[Fragility in a Public Health perspective: principles and tools for a "life course" approach prevention- oriented]. / La Fragilità in una prospettiva di Sanità Pubblica: principi e strumenti per un approccio "life course" orientato alla prevenzione.

The Covid-19 pandemic significantly increased the workload for the Italian Health Service. There is few information in the literature on the pediatric population and on the management of pediatric hospitals. The aim of this article is to describe the management of healthcare services during Covid-19 emergency in Regina Margherita Children's Hospital. The Regina Margherita Children's Hospital is specialized in the prevention, diagnosis and treatment of pediatric diseases. About 1000 health worker work in this Hospital and 278 hospitalization places are available.

The evolving burden of HIV infection compared with other chronic diseases in northern Italy.

OBJECTIVES: The aim of the study was to estimate the burden and direct costs of diseases in HIV-infected patients (either opportunistic illnesses or other chronic diseases) with respect to the HIV-uninfected population. These estimates will be useful for the projection of future direct costs of HIV care. PATIENTS AND METHODS: A population-based study was conducted in the Brescia Local Health Agency in northern Italy. An administrative database recorded diagnoses, deaths, drug prescriptions and health resource utilization for all medical and surgical patients in the region from 2003 to 2007. The study estimated the prevalence of HIV infection as well as HIV-related mortality and annual cost per patient, and compared mortality and costs related to HIV infection with those for a set of 15 other chronic diseases. The standardized hazard ratio (SHR) and standardized mortality ratio (SMR) were obtained using an indirect standardization method. RESULTS: The prevalence of HIV infection increased from 218 per 100,000 inhabitants in 2003 to 263 per 100,000 in 2007. Although mortality rates decreased markedly (from 24 per 1000 HIV-infected patients in 2003 to 16 per 1000 in 2007), the data show that mortality was still higher in HIV-infected patients compared with the general population in the most recent years (SMR 8.8 in 2007). In each year included in the study, HIV-infected patients had higher rates of care-seeking for chronic diseases, including liver diseases (SHR>8), neuropathy, oesophagus-gastro-duodenum diseases, serious psychiatric disorders and renal failure (SHR approximately 3 for each). Also, the rate of medical attendance for neoplasias, chronic pulmonary disease, diabetes, and cardiovascular disease increased over time in HIV-infected patients compared with the general population. Ranking diseases in order of their total cost to the health system, HIV infection ranked 12th, with total costs of €28.6 million in 2007. Ranking in order of cost per patient, HIV infection ranked third, with a cost per patient of €9894 in 2007. HIV-infected patients with concomitant chronic diseases had higher average costs. The cost per patient in 2007 was €8104 for HIV-infected patients without other chronic diseases, €9908 for HIV infection plus cardiovascular disease, €11,370 for HIV infection plus chronic liver disease and €12,013 for HIV infection plus neoplasias. CONCLUSIONS: The prevalence and population cost of people living with HIV are likely to increase as a result of prolonged survival, aging of HIV-infected patients and increased risk of other chronic diseases. In the near future, HIV infection will rank as one of the most costly chronic diseases. Prevention strategies need to be more widely adopted to control the growing burden of the HIV epidemic and other chronic diseases affecting HIV-infected patients.

Ten years experience of renal replacement treatment in the elderly.

UNLABELLED: Elderly patients constitute an increasing segment of the end-stage renal disease population beginning renal replacement therapy (RRT) in the Western Countries. In this study we studied 2447 end-stage renal disease (ESRD) patients who started renal replacement treatment (RRT) in Lombardy between 1983 and 1992 at the age of 65 or older, with particular emphasis on survival and morbidity. In the last decade the number of elderly patients admitted yearly to RRT increased from 113 [102 per million population (pmp), 20% of all accepted patients] in 1983 to 375 (282 pmp, 42% of all accepted patients) in 1992. The most frequent primary nephropathies in 1992 were glomerulonephritis (21% vs 25% in 1983), vascular diseases (18% vs 13%) and diabetes (12% vs 7%). The use of acetate HD and IPD declined over the 10 years period from 49 to 11% and from 26 to 5%; that of bicarbonate HD and CAPD increased from 3 to 46% and from 26 to 32%. Hospitalization rate was related to age, sex, presence of systemic nephropathies or malignancy, but not to treatment modality. The main causes of death in 1992 were cardiovascular diseases (53 vs 42% in 1983) and cachexia (24 vs 18%). The survival rate of all elderly patients was 64, 39 and 13% at 2, 4 and 8 years. The covariates affecting patient survival (Cox model) were the presence at the start of RRT of systemic nephropathies (Hazard ratio 1.7), systemic atherosclerosis (1.6), other comorbidity conditions (1.38) and peritoneal dialysis (1.31). CONCLUSIONS: (1) The progressive increase in the number of patients admitted to RRT in the last decade is due to loose criteria of acceptance of elderly patients (increase in the acceptance rate of diabetics and patients with vascular disease), (2) patients' survival is affected by the presence of comorbid conditions at the start of RRT, (3) the worse survival rate in peritoneal dialysis could result from a hidden negative selection of patients, unmeasured by Cox analysis.

