

To assess the accuracy of targeted and systematic biopsies for the detection of prostate cancer (PCa) and clinically significant PCa (csPCa) in the everyday practice, evaluating the need for additional systematic biopsies at the time of targeted biopsy.

PATIENTS AND METHODS

From our multicentric database gathering data on 2,115 patients who underwent fusion biopsy with Koelis™ system between 2010 and 2017, we selected 1,119 patients who received targeted biopsies (a median of 3 for each target), followed by systematic sampling of the prostate (12 to 14 cores). Overall and clinically significant cancer detection rate (CDR) of Koelis™ fusion biopsies were assessed, comparing target and systematic biopsies. Secondary endpoint was the identification of predictors of PCa detection.

RESULTS

The CDR of targeted biopsies only was 48% for all cancers and 33% for csPCa. The performance of additional, systematic prostate sampling improved the CDR of 15% for all cancers and of 12% for csPCa. PCa was detected in 35%, 69%, and 92% of patients with lesions scored as PI-RADS 3, 4 and 5, respectively. Elevated PI-RADS score and positive digital rectal examination were predictors of PCa, whereas biopsy-naïve status was associated with csPCa.

CONCLUSION

In the everyday practice target biopsy with Koelis™ achieves a good CDR for all PCa and csPCa, which is significantly improved by subsequent systematic sampling of the prostate. The outstanding outcomes of fusion biopsy are confirmed also in biopsy-naïve patients. Elevated PI-RADS score and positive digital rectal examination are strongly associated with presence of PCa.

Clinical characteristics of juvenile idiopathic arthritis in an area of central Italy: a population-based study

BACKGROUND

Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disease in children and an important cause of short and long-term disability. In a recent systematic review of population based studies, the epidemiology of JIA is variable worldwide with incidence rates ranging between 1.6 and 23.0/100,000, and prevalence rates between 3.8 and 400.0/100,000. We investigate the incidence and describe the characteristics of juvenile idiopathic arthritis in the pediatric population of the central Italy, in the period 2000-2009.

METHODS

A retrospective study was conducted in the Marche region to identify patients with a diagnosis of juvenile idiopathic arthritis according to ILAR criteria, between January 1, 2000 and December 31, 2009. JIA was classified according to the ILAR criteria, that is, arthritis of unknown etiology that persisted for > 6 weeks with onset before the age of 16 years. The pooled global ascertainment of cases was estimated by capture-recapture methods and two independent information sources of ascertainment of new cases of JIA were considered.

RESULTS

We studied 151 patients (56 males, 37.1% and 95 females, 62.9%) meeting the ILAR criteria of juvenile idiopathic arthritis. Mean age at presentation was 6.8 ± 3.7 years for males and 6.0 ± 4.0 years for females (p=0.22). The overall incidence rate was 6.34 per 100,000/year (C.I. 6.26-7.35) and the total incidence rate increase from 2000-2009 was 8.16%. Oligoarthritis was the most common onset type (n=98, 65.0%) with 62.5% of ANA-positive patients in at least two determinations.

CONCLUSIONS

Our results indicate that juvenile idiopathic arthritis incidence rates in Italy are comparable to previous data from southern Europe, with a higher frequency of oligoarthritis. To the best of our knowledge, this is the first population-based epidemiological study carried out in Italy focusing on the incidence of juvenile idiopathic arthritis.

High temperature requirement A1, transforming growth factor beta1, phosphoSmad2 and Ki67 in eutopic and ectopic endometrium of women with endometriosis

Increasing evidence supports the hypothesis that TGFb1 signalling may be mediated by high temperature requirement A1 (HtrA1) serine protease, acting on important regulatory mechanisms such as cell proliferation and mobility. Evidence is now accumulating to suggest that HtrA1 is involved in the development and progression of several pathologies. The aim of this study was to evaluate: i) if HtrA1 and TGFb1 expressions differ in eutopic and ectopic endometrium in women with endometriosis; ii) if HtrA1 correlates to TGFb1, pSmad and Ki67. This study was carried out including 10 women with ovarian endometriosis (cases) and 10 women with non endometriotic diseases (controls). Endometrial tissue underwent immunohistochemical H-score analysis for HtrA1, TGFb1, pSmad and Ki67 molecules. Data evaluation was performed by a nonparametric Kruskal-Wallis test and Spearman correlation was applied to evaluate the relationship among the molecules investigated in the epithelial and in the stromal compartment. The HtrA1 was significant decreased in ectopic and eutopic endometrium of women with endometriosis when compared with control endometrium in epithelial compartment. TGFb1was significantly increased in eutopic endometrium and decreased in ectopic endometrium in epithelial and stromal compartment. In addition, Ki67 was significant increased and an increase, but not significant, was detected for pSMAd2 in eutopic and ectopic endometrium compared to control one.  In summary, the significant direct correlation between TGFb1 and pSmad2 as well as between HtrA1 and TGFb1 and the very significant increase of Ki67 in stromal compartment of eutopic endometrium suggest a possible involvement of HtrA1 in the pathogenesis of endometriosis.

Self-sampling to increase participation in cervical cancer screening: an RCT comparing home mailing, distribution in pharmacies, and recall letter

Background:

We performed a multicentre randomised controlled trial to evaluate the effect on participation in organised screening programmes of a self-sampling device mailed home or picked up at a pharmacy compared with the standard recall letter.

Methods:

Women aged 30–64 non-responding to screening invitation were eligible. Response rate to first invitation ranged from 30% to 60% between centres. The control was the standard reminder letter to undergo the test used by the programme (Pap test in three centres and HPV DNA test in three other centres). Home mailing of the self-sampler was preceded by a letter with a leaflet about HPV. The analysis was intention-to-treat.

