Developing a new predictor of health expenditure: preliminary results from a primary healthcare setting.

OBJECTIVES: Risk adjustment is a widely used tool for health expenditure prediction and control. Early approaches for estimating health expenditure were based on patient demographic variables alone, whereas more recent models incorporate patient information, such as chronic medical conditions, clinical diagnoses, and self-reported health status. Many studies have investigated the health expenditure predictive capacity of single demographic, morbidity, or health-related quality of life measures, but the best models prove to be those that include them all. The aim of this study was to develop an index that combines measures of perceived health and disease severity and to compare its efficacy in predicting health expenditure with that of the measures taken individually. STUDY DESIGN: This is a linked cross-sectional study. METHODS: In 2009 and 2010, the health-related quality of life questionnaire SF-36 (8 scales, two indices: Physical Component Summary [PCS] and Mental Component Summary [MCS]) was distributed to 886 patients of general practitioners in the Province of Siena, Italy. Severity of diseases was calculated for each patient using the Charlson Index (CH-I) and Cumulative Illness Rating Scale Severity Index (CIRS-SI). Siena Local Health Unit 2012 data on health expenditure were obtained for each patient. Multivariate linear regression was applied to test the performance of severity (CH-I, CIRS-SI) and perceived health (PCS and MCS) measures in predicting health expenditure. The indexes that predicted health expenditure best were then combined in a new tool, and its expenditure predictive capacity was tested. RESULTS: The best health expenditure predictors proved to be PCS and SI (R2 = 0.15 and R2 = 0.17, respectively). When combined in a new index (PCS-SI), better predictive capacity of health expenditure was obtained than with the two single measures separately (R2 = 0.19). CONCLUSIONS: A multidimensional indicator proved to be a better predictor of healthcare expenditure than single health measures.

BVOC responses to realistic nitrogen fertilization and ozone exposure in silver birch.

Emission of BVOC (Biogenic Volatile Organic Compounds) from plant leaves in response to ozone exposure (O3) and nitrogen (N) fertilization is poorly understood. For the first time, BVOC emissions were explored in a forest tree species (silver birch, Betula pendula) exposed for two years to realistic levels of O3 (35, 48 and 69 ppb as daylight average) and N (10, 30 and 70 kg ha(-1) yr(-1), applied weekly to the soil as ammonium nitrate). The main BVOCs emitted were: α-pinene, ß-pinene, limonene, ocimene, (E)-4,8-dimethyl-1,3,7-nonatriene (DMNT) and hexanal. Ozone exposure increased BVOC emission and reduced total leaf area. The effect on emission was stronger when a short-term O3 metric (concentrations at the time of sampling) rather than a long-term one (AOT40) was used. The effect of O3 on total leaf area was not able to compensate for the stimulation of emission, so that responses to O3 at leaf and whole-plant level were similar. Nitrogen fertilization increased total leaf area, decreased α-pinene and ß-pinene emission, and increased ocimene, hexanal and DMNT emission. The increase of leaf area changed the significance of the emission response to N fertilization for most compounds. Nitrogen fertilization mitigated the effects of O3 exposure on total leaf area, while the combined effects of O3 exposure and N fertilization on BVOC emission were additive and not synergistic. In conclusion, O3 exposure and N fertilization have the potential to affect global BVOC via direct effects on plant emission rates and changes in leaf area.

Effects of long-term ambient ozone exposure on biomass and wood traits in poplar treated with ethylenediurea (EDU).

This is the longest continuous experiment where ethylenediurea (EDU) was used to protect plants from ozone (O3). Effects of long-term ambient O3 exposure (23 ppm h AOT40) on biomass of an O3 sensitive poplar clone (Oxford) were examined after six years from in-ground planting. Trees were irrigated with either water or 450 ppm EDU. Above (-51%) and below-ground biomass (-47%) was reduced by O3 although the effect was significant only for stem and coarse roots. Ambient O3 decreased diameter of the lower stem, and increased moisture content along the stem of not-protected plants (+16%). No other change in the physical wood structure was observed. A comparison with a previous assessment in the same experiment suggested that O3 effects on biomass partitioning to above-ground organs depend on the tree ontogenetic stage. The root/shoot ratios did not change, suggesting that previous short-term observations of reduced allocation to tree roots may be overestimated.