Cancer incidence in 854 kidney transplant recipients from a single institution: comparison with normal population and with patients under dialytic treatment.

In this retrospective historical study, we compared the incidences of malignancies observed among 854 renal transplant recipients (RT) with at least 1 yr of follow-up, with the incidences of neoplasias among patients under regular dialytic treatment (RDT) and a control population from Northern Italy. Cox's proportional hazard model was used in RT recipients in order to evaluate the prognostic factors related to the development of neoplasia. Seventy six out of 854 RT patients (8.9%) developed some malignant neoplasia: 46% of these 76 were cutaneous neoplasias including melanomas, and the remaining 54% non cutaneous cancers: 33% miscellaneous tumors (MT), mostly adenocarcinomas, 17% Kaposi's sarcomas (KS), 4% non-Hodgkin's lymphomas (NHL). Malignancies had a higher incidence (p < 0.01) among RT recipients than among control and RDT patients. However, MT were equally frequent among the three groups. RDT patients on the contrary, had similar incidence of neoplasias when compared to the control population, but showed a lower incidence of squamous cell carcinomas (SCC). The risk ratios (RR) for the most frequent neoplasias among RT recipients vs. control population were: 224.7 for KS, 7.4 for NHL, 6.2 for SCC, 5.7 for basal cell carcinomas (BCC), 4.0 for MT. The risk of developing a de novo neoplasia was of about 13% at 10 yr and of 34% at 20 yr. In RT recipients, Cox's proportional analysis showed that age > 40 at transplantation and male sex were the only risk factors associated with an increased incidence of neoplasias, while no difference was observed between conventional (azathioprine+methylprednisolone: Aza+MP) and CsA therapy or in CsA monotherapy vs. double or triple therapy. However, KS occurrence correlated both with CsA dose (RR 15.2 for monotherapy; 12.5 for double therapy; 2.98 for triple therapy) and with 10 or more i.v. methylprednisolone pulses for treatment of rejection (RR 5.2). We conclude that in our series CsA does not increase the risk for development of neoplasias, when compared to conventional immunosuppression.

Survival of diabetic patients on peritoneal dialysis or hemodialysis.

Our objective was to analyze the survival of diabetic patients on renal replacement therapy and to compare their survival on extracorporeal and on peritoneal dialysis. All data regarding diabetic patients admitted to dialysis between 1 January 1983 and 31 December 1993 were collected by means of individual patient questionnaires sent to all of the 44 regional Renal Units (100% answers) of Lombardy, Italy. Cox proportional hazards model, stepwise procedure, was applied in order to select the covariates significantly associated with survival. Age (at baseline), sex, type of diabetes, initial modality of treatment (hemodialysis or peritoneal dialysis), and initial clinical risk factors (malignancies, serious heart disease, vascular disease, cirrhosis of the liver, cachexia) were considered. Descriptive analysis of survival was performed using the Kaplan-Meier technique. The survival of all diabetic patients (895) was 86.5% at one year, 52% at three years, and 34% at five years. The main causes of the 488 deaths of diabetic patients were cardiovascular diseases (56%), cachexia (18%), and infections (11%). The relative death risk of patients on peritoneal dialysis versus those on hemodialysis, after taking into account the main comorbid conditions, did not significantly differ from 1, as estimated by the Cox proportional hazards regression model. Five-year survival of diabetic patients was 34%, and no differences were found between peritoneal dialysis and hemodialysis as far as mortality is concerned.

Prognosis of diabetic patients on dialysis: analysis of Lombardy Registry data.