Results:

In all, 14 041 women were randomised and recruited: 5012 in the control arm, 4516 to receive the self-sampler at home, and 4513 to pick up the self-sampler at a pharmacy. Participation was 11.9% in the control, 21.6% (relative participation: 1.75; 95% CI 1.60–1.93) in home, and 12.0% (relative participation: 0.96; 95% CI 0.86–1.07) in the pharmacy arms, respectively. The heterogeneity between centres was high (excess heterogeneity of that expected due to chance, i.e., I², 94.9% and 94.1% for home and pharmacy arm, respectively). The estimated impact on the overall coverage was +4.3% for home mail self-sampling compared with +2.2% for standard reminder.

Conclusions:

Home mailing of self-sampler proved to be an effective way to increase participation in screening programmes, even in those with HPV as primary testing. Picking up at pharmacies showed effects varying from centre to centre.

Chinese IUD removal techniques in a Chinese population in central Italy

OBJECTIVE

To describe routine techniques and a newly developed approach to the removal of Chinese intrauterine devices (IUs).

METHODS

Office records regarding women of Chinese nationality who presented to a tertiary care hospital for IUD removal between January 2007 and March 2012 were retrieved. Their demographic data were reviewed and menstrual/obstetric history, IUD type, and reasons given for removal were recorded. All underwent pelvic transvaginal ultrasound scanning.

RESULTS

Of 134 Chinese IUDs, 18 (13.4%) were removed successfully in an office setting using a hook or uterine curette without general anesthesia or cervical dilation. Extraction under brief general anesthesia was performed in 55 (41.0%) cases. A further 61 (45.5%) Chinese IUDs were successfully removed in an office setting using a miniature resectoscope. Four types of Chinese IUDs were removed, the most common being the stainless steel ring (55.7%).

CONCLUSIONS

All removal procedures were effective and safe. The mini-resectoscope appears to be a safe and effective tool enabling minimally invasive surgery.

Burden of celiac disease in Europe: a review of its childhood and adulthood prevalence and incidence as of September 2014

BACKGROUND

Recent epidemiological studies have demonstrated that coeliac disease (CD) prevalence is still underestimated both in Europe and in Mediterranean regions. Here we review the latest data on CD prevalence and incidence in the European Union (EU) as of September 2014.

METHODS

The current epidemiological scenario of CD prevalence and incidence was investigated by searching PubMed for papers in English using the following key words: "celiac disease", "celiac disease plus prevalence" (limits: 1990-2014), "incidence" (limits: 1970-2014), and "frequency", plus "in Europe". Another search was performed with the same key words plus the name of each European country. Only prevalence data obtained by serology using anti-gliadin antibodies (AGA), EMA test, tTG test, and/or duodenal biopsy were included. The study designs considered were retrospective and prospective studies: population-based (PB), cross-sectional, case-control and cohort studies.

RESULTS

Extensive research based on serological screening has demonstrated that 0.5-1% of the EU population suffers from undiagnosed CD, whereas the highest estimate reported in PB studies is approximately 1%. Considering data from different periods, incidence seems to range from 0.1 to 3.7/1000 live births in the child population and from 1.3 to 39/100,000/year in the adult population.

CONCLUSIONS

The present data disclose marked geographical variation in CD incidence and prevalence in different European countries. Here we document rising CD occurrence in recent decades in European countries due partly to the advent of improved serological testing (tTG + EMA) and partly to increased awareness of its clinical presentation.

Breast cancer in European Union: an update of screening programmes as of March 2014 (review)

Breast cancer, a major cause of female morbidity and mortality, is a global health problem; 2008 data show an incidence of ~450,000 new cases and 140,000 deaths (mean incidence rate 70.7 and mortality rate 16.7, world age-standardized rate per 100,000 women) in European Union Member States. Incidence rates in Western Europe are among the highest in the world. We review the situation of BC screening programmes in European Union. Up to date information on active BC screening programmes was obtained by reviewing the literature and searching national health ministries and cancer service websites. Although BC screening programmes are in place in nearly all European Union countries there are still considerable differences in target population coverage and age and in the techniques deployed. Screening is a mainstay of early BC detection whose main weakness is the rate of participation of the target population. National policies and healthcare planning should aim at maximizing participation in controlled organized screening programmes by identifying and lowering any barriers to adhesion, also with a view to reducing healthcare costs.

Colorectal cancer prevention in Europe: burden of disease and status of screening programs

Colorectal cancer is a major public health challenge worldwide. In Europe it is the first malignancy in terms of incidence and the second in terms of mortality in both genders. Despite evidence indicating that removal of premalignant and early-stage cancer lesion scan greatly reduce mortality, remarkable differences are still found among countries both in terms of organized screening programs and of the tests used. In 2003 the European Council recommended that priority be given to activation of organized cancer screening programs, and various states have been making significant efforts to adopt effective prevention programs with international quality standards and centralizing screening organization and result evaluation. After a 2008 European Union report on the state of screening program, activation highlighted that little more than 50% (12/22) of Member States had colorectal cancer screening programs, Screening programs have been adopted or earlier pilot projects have been extended nationwide. This paper examines the state of activation and the screening strategies of colorectal cancer screening programs in EU States as of July 2013.

Insulin resistance in migraineurs: results from a case-control study

OBJECTIVES

Several studies have suggested an association between migraine and insulin resistance (IR) without adequately addressing the issue according to migraine type. We assessed IR in subjects with migraine with aura (MwA) and migraine without aura (MwoA) to estimate the consistency of the possible association.

METHODS

In a case-control study we included case subjects with MwA and MwoA, who were consecutively selected from those referred to our Regional Headache Center from September 2011 to February 2013, and age-matched control subjects selected using general practitioners' databases. IR was calculated by means of the homeostatic model assessment of IR (HOMA-IR), β-cell function (HOMA-B), and the quantitative insulin sensitivity check index (QUICKI) measuring glucose and insulin values in a blood sample collected in the morning after overnight fasting. Data regarding anthropometric measures, comorbidity risk factors, and migraine characteristics were also recorded.