Early, intermediate and late infectious complications after transcatheter or surgical aortic-valve replacement: a prospective cohort study.

Transcatheter aortic valve implantation (TAVI) has been proposed to treat older surgical high-risk patients with severe symptomatic aortic stenosis. There are no data regarding short-term and long-term infectious complications in these patients. The objective of this study was to define the incidence, aetiology and outcome of early and late infectious complications following TAVI compared with patients >65 years old undergoing traditional surgical aortic replacement (SAR). This was a prospective observational study evaluating all consecutive patients who underwent TAVI or SAR. Follow up was performed up to 1 year after the procedure of valve implantation. Fifty-one patients underwent TAVI and were compared with 102 patients who underwent SAR. Compared with SAR patients, those who underwent TAVI had lower incidence of early post-operative (11.7% vs 26.4%, p 0.04), intermediate (5.9% vs 17.6%, p 0.01) and late (7.8% vs 11.7%, p 0.03) infections. Among SAR patients the most common infections were bloodstream infections, pneumonias, urinary tract infections and sternal wound infections. Patients who underwent TAVI had a longer survival without infection (358 days vs 312.9, p 0.006). There were no significant differences in 12-month crude survival between the two study populations. Despite a high frequency of coexisting illnesses, patients undergoing TAVI develop few infectious complications. TAVI appears to be a reasonable and safe option in high-risk patients with severe symptomatic aortic stenosis.

Hypersensitivity to pets in Italy.

Eight hundred and two consecutive symptomatic outpatients (with asthma and rhinitis) were studied to evaluate the incidence of prick test positivity to cat and dog danders and the association of exposure to these animals in the home, as revealed by a standard questionnaire. 14.3% were found to be skin positive to cat and/or dog danders. The incidence of cutaneous hypersensitivity to cat and/or dog danders was 25% in the 216 subjects who kept animals, significantly higher (p less than 0.0005) than the 10.4% of 586 subjects who did not keep animals. In the 57 subjects who owned both dogs and cats, a significantly higher incidence of skin hypersensitivity was found compared to the other subjects. Our data does not demonstrate a greater incidence in sensitivity to cat danders compared to dog danders, or increased sensitization to dermatophagoides pteronyssinus, nor a different incidence of clinical manifestations (asthma and rhinitis) between those with animals in the house and those without.

Mast cells in bronchoalveolar lavage in sarcoidosis: correlation with alveolar lymphocytes.

Today it is believed that mast cells (MC) are important not only in IgE-mediated reactions, but also in delayed hypersensitivity reactions, and that their functions are mediated by factors released by T lymphocytes. Recent studies have shown their presence in bronchoalveolar lavage (BAL) of patients with asthma and interstitial lung disease. MC have been identified by us in the BAL of patients with sarcoidosis and lung cancer, and in controls. A statistically significant correlation has been found between MC and lymphocytes, CD3+ and CD4+ cells present in BAL, thus supporting the hypothesis of interactions between T lymphocytes and MC in immune reactions at the alveolar level.

Immunocomplexes and primary lung cancer.

Circulating immune complexes (CIC) were found in 47% of 71 patients before treatment, in a horizontal study of the presence of CIC in primary lung cancer (PLC). The precipitation technique in PEG was used, and C1q, IgG and IgM fractions in the precipitate were assayed. Especially in epidermoid carcinoma, CIC were found in 1/6 cases with stage 1, 2/9 with stage II and 21/34 with stage III. The frequency was significantly higher in stage III cases, and showed a significant tendency to increase with progression of the clinical stage. If stage parameters are considered separately, this tendency correlates significantly (p less than 0.002) with the amount of lymph node involvement (N) but not to the tumor (T) size nor to the presence of metastases (M). Analysis of CIC behavior in comparison with the single fractions showed that C1q and/or IgG were elevated in 40% of cases. The presence of C1q and/or IgG associated with IgM is more characteristic of stage N2, while the presence of CIC with the fractions C1q and/or IgG not associated with IgM is more frequent in stage N1. There was a lower survival rate at 12 months in patients with CIC as compared to those without (p less than 0.05).