Carla Ancona

Air pollution and myocardial infarction in Rome: a case-crossover analysis.

Background: Daily air pollution is associated with increased hospital admissions for cardiovascular diseases, but there are few observations on the link with acute myocardial infarction. To evaluate the relation between various urban air pollutants (total suspended particulate, SO2, CO, NO2) and hospital admissions for acute myocardial infarction in Rome, Italy, we performed a case-crossover analysis and studied whether individual characteristics act as effect modifiers. Methods: We studied 6531 subjects residing in Rome and hospitalized for a first episode of acute myocardial infarction (International Classification of Diseases, 9th edition: 410) from January 1995 to June 1997. The following individual information was available: sex, age, date of hospitalization, coexisting illnesses (hypertension, 25%; diabetes, 15%), and cardiac severity (conduction disorders, 6%; cardiac dysrhythmias, 20%; heart failure, 11%). Daily air pollution data were taken from 5 city monitors. We used a time-stratified case-crossover design; control days were the same day of the week as the myocardial infarction occurred, in other weeks of the month. Results: Positive associations were found for total suspended particulate, NO2 and CO. The strongest and most consistent effect was found for total suspended particulate. The odds ratio (OR) associated with 10 &mgr;g/m3 of total suspended particulate over the 0- to 2-day lag was 1.028 (95% confidence interval [CI] = 1.005–1.052). The association with total suspended particulate tended to be stronger among people older than 74 years of age (OR = 1.046; CI = 1.005–1.089), in the warm period of the year (OR = 1.046; CI = 1.008–1.087), and among subjects who had heart conduction disorders (OR = 1.080; CI = 0.987–1.181). Conclusions: The results suggest that air pollution increases the risk of myocardial infarction, especially during the warm season. There was a tendency for a stronger effect among the elderly and people with heart conduction disturbances.

Air pollution and daily mortality in Rome, Italy

OBJECTIVES: To assess the relation between several daily indicators of air pollution (particulates and gases) and daily mortality in the metropolitan area of Rome and in the central part of the city. METHODS: Time series analysis. The associations between daily concentrations of pollutants (particles, SO2, NO2, CO, O3) recorded by five fixed monitors and daily total mortality in the period from January 1992 to June 1995 were evaluated. The analysis included examination of the pollution effect on mortality by place of residence within the metropolitan area, by season, age, place of death (in and out a hospital), and cause of death (cardiovascular and respiratory disease). The Poisson model included loses smooth functions of the day of study, mean temperature, mean humidity, and indicator variables for day of the week and holidays. RESULTS: The mean daily number of deaths was 56.9 (44.8 among people > or = 65 years old). A mean of 36.3 deaths occurred in the city centre; 37.3 deaths a day were recorded in a hospital. Total mortality was significantly associated with a 10 micrograms/m3 increase in particles (0.4%) on that day (log 0), and with a 10 micrograms/m3 increase in NO2 at lag 1 (0.3%) and lag 2 (0.4%) (1 and 2 days before, respectively). The effect of particles (lag 0) and of NO2 (lag 2) on total mortality was higher among those living in the city centre (0.7% and 0.5%, respectively). The risk estimates were higher in the warmer season (1.0% and 1.1%, respectively), whereas no difference was found for those dying in or out of the hospital. The effect of particles was robust to a sensitivity analysis and to the inclusion of NO2 in the regression model. CONCLUSIONS: Increase in particulates and NO2, generated by the same mobile combustion sources, is associated with a short term increase in mortality in Rome. The effect is more evident among residents in the city centre, where the levels of exposure to pollutants recorded by fixed monitors are probably more reliable indicators of personal exposure.

Inequality in health: socioeconomic differentials in mortality in Rome, 1990-95.