RESULTS

We recruited 50 case subjects with MwA (38 women) and 50 with MwoA (40 women) and 50 control subjects (40 women). Proportions of arterial hypertension, cigarette smoking, hypercholesterolemia, use of oral contraceptives, and mean values of the body mass index (BMI) were similar in the three groups. We found significantly different glucose values among and within groups considering case subjects with MwA and MwoA and control subjects (4.9 ± 0.6 vs 4.7 ± 0.5 vs 4.6 ± 0.5 mmol/l; P  = 0.018) in the absence of any difference in insulin (53.1 ± 24.0 vs 56.7 ± 34.4 vs 53.8 ± 24.4 pmol/l; P  = 0.811), HOMA-IR (1.6 ± 0.8 vs 1.7 ± 1.0 vs 1.6 ± 0.7; P  = 0.765), HOMA-B (121.4 ± 71.1 vs 149.2 ± 93.8 vs 162.8 ± 109.7; P  = 0.107), and QUICKI (0.36 ± 0.03 vs 0.37 ± 0.03 vs 0.37 ± 0.03; P  = 0.877) values. The logistic regression model showed increased odds of MwA in subjects exposed to the highest tertile of glucose values. This association was confirmed in the adjusted model, in which case subjects with MwA were compared with those with MwoA but not with control subjects.

CONCLUSIONS

In contrast to what has been shown by the majority of the available studies, the results of our study do not support the association of migraine with IR. As our study was not population-based and several patients had low disease activity, these findings need further confirmation.

Alterations of maternal plasma HTRA1 level in preeclampsia complicated by IUGR

We evaluated the presence of HtrA1 in maternal plasma of normal pregnancies and of pregnancies complicated by preeclampsia (PE) without and with Intrauterine Growth Restriction (IUGR). We demonstrate that HtrA1 maternal plasma levels show significant different concentrations in first, second and third trimester of gestation and that HtrA1 concentration increases in maternal plasma of gestations complicated by PE with IUGR compared with control maternal plasma matched for gestational age. Based on these data high maternal plasma levels of HtrA1 could be considered as a possible marker of an occurring IUGR in preeclamptic women.

Current psoriasis treatments in an Italian population and their association with socio-demographical and clinical features

BACKGROUND

Patient adherence is a key element for therapeutic success and represents a major concern for all healthcare professionals.

OBJECTIVE

Aim of our study was to assess the frequency of use of treatments currently available for psoriasis and its association with specific socio-demographical and clinical variables.

METHODS

The study population consisted of 1689 patients, aged 12-85 years. Information concerning socio-demographical variables, clinical features and the type of current treatment was collected. Items on patients' satisfaction of current treatments and of dermatologist-patient relationship were also included. The chi-squared test was used to estimate the association between the categorical variables, whereas Wilcoxon and Kruskal-Wallis tests were applied to the interval and ordinal variables. The Cochran-Mantel-Haenszel chi-squared trend test was used to evaluate the degree of satisfaction related to dermatologist-patient relationship.

RESULTS

Of the 1689 psoriatic patients, 54.1% did not use any treatments and 45.9% used at least one treatment. The use of drugs was significantly associated exclusively to severity of disease and affected body surface area. Systemic therapies, both traditional treatments and biological agents, were mainly used in patients with disease duration >10 years and disease severity. Treatment adherence was significantly associated to the degree of patient's satisfaction of his/her relationship with the dermatologist. Alternative treatment such as over the counter medications and acupuncture were used by 33% of patients.

CONCLUSION

The majority of psoriatic patients do not use any treatments. However, treatment adherence significantly increases when dermatologists clarify the treatment schedule, inform patients and meet the patients' needs.

Vascular patterns in basal cell carcinoma

BACKGROUND

Dermoscopy has been proved to increase the diagnostic accuracy of basal cell carcinoma (BCC).

OBJECTIVE

To characterize the type and frequency of vascular patterns in superficial and nodular BCCs.

METHODS

We retrospectively analysed the dermoscopic images of 504 histopathologically proven BCCs.

RESULTS

The most common vascular pattern was represented by arborizing vessels (306/504; 60.7%), which were significantly more frequent in nodular BCCs (nBCCs) compared with superficial BCCs (sBCCs), and in pigmented sBCCs vs. non-pigmented sBCCs (P<0.0001). Short fine telangectasias (SFTs) were found in 33.1% (167/504) of cases and were significantly more frequent in sBCCs compared with nBCCs (P<0.0001). Hairpin vessels were detected in 52/504 (10.3%) BCCs. Minor vascular patterns included glomerular vessels (41/504; 8.1%), dotted (21/504; 4.2%), comma vessels (5/504; 1.0%) and polymorphous pattern (9/504; 1.8%).

CONCLUSIONS

Arborizing vessels are prototypic of nBCCs, whereas SFTs are characteristics of sBCCs. Differential diagnosis with squamous cell carcinoma or melanoma is mandatory when a polymorphous pattern is detected.

[Research Ethics Committees in Abruzzo: criticisms and prospects for developments]

The first legislative bills on Ethics Committee (EC) activity were adopted across the Italian Regions simultaneously (1998). This widespread implementation meant it was necessary to define new qualitative and quantitative standards (Decree Law, 12th May 2009), creating expectations about the EC's role in research and clinical practice and its potential to improve the quality of medical assistance. The present paper presents the results of a descriptive survey that maps out the framework, organization and operating methods of ECs in the Abruzzo Region in Italy. Differences between ECs have been outlined, with special concern for differences in organization and way of operating. It was found that interaction between the EC and the experimenter is limited to the authorization phase of the research protocol, with low level involvement in the planning and execution phases. Additionally, the exchange of information between the co-ordinating EC and EC practitioners is not well organized in multicentre experimentation. A certain amount of criticism emerged regarding those areas of activity that would help to place the EC at the centre of the cultural growth process with regards to Bioethics and Clinical Research (e.g. education, on-line news on Bioethics topics).These criticisms are part of the reality of the Abruzzo Region that lacks economic and structural resources which penalizes EC activity.

Afebrile benign convulsions with mild gastroenteritis: a new entity?