METHODS: This 1993 Lombardy Registry Report refers to all of the data regarding treated diabetics collected between 1 January 1983 and 31 December 1992 by means of individual patient questionnaires sent to all of Lombardy's 44 Renal Units (100% replies). RESULTS: The acceptance rate of diabetics for dialysis increased from 5.6 in 1983 to 10.4 patients per million population in 1992 for a total of 731 patients (379 type I, 352 type II). The yearly percentage of new diabetics increased from 9 to 11%, and the proportion of patients with two or more risk factors increased from 14.7% in 1983-1987 to 22.0% in 1988-1992. The use of peritoneal dialysis declined over the 10-year period from 50% in 1983-1984 to 30% in the last 2 years. The difference in age of the patients on peritoneal and haemodialysis tended to decrease. The survival of all diabetic patients was 82% at 1 year, 48% at 3 years, and 28% at 5 years. The relative death risk of the patients on peritoneal dialysis compared to those on haemodialysis, after taking into account age and the main comorbid conditions (type of diabetes, severe vascular disease, cirrhosis and the generic other risk factors), did not differ significantly from one, as estimated by the Cox proportional hazard regression model (344 events). The main causes of death of these patients were cardiovascular diseases (about 50.0%), cachexia (from 17.2% in 1983/1984 to 22% in 1991/1992), and infection (about 11%). The mean hospitalization rate was higher in diabetics than in patients with standard nephropathies (i.e. in 45-64-year-old patients: 32.8 versus 13.9 days/patient-year). CONCLUSION: Multivariate analysis showed that age, type of diabetes, severe vascular disease, cirrhosis, and the generic other risk factors were significantly related to survival; but diabetic patients without any baseline risk factors also had a poor prognosis and morbidity was very high in absolute terms. Medical care therefore needs to be improved in order to reverse prognostic risk factors and prevent cardiovascular and noncardiovascular events.

1983 to 1992: report on regular dialysis and transplantation in Lombardy.

This 1993 report of the Lombardy Regional Dialysis and Transplant Registry refers to all the data collected between January 1, 1983, and December, 31, 1992, by means of individual patient questionnaires sent to all of Lombardy's 44 renal units (100% replies). The number of patients recorded by the Registry as being alive progressively increased; by the end of 1992, the number was 6,014 (655 patients per million population): 4,770 patients were on dialysis treatment (515 patients per million population, 79.3%) and 1,244 patients (140 patients per million population, 20.7%) had received a kidney graft. The acceptance rate for dialysis increased from 64 per million population in 1983 to 102 per million population in 1992; the increase in the transplant rate was much lower (from 18.7 to 21.3 per million population). The percentage of primary nephropathies in the new patients accepted for dialysis treatment were 22.0% glomerulonephritis, 13.8% interstitial nephritis, 15.2% vascular diseases, 10.1% cystic kidney, and 10.6% diabetes. The use of acetate hemodialysis declined over the 10-year period from 72.4% to 17.5%; that of bicarbonate hemodialysis increased from 8.8% to 50.1% and that of hemodiafiltration increased from 0.2% to 11.1%. The prevalence of hospital hemodialysis was stable, ranging from 55.4% to 52.2%; home hemodialysis decreased from 15.7% to 5.3%, continuous ambulatory peritoneal dialysis increased from 13.3% to 19.6%, and limited care increased from 13.7% to 22.4%. The crude death rate increased from 7.5% in 1983 to 10.5% in 1992. The survival rate (Kaplan-Meier) of all patients on dialysis was 78.8% at 2 years, 62.2% at 4 years, and 40% at 8 years; for transplanted patients, the survival and graft survival rate at 2 years was, respectively, 95% and 86%. The relative death risk of the patients on peritoneal dialysis with respect to those on hemodialysis was 1.419, as estimated by the Cox proportional hazard regression model. The main causes of deaths of patients on dialysis treatment during the year 1992 were cardiovascular diseases (47.0%) and cachexia (19.5%); in transplanted patients, they were cardiovascular diseases (36.6%) and infections (34%). Registries are not only important for planning health care but are also very useful instruments for clinical research.

Computerised program to compare tolerance of dialysis patients to different dialysis schedules.

In the attempt to compare rapidly and easily the tolerance of dialysis patients to different dialysis schedules, we developed a computerised program for use with a personal computer. As a first application of this program we analysed the effects of long-term substitution of bicarbonate for acetate in reducing dialysis hypotension.

No relationship between acetate and hypotension in a standard dialysis schedule.

Plasma acetate (PA) kinetics was analysed in two groups of patients on regular dialysis treatment (RDT). The first group presented frequent symptomatic hypotension (SHY), the second did not experience SHY during RDT. The parameters examined showed no difference between the two groups. Seven patients of the first group were then switched to bicarbonate dialysis. SHY rate and blood pressure changes did not significantly differ between the two methods of treatment.