STUDY OBJECTIVE: Population groups with a lower socioeconomic status (SES) have a greater risk of disease and mortality. The aim of this study was to investigate the relation between SES and mortality in the metropolitan area of Rome during the six year period 1990-1995, and to examine variations in mortality differentials between 1990-92 and 1993-95. DESIGN: Rome has a population of approximately 2,800,000, with 6100 census tracts (CTs). During the study period, 149,002 deaths occurred among residents. The cause-specific mortality rates were compared among four socioeconomic categories defined by a socioeconomic index, derived from characteristics of the CT of residence. MAIN RESULTS: Among men, total mortality and mortality for the major causes of death showed an inverse association with SES. Among 15-44 year old men, the strong positive association between total mortality and low SES was attributable to AIDS and overdose mortality. Among women, a positive association with lower SES was observed for stomach cancer, uterus cancer and cardiovascular disease, whereas mortality for lung and breast cancers was higher in the groups with higher SES. Comparing the periods 1990-92 and 1993-95, differences in total mortality between socioeconomic groups widened in both sexes. Increasing differences were observed for tuberculosis and lung cancer among men, and for uterus cancer, traffic accidents, and overdose mortality among women. CONCLUSIONS: The use of an area-based indicator of SES limits the interpretations of the findings. However, despite the possible limitations, these results suggest that social class differences in mortality in Rome are increasing. Time changes in lifestyle and in the prevalence of risk behaviours may produce differences in disease incidence. Moreover, inequalities in the access to medical care and in the quality of care may contribute to an increasing differentials in mortality.

Coronary artery bypass graft surgery: socioeconomic inequalities in access and in 30 day mortality. A population-based study in Rome, Italy

OBJECTIVES To evaluate whether coronary artery bypass graft (CABG) surgery is equally provided among different socioeconomic status (SES) groups in accordance with need. To estimate the association between SES and mortality occurring 30 days after CABG surgery. DESIGN Individual socioeconomic index assigned with respect to the characteristics of the census tract of residence (level I = highest SES; level IV = lowest SES). Comparison of age adjusted hospital admission rates of ischaemic heart disease (IHD) and CABG surgery among four SES groups. Retrospective cohort study of all patients who underwent CABG surgery during 1996–97. SETTING Rome (2 685 890 inhabitants) and the seven cardiac surgery units in the city. PARTICIPANTS All residents in Rome aged 35 years or more. A cohort of 1875 CABG patients aged 35 years or more. MAIN OUTCOME MEASURES Age adjusted hospitalisation rates for CABG and IHD and rate of CABG per 100 IHD hospitalisations by SES group, taking level I as the reference group. Odds ratios of 30 day mortality after CABG surgery, adjusted for age, gender, illness severity at admission, and type of hospital where CABG was performed. RESULTS People in the lowest SES level experienced an excess in the age adjusted IHD hospitalisation rates compared with the highest SES level (an excess of 57% among men, and of 94% among women), but the rate of CABG per 100 IHD hospitalisations was lower, among men, in the most socially disadvantaged level (8.9 CABG procedures per 100 IHD hospital admissions in level IV versus 14.1 in level I rate ratio= 0.63; 95% CI 0.44, 0.89). The most socially disadvantaged SES group experienced a higher risk of 30 day mortality after CABG surgery (8.1%) than those in the highest SES group (4.8%); this excess in mortality was confirmed even when initial illness severity was taken into account (odds ratio= 2.89; 95% CI 1.44, 5.80). CONCLUSIONS The universal coverage of the National Health Service in Italy does not guarantee equitable access to CABG surgery for IHD patients. Factors related to SES are likely to influence poor prognosis after CABG surgery.

Short term respiratory effects of acute exposure to chlorine due to a swimming pool accident

OBJECTIVE Acute exposure to chlorine causes lung damage, and recovery may proceed slowly for several weeks. The short term respiratory effects of acute chlorine inhalation during a swimming pool accident were examined. METHODS A total of 282 subjects (134 children, aged <14 years) inhaled hydrogen chloride and sodium hypochlorite during an accident caused by a malfunction of the water chlorinating system in a community pool in Rome in 1998. Most people received bronchodilators and cortisone at the emergency room; five children were admitted to hospital. A total of 260 subjects (92.2%) were interviewed about duration of exposure (<3, 3–5, >5 minutes), intensity of exposure (not at all or a little, a moderate amount, a lot), and respiratory symptoms. Lung function was measured in 184 people (82 children) after 15–30 days. The effects of exposure to chlorine were analysed through multiple linear regression, separately in adults and in children. RESULTS Acute respiratory symptoms occurred among 66.7% of adults and 71.6% of children. The incidences were highest among those who had chronic respiratory disease and had a longer duration of exposure. In about 30% of the subjects, respiratory symptoms persisted for 15–30 days after the accident. Lung function levels were lower in those who reported a high intensity of exposure than in those who reported low exposure, both in children and in adults (mean (95% confidence interval (95% CI)) differences in forced expiratory volume in 1 second (FEV1,) were −109 (−310 to 93) ml, and −275 (−510 to −40) ml, respectively). CONCLUSION Persistent symptoms and lung function impairment were found up to 1 month after the incident. Although community pool accidents happen rarely, the medical community needs to be alerted to the possible clinical and physiological sequelae, especially among susceptible people.