Afebrile seizures in children usually necessitate investigations in order to determine the etiology and estimate the prognosis. Recently, convulsions that are described as benign but afebrile have been documented in children, in association with diarrhea, and are now recognized as a distinct entity. Benign afebrile seizures with mild gastroenteritis are defined as convulsions accompanying symptoms of mild diarrhea without dehydration or electrolyte derangement and without fever before and after the seizures in healthy children without meningitis, encephalitis or encephalopathy. The convulsions are short, symmetrical, generalized tonic-clonic seizures, occurring in clusters. Laboratory studies (full blood count, blood glucose, creatinine, serum electrolytes, cerebrospinal fluid, bacterial and viral cultures) are usually normal, and other investigations (neuroimaging and electroencephalogram) are not necessary. Prognosis is always favorable (normal psychomotor development, no recurrences of seizures), and anticonvulsant therapy is not warranted. Recognition of this benign infantile convulsion avoids extensive evaluation and long-term anticonvulsant therapy; physicians may reassure the parents regarding the lack of long-term sequelae. In conclusion, this type of seizure seems to be a new entity, but it awaits a correct place in the large group of infantile convulsion disorders.

CD1a and CD1e allele frequencies in an Italian population from the Abruzzo region

CD1 is a small family comprising 5 MHC-like genes located on chromosome 1 and encoding glycoproteins termed CD1a, CD1b, CD1c, CD1d and CD1e. They are expressed mainly on the surface of dendritic cells, monocytes and some thymocytes and are specialized in presenting lipid antigens to T lymphocytes. The structure is similar to that of MHC class I molecules with 3 globular domains and the Beta2-microglobulin. It has been shown that all five human CD1 genes exhibit a limited number of polymorphisms in the alpha1 domain whose effects are still unknown. CD1e results to be the most polymorphic isoform with six CD1e alleles (01, 02 in exon 2 and 03, 04, 05, 06 in ex3) described to date. At this moment, few investigations on the allele frequencies of the CD1 genes have been reported and all additional information improves our knowledge on this new class of antigen-presenting molecules. In order to study possible allelic variations of exon 2 of human CD1a and CD1e genes, we analyzed, by a sensitive technique, the sequence-based typing (SBT), 114 DNA samples from unrelated healthy Italian individuals from the Abruzzo region. Our experimental findings indicate that the allele frequency distribution of both CD1a and CD1e genes is in accordance with that observed in other geographic areas and did not identify any new allele, thus confirming a very low polymorphism.

HLA DR/DQ alleles and risk of type I diabetes in childhood: a population-based case-control study

The objective was to evaluate HLA DR/DQ alleles and their risk factor for type 1 diabetes in the Abruzzo region (central Italy). Sixty incident cases from the Abruzzo region were studied together with 120 unrelated control subjects living in the same administrative areas. The relative risk of diabetes associated with the alleles under study was calculated by deriving the odds ratio (OR) maximum likelihood estimates and their 95% confidence intervals (CI) by the exponentiation of the logistic regression beta-parameter. The combination DRB1*03/DQA1*0501/DQB1*0201 was found in 20.0% of patients and 7.1% of the control subjects, conferring an OR of 4.04 and a CI of 1.97-8.49. The combination DRB1*04/DQA1*0301/DQB1*0302 was found in 23.3% of diabetic patients and 6.7% of controls, giving an OR of 5.69 and a CI of 2.77-12.05. DRB1*11/DQA1*0505/DQB1*0301 and DQA1*0505/DQB1*0301 were negatively associated with type 1 diabetes (OR=0.27, CI 0.11-0.57; OR=0.07, CI 0.02-0.19). The DQA1 genotype at risk was found to be DQA1*0301/DQA1*0501: OR=23.80, CI 2.97-190.89, as it occurred with the highest frequency in the patient group. The DQB1 genotype at risk was found to be DQB1*0201/DQB1*0302, which occurred in 13.3% of patients but in only 1.1% of the control group (OR=29.75, CI 5.36-549.25). Our results shed further light on the risk of development of this disease during a specific time period in an area where the overall incidence of type 1 diabetes is known.

Amyotrophic lateral sclerosis and sports: a case-control study

An increased incidence of amyotrophic lateral sclerosis (ALS) amongst soccer players in Italy has recently been reported. A case-control study (300 cases and 300 matched controls) was conducted to explore the association between ALS and physical/sports activities, with specific reference to trauma-related risk. Neither the practice of competitive sports nor sports-related traumas were found to be associated with an increased risk of ALS. The practice of physical activities or sports is not per se a risk factor for ALS. Our results exclude sports-related microtraumas as etiopathogenic factors in the natural history of ALS.

[Association between drug, alcohol and tobacco use in adolescents and socio-familiar factors]

Substance abuse is the result of interaction between constitutional, environmental and socio-demographic factors. Several studies have been demonstrated that the adolescent substance abuse is a serious and growing problem. The aim of our study is to investigate the association between substance, alcohol and tobacco abuse and socio-familiar factors, to evaluate a substance abuse prevention program which decreases substance use in adolescents. A cross-sectional survey was developed and carried out by involving a group of adolescents, randomly selected from the secondary school of Teramo province. Data were collected by a self-administered questionnaire. The associations between substance use and the determinants taken into account was evaluated by the chi-square test of Fisher exact test or trend test when appropriated. Our data show that the alcohol abuse is more frequent in males (41.1%, p = 0.000), while the nicotine abuse is more frequent in females (46.1%, p = 0.005). However, our results show that the abuse of alcohol, nicotine, heroine, cocaine and ecstasy is associated to lack of stability in the family, respectively: 61.5% (p = 0.001); 61.5% (p = 0.022); 7.7% (p = 0.018); 7.7% (p = 0.010): 7.7% (p = 0.004). The nicotine abuse is higher in adolescents living with a smoker: 50.3% (p = 0.000). Finally, the substance abuse is higher in adolescents having friends that are drug-addicts, in particular: alcohol 49.6% (p = 0.000), nicotine 43.0% (p = 0.000), cannabis 27.9% (p = 0.000). This survey suggests that the knowledge of factors influencing the initiation, combination and cessation of the use of substance is crucial for the prevention of drug use among adolescents.

