Danilo Fusco

Air pollution and hospital admissions for respiratory conditions in Rome, Italy

Most of the evidence regarding the association between particulate air pollution and emergency room visits or hospital admissions for respiratory conditions and asthma comes from the USA. European time-series analyses have suggested that gaseous air pollutants are important determinants of acute hospitalization for respiratory conditions, at least as important as particulate mass. The association between daily mean levels of suspended particles and gaseous pollutants (sulphur dioxide, nitrogen dioxide, carbon monoxide, ozone) was examined. The daily emergency hospital admissions for respiratory conditions in the metropolitan area of Rome during 1995-1997 were also recorded. Daily counts of hospital admissions for total respiratory conditions (43 admissions day(-1)), acute respiratory infections including pneumonia (18 day(-1)), chronic obstructive pulmonary disease (COPD) (13 day(-1)), and asthma (4.5 day(-1)) among residents of all ages and among children (0-14 yrs) were analysed. The generalized additive models included spline smooth functions of the day of study, mean temperature, mean humidity, influenza epidemics, and indicator variables for day of the week and holidays. Total respiratory admissions were significantly associated with same-day level of NO2 (2.5% increase per interquartile range (IQR) change, 22.3 microg x m(-3)) and CO (2.8% increase per IQR, 1.5 mg x m(-3)). No effect was found for particulate matter and SO2, whereas O3 was associated with admissions only among children (lag 1, 5.5% increase per IQR, 23.9 microg x m3). The effect of NO2 was stronger on acute respiratory infections (lag 0, 4.0% increase) and on asthma among children (lag 1, 10.7% increase). The admissions for all ages for asthma and COPD were associated only with same-day level of CO (5.5% and 4.3% increase, respectively). Multipollutant models confirmed the role of CO on all respiratory admissions, including asthma and COPD, and that of NO2 on acute respiratory infections. Among children, O3 remained a strong indicator of acute respiratory infections. Carbon monoxide and photochemical pollutants (nitrogen dioxide, ozone) appear to be determinants of acute respiratory conditions in Rome. Since carbon monoxide and nitrogen dioxide are good indicators of combustion products from traffic related sources, the detected effect may be due to unmeasured fine and ultrafine particles.

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.

Socioeconomic Status and Survival of Persons with Aids before and after the Introduction of Highly Active Antiretroviral Therapy

We estimated the AIDS survival by neighborhood socioeconomic status before (1993–1995) and after (1996–1997) the introduction of highly active antiretroviral therapy in Rome, Italy, in a retrospective cohort of persons with AIDS followed through July 31, 1998. Participants included 1,474 persons with AIDS residing in Rome who were diagnosed in 1993–1997. We calculated hazard ratios (HRs) of death for two diagnostic periods (before and after highly active antiretroviral therapy was introduced) by neighborhood socioeconomic status categorized into four levels (level I = highest socioeconomic status), using the Cox model and adjusting for gender, age, intravenous drug use, CD4 cell count at diagnosis, AIDS-defining disease, and hospital of diagnosis. Thirty-four per cent of persons with AIDS (N = 503) had survived as of mid-1998. For persons with AIDS diagnosed in 1993–1995, we found little difference in the risk of death by neighborhood socioeconomic status. For 1996–1997, the risk of death was greater for persons with lower neighborhood socioeconomic status, especially for levels III and IV [HR = 2.81 (95% confidence interval = 1.38–5.76), and HR = 2.55 (95% confidence interval = 1.27–5.14), respectively, compared with level I]. Stratified analyses showed that the greatest difference was found for women and drug users. In conclusion, even in a country with universal health coverage that provides therapy at no cost, differences in survival of persons with AIDS have emerged by neighborhood socioeconomic status since highly active antiretroviral therapy was introduced. Inequalities in health-care access or in medical management, or poor adherence to treatment, could explain the observed heterogeneity.

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.

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.