Associations of area based deprivation status and individual educational attainment with incidence, treatment, and prognosis of first coronary event in Rome, Italy.

Background: Socioeconomic gradients in the occurrence of myocardial infarction are well known, but few studies have examined socioeconomic disparities in post-infarction outcomes. The objective of this study was to explore relations of socioeconomic status with the incidence, treatment, and outcome of first coronary event in Rome, Italy, during the period 1998–2000, examining effect modification by gender. Methods: Subjects were Rome residents aged 35–84 years who died from first acute coronary event before reaching the hospital (n = 3470) or were hospitalised for first acute myocardial infarction (n = 8467). Area based deprivation status and patients’ educational attainment were the exposure variables. The outcomes were: incidence of coronary event; recanalisation at the index hospitalisation and fatality within 28 days of hospitalisation; cardiac readmissions and fatality between 28 days and one year of index hospitalisation. Results: Incidence rates increased as area based deprivation status increased; the effect was stronger among women than among men (men RR = 1.40, 95%CI:1.30, 1.50, women RR = 1.78, 95%CI:1.60, 1.98, most compared with least deprived). Rates of recanalisation were significantly lower in the most deprived patients than in the least deprived (OR = 0.77, 95%CI:0.59, 0.99) and in the less educated than in the highly educated (OR = 0.73, 95%CI:0.58, 0.90). Associations of short term fatality with area based deprivation status and educational attainment were weak and inconsistent. However, neither deprivation status nor education was associated with one year outcomes. Conclusions: Area based deprivation status is strongly related to incidence of coronary events, and more so among women than among men. Deprivation status and educational attainment are weakly and inconsistently associated with short term fatality but seem not to influence one year prognosis of acute myocardial infarction. Deprived and less educated patients experience limited access to recanalisation procedures.

Small area study of mortality among people living near multiple sources of air pollution.

OBJECTIVE: In the area of Malagrotta, a suburb of Rome (Italy), a large waste disposal site, a waste incinerator plant, and an oil refinery plant became operational in the early 1960s and have represented three major sources of air pollution. To evaluate the potential health risk due to airborne contamination around these point sources, a small area analysis of mortality was conducted. Cancer of the liver, larynx, lung, kidney, lymphatic, and haematopoietic systems were evaluated. METHODS: Sex and age specific mortality (1987-93) and population denominators (1991) were available for the census tracts of the metropolitan area of Rome. Standardised mortality ratios (SMRs) were computed separately for males and females in bands of increasing distance from the plants, up to a radius of 10 km. Stones test for the decline in risk with distance was performed with increments in radius of 1 km; SMRs were also computed after adjusting for a four level index of socioeconomic status. RESULTS: No overall excess or decline in risk with distance was found for liver, lung, and lymphohaematopoietic cancers in either sex. For laryngeal cancer, an increased but not significant risk was found at 0-3 km and at 3-8 km. A significant decline with distance in mortality from laryngeal cancer was found among men (p = 0.03); the trend remained after adjusting for the socioeconomic index (p = 0.06). CONCLUSIONS: The study showed no association between proximity to the industrial sites and mortality for most of the several conditions considered. However, mortality from laryngeal cancer declined with distance from the sources of pollution. This result is interesting, as previous findings of an increased risk of laryngeal cancer near incinerators have been controversial.

Stroke Outcomes and Neuroimaging of Intracranial Atherosclerosis (SONIA): Design of a Prospective, Multicenter Trial of Diagnostic Tests