Clinical efficacy and cost-effectiveness evidence of spa therapy in osteoarthritis. The results of "Naiade" Italian Project

AIM

The "Naiade" Project was carried out in execution of the Decree of December 1994 by the Italian Ministry of Health, with the objective of defining the therapeutic role of spa therapy in the various sectors of medicine. In this study the authors refer to the results obtained in osteoarthritis (OA).

METHODS

The OA study included the observation of patients for 2 consecutive years, with the compilation of a series of clinical and socio-economic data. The initial sample was of 11437 patients suffering from primary and secondary OA, and in the 2(nd) year the total number of assessable patients was 6111 (53.4%). All patients underwent 1 annual cycle of balneotherapy and mud packs therapy for 2 consecutive years. The thermal treatments were carried out in 98 Italian spas with sulphurous water, sodium chloride-bromide-iodide water, sulphate water, and bicarbonate water. Analysis of the data collected confirmed the clinical efficacy of spa treatments for OA, particularly for localisations in the cervical and lumbar spine. The benefits of these treatments and the persistence of the therapeutic effects over time were clearly demonstrated by the collection of some socio-economic indicators relative to the year before each cycle of thermal therapy.

RESULTS

In fact, the analysis of these indicators showed a significant reduction in recourse to additional treatments (hospital admissions, physical and pharmacological therapies) and absence from work.

CONCLUSION

The obtained data was particularly interesting for the number of samples examined, the follow-up over a period of 2 years, and the collection of clinical and, especially, socio-economic parameters. The results of the Naiade Project confirmed the value of spa therapies in the treatment of OA.

Anticardiolipin, glutamic acid decarboxylase, and antinuclear antibodies in epileptic patients

To explore the hypothesis that raised anticardiolipin antibodies, glutamic acid decarboxylase, and antinuclear antibodies may be associated with epilepsy and/or pharmacoresistance, we studied titers in 74 epileptic patients and 50 controls. Epileptic patients were divided into two groups according to their response to anticonvulsant therapy. Group I included 52 children (30 females and 22 males with a mean age+/-SD of 7.0+/-2.4 years) suffering from different types of epilepsy who were treated with various anticonvulsants. Group II included 22 children (10 females and 12 males with a mean age of 6.2+/-3.6 years) suffering from therapy resistant epilepsy. We found that the prevalence of anticardiolipin antibodies was significantly higher in epileptic patients than in controls, while there was no significant difference between patients who were seizure free and those with uncontrolled epilepsy. No significant difference was found in glutamic acid decarboxylase antibodies between epileptic children and controls, and between patients who were seizure free and those with uncontrolled epilepsy. A significant difference in the incidence of antinuclear antibodies was found between epileptic children and controls, while no difference was found between well-controlled and drug-resistant epilepsy. In conclusion, the prevalence of anticardiolipin and antinuclear antibodies was higher in patients with epilepsy than in controls. There was no significant difference in serum glutamic acid decarboxylase antibodies between epileptic children and controls, and between patients who were seizure free and those with uncontrolled epilepsy.

Changes in the use of health resources by patients with chronic phlebopathies after thermal hydrotherapy. Report from the Naiade project, a nation-wide survey on thermal therapies in Italy

BACKGROUND

Chronic venous disorders carry lifelong medical and social burdens. Within conservative approaches, spa hydrotherapy is popular among patients with venous disorders in Europe, but whether the practice is associated with health or social benefits remains controversial.

METHODS

The present work is a substudy of the nation-wide Italian Naiade Project, a large multicenter observational exercise on spa treatments in different disease groups. The "Chronic Phlebopathies" substudy included 2504 patients with primary or secondary varicosis or non-varicose venous insufficiency. After a first visit and administration of a detailed questionnaire, patients underwent a "thermal cycle" of 15-20 days consisting of underwater active and passive physical therapy with mineral waters. The same procedures were repeated after 1 year on the 1352 patients (54%) who spontaneously returned to the same spa. Primary endpoints of the study were some indicators of the use of health resources related to the year after the first thermal cycle, compared with the same indicators recorded at first visit using appropriate statistical methods.

RESULTS

The occurrence of acute venous episodes, working days missed, number and duration of hospital admissions, consumption of drugs and physical therapies were all significantly reduced in the year after thermal therapy, thus indicating lesser use of health resources.

CONCLUSIONS

The study suggests that thermal hydrotherapy in patients with chronic venous disorders is associated with health and social benefits.

High prevalence of HCV infection among the general population in a rural area of central Italy

The hepatitis C virus infection (HCV) is the most frequent cause of hepatic infection in Europe. In Italy, anti-HCV positivity values are extremely variable, depending on the age and geographic location of the population being analysed. The aims of the study were: (1) evaluating positivity for anti-HCV antibodies in various age groups and determining the HBsAg in a mountainous and predominantly farming area in central Italy; (2) assessing some anamnestic and clinical variables through a questionnaire, submitted during the taking of blood samples, in order to determine HCV exposure and risk factors for the target population. 344 subjects selected by random sampling among 3308 people, older than 16, were considered as the target population. A prevalence study was carried out. The sources of data were: blood samples taken to carry out the HCV positivity test; a questionnaire including items about exposures at risk and case-historical and clinical patient data. The risk of infection was evaluated by a multiple logistic regression model. The inferred HCV+ prevalence rate is 22.4/100 (95% confidence interval (CI): 20.8-24.1). An increasing age trend is shown with a higher positive predominance among females (28.99/100 vs. 14.29/100 in males). The positive HBsAg prevalence in the examined survey is 1.2/100. Variables associated with the HCV occurrence are case history of pneumonopathy (OR: 4.9) and exposure to parenteral therapies with glass syringes (OR: 3.3). This study is consistent with literature about the hypothesis of a north-south geographic gradient in the hepatitis C occurrence in Italy. Data clearly show the effects of the inappropriate use of medical or surgery practices on the population, with particular reference to the use of glass syringes. No elements prove that the farming features of the area may be predictive of HCV infection risk. The extent of the recorded prevalence values calls for the implementation of programmes aimed at detecting clusters or population areas at risk.