Immediate and Intermediate Outcome After Transapical Versus Transfemoral Transcatheter Aortic Valve Replacement

A few studies recently reported controversial results with transfemoral transcatheter aortic valve replacement (TF-TAVR) versus transapical transcatheter aortic valve replacement (TA-TAVR), often without adequate adjusted analysis for baseline differences. Data on patients who underwent TF-TAVR and TA-TAVR from the Observational Study of Effectiveness of avR-tavI procedures for severe Aortic stenosis Treatment study were analyzed with propensity score 1-to-1 matching. From a cohort of 1,654 patients (1,419 patients underwent TF-TAVR and 235 patients underwent TA-TAVR), propensity score matching resulted in 199 pairs of patients with similar operative risk (EuroSCORE II: TF-TAVR 8.1 ± 7.1% vs TA-TAVR, 8.4 ± 7.3%, p = 0.713). Thirty-day mortality was 8.0% after TA-TAVR and 4.0% after TF-TAVR (p = 0.102). Postoperative rates of stroke (TA-TAVR, 2.0% vs TF-TAVR 1.0%, p = 0.414), cardiac tamponade (TA-TAVR, 4.1% vs TF-TAVR 1.5%, p = 0.131), permanent pacemaker implantation (TA-TAVR, 8.7% vs TF-TAVR 13.3%, p = 0.414), and infection (TA-TAVR, 6.7% vs TF-TAVR 3.6%, p = 0.180) were similar in the study groups but with an overall trend in favor of TF-TAVR. Higher rates of major vascular damage (7.2% vs 1.0%, p = 0.003) and moderate-to-severe paravalvular regurgitation (7.8% vs 5.2%, p = 0.008) were observed after TF-TAVR. On the contrary, TA-TAVR was associated with higher rates of red blood cell transfusion (50.0% vs 30.4%, p = 0.0002) and acute kidney injury (stages 1 to 3: 44.4% vs 21.9%, p <0.0001) compared with TF-TAVR. Three-year survival rate was 69.1% after TF-TAVR and 57.0% after TA-TAVR (p = 0.006), whereas freedom from major adverse cardiovascular and cerebrovascular events was 61.9% after TF-TAVR and 50.4% after TA-TAVR (p = 0.011). In conclusion, TF-TAVR seems to be associated with significantly higher early and intermediate survival compared with TA-TAVR. The transfemoral approach, whenever feasible, should be considered the route of choice for TAVR.

Transcatheter Aortic Valve Implantation Compared With Surgical Aortic Valve Replacement in Low-Risk Patients

Background—The proven efficacy of transcatheter aortic valve implantation (TAVI) in high-risk patients is leading to the expansion of its indications toward lower-risk patients. However, this shift is not supported by meaningful evidence of its benefit over surgical aortic valve replacement (SAVR). This analysis aims to describe outcomes of TAVI versus SAVR in low-risk patients. Methods and Results—We compared the outcome after TAVI and SAVR of low-risk patients (European System for Cardiac Operative Risk Evaluation II [EuroSCORE II] <4%) included in the Observational Study of Effectiveness of SAVR–TAVI Procedures for Severe Aortic Stenosis Treatment (OBSERVANT) study. The primary outcome was 3-year survival. Secondary outcomes were early events and major adverse cardiac and cerebrovascular events at 3 years. Propensity score matching resulted in 355 pairs of patients with similar baseline characteristics. Thirty-day survival was 97.1% after SAVR and 97.4% after TAVI (P=0.82). Cardiac tamponade, permanent pacemaker implantation, major vascular damage, and moderate-to-severe paravalvular regurgitation were significantly more frequent after TAVI compared with SAVR. Stroke rates were equal in the study groups. SAVR was associated with higher risk of cardiogenic shock, severe bleeding, and acute kidney injury. At 3 years, survival was 83.4% after SAVR and 72.0% after TAVI (P=0.0015), whereas freedom from major adverse cardiac and cerebrovascular events was 80.9% after SAVR and 67.3% after TAVI (P<0.001). Conclusions—In patients with low operative risk, significantly better 3-year survival and freedom from major adverse cardiac and cerebrovascular events were observed after SAVR compared with TAVI. Further studies on new-generation valve prostheses are necessary before expanding indications of TAVI toward lower-risk patients.

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.