Background and Relevance: Intracranial atherosclerosis is responsible for 70,000 ischemic strokes each year in the USA. Noninvasive testingsuch as transcranial Doppler ultrasound (TCD) and magnetic resonance angiography (MRA) to identify intracranial atherosclerosis is in widespread use, but has not been rigorously validated against the gold standard, catheter angiography. The recently NIH-funded Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) trial will compare warfarin with aspirin for stroke prevention in patients with intracranial atherosclerosis. WASID requires performance of angiography along with TCD and MRA, providing an opportunity to critically evaluate these noninvasive tests. Main Objective: The purpose of the Stroke Outcomes and Neuroimaging of Intracranial Atherosclerosis (SONIA) study is to develop the noninvasive diagnosis of intracranial atherosclerosis. The primary aim of SONIA is to define velocity values on TCD and anatomic abnormalities on MRA that identify severe (50–99%) intracranial stenosis of large, proximal arteries seen on catheter angiography. SONIA will define the criteria, or ‘cutpoints’, for an abnormal TCD or MRA and show that they perform with a reliable positive predictive value (PPV). Study Design: SONIA will be conducted in collaboration with WASID. Study-wide cutpoints defining positive TCD and MRA have been developed and reviewed by the site investigators of WASID. Hard copy angiography, TCD and MRA generated in WASID will be centrally read in SONIA. TCD and MRA cutpoints seek to achieve a target PPV of 80% for the identification of severe intracranial stenosis on angiography. Conclusions: Central readings will be used to validate the cutpoints and to develop measures of negative predictive value, and inter- and intra-observer variability. Sensitivity and specificity will be determined after adjustment for verification bias and employed in receiver-operator characteristic analyses. SONIA will use these techniques to develop TCD and MRA cutpoints that minimize the clinical consequences of test errors occurring in the noninvasive evaluation of patients with suspected intracranial atherosclerosis.

Differences in access to coronary care unit among patients with acute myocardial infarction in Rome: old, ill, and poor people hold the burden of inefficiency.

BackgroundDirect admission to Coronary Care Unit (CCU) on hospital arrival can be considered as a good proxy for adequate management in patients with acute myocardial infarction (AMI), as it has been associated with better prognosis. We analyzed a cohort of patients with AMI hospitalized in Rome (Italy) in 1997–2000 to assess the proportion directly admitted to CCU and to investigate the effect of patient characteristics such as gender, age, illness severity on admission, and socio-economic status (SES) on CCU admission practices.MethodsUsing discharge data, we analyzed a cohort of 9127 AMI patients. Illness severity on admission was determined using the Deyos adaptation of the Charlsons comorbidity index, and each patient was assigned to one to four SES groups (level I referring to the highest SES) defined by a socioeconomic index, derived by the characteristics of the census tract of residence. The effect of gender, age, illness severity and SES, on risk of non-admission to CCU was investigated using a logistic regression model (OR, CI 95%).ResultsOnly 53.9% of patients were directly admitted to CCU, and access to optimal care was more frequently offered to younger patients (OR = 0.35; 95%CI = 0.25–0.48 when comparing 85+ to >=50 years), those with less severe illness (OR = 0.48; 95%CI = 0.37–0.61 when comparing Charlson index 3+ to 0) and the socially advantaged (OR = 0.81; 95%CI = 0.66–0.99 when comparing low to high SES).ConclusionIn Rome, Italy, standard optimal coronary care is underprovided. It seems to be granted preferentially to the better off, even after controversial clinical criteria, such as age and severity of illness, are taken into account.

Air pollution from incinerators and reproductive outcomes: a multisite study.

Background: The few studies that have investigated the relationship between emissions from municipal solid-waste incinerators and adverse pregnancy outcomes have had conflicting results. We conducted a study to assess the effects of air emissions from the eight incinerators currently in operation in the Emilia-Romagna Region of Italy on reproductive outcomes (sex ratio, multiple births, preterm births, and small for gestational age [SGA] births). Methods: We considered all births (n = 21,517) to women residing within a 4-km radius of an incinerator at the time of delivery during the period 2003–2010 who were successfully linked to the Delivery Certificate database. This source also provided information on maternal characteristics and deliveries. Each newborn was georeferenced and characterized by a specific level of exposure to incinerator emissions, categorized in quintiles of PM10, and other sources of pollution (NOx quartiles), evaluated by means of ADMS-Urban system dispersion models. We ran logistic regression models for each outcome, adjusting for exposure to other pollution sources and maternal covariates. Results: Incinerator pollution was not associated with sex ratio, multiple births, or frequency of SGA. Preterm delivery increased with increasing exposure (test for trend, P < 0.001); for the highest versus the lowest quintile exposure, the odds ratio was 1.30 (95% confidence interval = 1.08–1.57). A similar trend was observed for very preterm babies. Several sensitivity analyses did not alter these results. Conclusions: Maternal exposure to incinerator emissions, even at very low levels, was associated with preterm delivery.