Static perimetry and diabetic retinopathy: a long-term follow-up

In order to evaluate if central static perimetry is useful to identify patients at risk of developing diabetic retinopathy, 60 (27 male, 33 female) adolescents and young adults (mean age, 15.9 years) with insulin-dependent diabetes mellitus were studied prospectively. No patient showed fluorescein angiographic signs of retinopathy initially. The patients were evaluated at the beginning of the study and after 8 years. At the beginning of the study, mean defect in the population was -2.34 dB as determined by perimetry; no patient showed significant impairment of foveal threshold (mean, 33.17 dB). After 8 years of follow-up, 7 patients had developed fluorangiographic signs of retinopathy. Life-table analysis showed that the overall probability of retinopathy development was significantly higher in subgroups of patients with mean sensitivity in areas 2 and 3 below the cutoff. These results suggest that central static perimetry is a useful tool in predicting the development of retinopathy in children with insulin-dependent diabetes mellitus who do not have fluorescein angiographic signs of retinopathy. This tool can help the physician to identify those patients at risk of developing fluorangiographic signs of retinopathy.

Family and disease management in young type 1 diabetic patients

The main objectives of type 1 diabetes mellitus (DM) management include keeping glycemia levels within the euglycemic range to prevent complications. Daily self-monitoring is an important problem for many diabetic patients, particularly for adolescents. The aim of this study was to evaluate the determinants of poor daily self-monitoring, focusing on the patients' parents' perception of the problem. In order to evaluate parents' awareness of their children's disease-monitoring status, we carried out a cross-sectional investigation of a sample of children and adolescents from a population-based register, with the corresponding population of parents. To collect our data, we used a 33-item questionnaire, separately administered by diabetologists to both parents and children. We estimated the concordance with respect to patients' and parents' answers. Adolescents followed their overall medical prescriptions more regularly (48.8%) than children (29.7%), but most frequently they forgot to use glycemic tests (adolescents 42.4%, children 29.7%). A major duration of disease affected HbA1c levels (values > 8%) of patients younger than 14 years (pFisher = 0.016). Our results indicate a worse compliance of adolescents with respect to children in attending to daily self-monitoring, not just regarding daily glycemic levels but also the course of daily activities such as going to school, studying, working, and simulating symptoms and signs of hypo-hyperglycemia. Parents mostly ignored their child's self-monitoring status and the related motivations.

Platelet count and function in children receiving sodium valproate

To evaluate whether valproic acid (VPA) can cause thrombocytopenia and impaired platelet function, the authors prospectively studied 20 children (12 female and eight male; age range 4.9-9.2 years) before and after 6 months of VPA monotherapy. Fifteen healthy sex- and age-matched children served as control subjects. VPA was prescribed at normal dosages (19.7 +/- 9.9 mg/kg), and plasma levels were within the therapeutic range (60.1 +/- 16.5 microg/mL). At the first evaluation, no significant difference between patients and control subjects was observed for platelet count and function. At the second evaluation the platelet counts were significantly lower in the patients (194,200 +/- 37,800/microL; range 157,700-222,400) than in the control subjects (291,100 +/- 41,300/microL; range 261,000-332,500; P < 0.01). Significant differences occurred between patients and control subjects in the release of adenosine triphosphate (ATP) after collagen and adenosine diphosphate (ADP) stimuli and in aggregation after stimulation with collagen, ADP, and arachidonic acid. Significant correlations between platelet count, aggregation, and ATP release and VPA dosage and plasma concentration were also observed. VPA can cause a decreased platelet count and aggregation and ATP release impairment. These side effects can appear after a few months of therapy and with plasma valproate levels within the normal range. They do not seem to be associated with clinical symptoms, and drug discontinuation is not necessary.

Pre-operative angiography in gastric cancer surgery with extended lymphadenectomy

BACKGROUND/AIMS

The value of pre-operative angiographic evaluation in patients undergoing gastric cancer surgery with extended lymphadenectomy was assessed in a prospective study comparing exposed and unexposed groups of patients.

METHODOLOGY

During the period from July 1991 to October 1997, 76 patients (Group A--exposed) were pre-operatively submitted to a digital subtraction angiography (DSA) after informed consent. Concurrently, 94 patients (Group B--unexposed) were included as an unexposed reference group. All patients underwent total or subtotal gastrectomy with D2 lymphadenectomy according to the guidelines proposed by the Japanese Research Society for Gastric Cancer (JRSGC).

RESULTS

In 34 (45%) exposed patients (Group A), DSA detected an atypical vascular anatomy. Major anatomical variations of the celiac axis, its branches and the superior mesenteric artery were discovered in 4 subjects (5%). Vascular anomalies affecting the surgical tactics of lymphadenectomy were detected in less than 8% of patients. Five post-operative deaths (6.6%) were registered between patients of the Group A, exposed to pre-operative angiography, 8 in the unexposed Group B (8.5%). Post-operative morbidity was significantly higher (P = 0.038) in the Group B (34%) in comparison to Group A (20%) but no difference in risk of individual complications was detected.

CONCLUSIONS

Although useful in the presence of major vascular anomalies, it appears that pre-operative angiography did not significantly reduce intra- and post-operative complications associated with radical gastrectomy combined with extended lymphadenectomy. Arteriography is therefore not routinely recommendable but its use is mandatory in specific operations for gastric cancer.

Large incidence variation of Type I diabetes in central-southern Italy 1990-1995: lower risk in rural areas

AIMS/HYPOTHESIS

To evaluate the relation between the incidence of childhood Type I (insulin-dependent) diabetes mellitus and the degree of urbanization in the central-southern part of Italy.

METHODS

The incidence was determined in two areas: area A encompasses 3 regions of central-eastern Italy (Marche, Abruzzo, Umbria), whereas area B encompasses one southern region (Campania). During 1990-1995, 706 children aged 14 or under with insulin-dependent diabetes mellitus of recent onset were registered. The completeness of the case ascertainment in the registries analysed separately for each region was high, ranging from 96.3 % to 99%.

RESULTS

The age-standardized incidence was higher in area A (9.6 per 100000 person per year; 95 % confidence interval: 8.5-10.8) than in area B (5.4 per 100000 person per year; 95% confidence interval: 4.9-6.0). In both areas the standardized incidence ratios increased with the degree of urbanization (chi-squared for trend: area A= 140, p < 0.0001; area B = 79, p < 0.0001). The highest standardized incidence ratios were in the most urban communities.

CONCLUSION/INTERPRETATION

This study showed a statistically significant difference in incidence of childhood insulin-dependent diabetes mellitus among different areas of the continental peninsula of Italy. People living in the rural communities appear to have a lower risk.

Centro-temporal spikes in non-epileptic children: a long-term follow up

OBJECTIVE

This study was undertaken in order to determine the natural evolution of centro-temporal spikes (CTS) in a healthy paediatric population.

METHODOLOGY

Forty children and adolescents (mean age +/- SD: 9.9 +/- 4.1 years) with non-epileptic disturbances (tics, headache, pavor nocturnus, vertigo, etc), who showed CTS during routine EEG recordings were studied. No patient suffered from seizures. A clinical and electroencephalographic follow-up of at least 5.5 years was carried out in all subjects.

RESULTS

At the follow-up examination, 33 of the 40 cases (82.5%) had no CTS or other epileptic discharges in awake and sleep EEGs, while six subjects continued to show CTS discharges in sleep EEG. Among those subjects who showed persistence of CTS in sleep EEG, rolandic epilepsy developed in two cases, while all other subjects continued to be seizure free.

CONCLUSIONS

This study demonstrates that CTS can be present in non-epileptic children and adolescents; in the majority of subjects this EEG abnormality disappears spontaneously and only a small percentage of subjects who have persistence of this pattern develops rolandic epilepsy.

Bone metabolism in children with congenital hypothyroidism--a longitudinal study

In order to evaluate the effect of thyroid replacement therapy on bone metabolism in congenital hypothyroid children, we studied 23 (10 girls and 13 boys) consecutive patients. Their age ranged from 3 to 8 weeks. One of these patients had familiar dyshormonogenesis, 21 had ectopic glands and one hemiagenesis. As a control group, we studied 46 sex- and age-matched healthy newborns. Before the beginning of therapy, the hypothyroid patients showed higher values of calcium (2.78 +/- 0.04 vs 2.65 +/- 0.07 mmol/l; p < 0.05) and of 1,25-dihydroxy-vitamin D (159.7 +/- 31.6 vs 90.5 +/- 33.1 ng/l; p < 0.01), while they showed lower values of osteocalcin (1.9 +/- 0.8 vs 2.9 +/- 0.9 ng/ml; p < 0.01) than controls. After 3 months of therapy, we found a complete normalization of all these parameters and a progressive increase of osteocalcin. Our data show that in congenital hypothyroid children there are abnormalities in calcium metabolism which seem to be transient and reversible after L-thyroxine replacement therapy.

Size of pancreas in children and adolescents with type I (insulin-dependent) diabetes

PURPOSE

The aim of this study was to evaluate the influence of insulin-dependent diabetes mellitus (IDDM) on the size of the pancreas in children.

METHODS

Pancreas size was evaluated sonographically in a group of 60 diabetic children and adolescents, aged 3-15 years, and 60 sex- and age-matched healthy controls.

RESULTS

A significant reduction in pancreatic area and other parameters was found in diabetic patients particularly in children aged 8-12 and 13-15 years. The pancreas was larger in children 3-7 years old who had had IDDM for 2 years of less (mean size, 8.61 cm2) than in children 8-12 and 13-15 years old who had had IDDM for more than 5 years (mean size, 8.06 and 8.40 cm2, respectively). An inverse correlation between area of the pancreas and duration of IDDM was seen in all age groups (p < 0.05).

CONCLUSIONS

Diabetes affects the growth of the pancreas in children with IDDM. Sonography can be used to noninvasively evaluate the influence of the disease on pancreas size.

Hypoglycaemic symptoms described by diabetic children and their parents

Hypoglycaemic events are frequent complications of insulin-dependent diabetes mellitus in children. The signs and symptoms referred to by young children can be difficult to understand and often seem to be different from those described by their parents. We analysed the hypoglycaemic symptoms described by a group of patients and their parents. We studied 40 pairs consisting of a parent and a diabetic child by using a structured questionnaire with 27 items concerning different symptoms of hypoglycaemia. The mean+/-SD age of the children was 10.4+/-2.4 years, with duration of disease 6.2+/-2.1 years and their HbA1c was 8.2 2.0%. For the statistical analysis we used the principal component analysis. All the children followed a multiple injection regimen. The frequency and intensity of the hypoglycaemic signs described by patients and parents were similar both for neuroglycopenic (uncoordination, confusion, odd behaviour, dizziness) and autonomic symptoms (trembling, sweating, pounding heart, hunger). Moreover, our questionnaire showed a high frequency of behavioural changes. In conclusion, from the analysis of the questionnaires collected, we found that both parents and children gave almost the same score to the symptoms observed. This means that there is a concordance between the symptoms reported by the children and those reported by their parents.

Incidence of insulin-dependent diabetes mellitus (0-14 years) in the Abruzzo Region, Italy, 1990-1995: results from a population-based register

OBJECTIVE

To provide incidence data of insulin dependent diabetes mellitus (IDDM) in the Abruzzo Region, Italy in 0-14 year-old children and contribute to a better understanding of IDDM geographical variability throughout Italy.

SUBJECTS AND METHODS

All incident cases younger than 15 years first diagnosed with IDDM according to the WHO criteria between 1 January 1990 and 31 December 1995 and resident in the Abruzzo Region were recorded. The primary sources were divisions of pediatrics, endocrinology or medicine, diabetic centers for adult patients and the Regional Pediatric Diabetology Centre. Secondary independent sources included registered prescriptions for insulin in local district units of the National Health System and the regional IDDM association for children.

RESULTS

During the six years, 117 new cases of IDDM in the age-group 0-14 were identified, with an overall standardized incidence rate of 9.34/100,000/year (95% C.I. 7.76-10.95). The crude incidence rate was highest in the 10-14 year age-group (10.64, 95% C.I. 7.66-13.62). Teramo province showed the highest standardized incidence rate, 10.30/100,000/year (95% C.I. 6.58-14.02); it is noteworthy that the IDDM rate in Teramo (15.40/100,000/year) was the highest in peninsular Italy in 1994. Abruzzo Region shows significantly higher rates than other central Italian regions. No significant difference in rates between males and females was observed. Seasonality was not observed from incidence data.

CONCLUSIONS

We report the highest incidence rate for IDDM in children in the Italian mainland in the years 1990-95. Our findings confirm the need for epidemiological research to provide more information about the distribution of genetic markers and the etiologic role of environmental factors in Italian regions.

Family history and risk of insulin-dependent diabetes mellitus: a population-based case-control study

Insulin-dependent diabetes mellitus (type 1) is a common chronic disease of childhood occurring throughout the world. In the literature, its most important determinants include genetic, environmental and familial factors. We evaluated family history as a determinant of the risk of type 1 diabetes mellitus with a population-based case-control study. Information about type 1 patients was taken from the dedicated register of the Abruzzo Region; the register has been collecting incident cases in the age group 0-14 years, diagnosed between 1 January 1990 and 31 December 1996. The control group was taken from the lists of patients attending family pediatricians. The family history data for type 1 and type 2 patients was obtained by a questionnaire, administered to their parents. The risk of type 1 diabetes mellitus associated with its occurrence in first- and second-degree relatives was estimated using logistic regression methods. Our results show that the risk is indeed increased with a positive family history (OR=3.96; 95% CI 1.54-10.14). This shows that the risk of type 1 diabetes mellitus for children whose fathers are affected by the disease is 11 times higher with respect to controls. Moreover, the risk for children whose brothers are affected by the disease is 20 times higher with respect to controls. In contrast, a family history for type 2 diabetes mellitus does not influence the risk.

[Family history and risk of insulin-dependent diabetes mellitus: a population-based case-control study]

Insulin-dependent diabetes mellitus (IDDM) is a worldwide occurrence disease of childhood with genetic, environmental and familial risk factors. Our study aims to evaluate family history as a determinant of IDDM. In a population-based case-control study informations on all incident IDDM cases, age 0-14, diagnosed between January 1st 1990 and December 31st 1996 were taken from the IDDM population-based register of the Abruzzo Region. The control group was taken from the lists of children attending family paediatricians. The family history data collection for IDDM and non insulin-dependent diabetes (NIDDM) were obtained by a questionnaire, administered to parents. Risk of IDDM associated with familiarity in first and second degree relatives was estimated using conditional regression analysis. Our results show that the risk of developing IDDM is increased by positive family history (OR = 3.99; 95% c.i. 1.56-10.23). The risk of IDDM for children whose fathers or brothers are affected by IDDM is respectively 11 and 20 times higher than for children with no family history. Family history for NIDDM does not influence the risk.

Mortality in psychiatric hospital patients: a cohort analysis of prognostic factors

BACKGROUND

This work followed a group of patients living in a psychiatric hospital in Central Italy in 1978 at the time of enforcement of the Italian reform law (No. 180) for closing down mental hospitals. The study had the following aims: a) to compare in terms of mortality patients discharged into the community with patients who did not experience deinstitutionalization; b) to determine the survival of the cohort of patients and to analyse prognostic risk factors for death; c) to analyse differences in mortality rates between psychiatric patients and the general population.

METHODS

The study was designed as an historical follow-up investigation. Univariate (product limit) and multivariate (proportional hazards model) methods were used to estimate prognostic variables and related death risks. Mortality was assessed using standardized mortality ratios (SMR) on the entire cohort as well as after stratification according to age, sex, cause of death and discharge status, assuming the Abruzzo Region's population as standard.

RESULTS

Length of hospitalization and discharge from hospital are prognostic variables for death risk, with relative risks respectively of 4.22 (95% confidence interval [CI]: 2.41-7.40) for a length of hospitalization of 10-25 years, and 8.13 (95% CI: 4.73-13.88) for non-discharge. The global SMR of the cohort was 2.68 (95% CI: 2.42-3.07). Non-discharged patients showed higher SMR than discharged. Excess mortality was found both in males and females for circulatory, respiratory and undefined diseases. A significantly lower mortality for cancer was observed in male patients. A strong excess mortality was observed in younger patients (20-29 years: SMRmales = 43.57; SMRfemales = 97.52).

CONCLUSIONS

Longer periods of hospitalization and non-discharge from hospital are the main risk factors for death in psychiatric patients, who globally experience higher death rates than the general population for a wide spectrum of causes of death, whatever their diagnosis or gender. These findings strongly suggest positive actions in order to overcome the effects of institutionalization.

Regional variability in the epidemiology of childhood diabetes in Italy

The incidence rates of IDDM in Italy show remarkable variability. Sardinia, a region with the second highest incidence rate in the world, co-exists with other regions with lower rates. We review and compare epidemiologic data on the incidence of childhood-onset IDDM in Italy. papers published from 1980 to 1996 reporting incidence data in Italian areas were found by search of Medline and non-indexed Italian journals. The incidence data found cover only 57% of the Italian population. The analysis of our results shows how difficult it is to make a careful study of epidemiology of IDDM in Italy. The RIDI (the Registry for Insulin-dependent Diabetes mellitus in Italy) project started in 1996 according to international guidelines. The aims is to coordinate local IDDM registries, to promote the start of new registries in uncovered areas, and to standardize registration and data collection.