Nera Agabiti

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.

Dietary factors associated with wheezing and allergic rhinitis in children

The effect of dietary factors on asthma is controversial. This study examined food consumption and the use of fats in relation to wheezing and allergic rhinitis in children. Baseline questionnaire data on individual and family characteristics were recorded by parents of 5,257 children aged 6–7 yrs living in central Italy participating in the International Study on Asthma and Allergies in Childhood study. A total of 4,104 children (78.1%) were reinvestigated after 1 yr using a second parental questionnaire to record occurrence of respiratory symptoms over the intervening 12 months. Consumption of foods rich in antioxidants, such as vitamins C and E, animal fats, and food containing omega‐3 fatty acids were investigated using a food-frequency questionnaire. Frequency of use of fats was also evaluated. Wheezing, shortness of breath with wheeze, and symptoms of allergic rhinitis in the past 12 months were considered. Intake of cooked vegetables, tomatoes, and fruit were protective factors for any wheeze in the last 12 months and shortness of breath with wheeze. Consumption of citrus fruit had a protective role for shortness of breath with wheeze. Consumption of bread and margarine was associated with an increased risk of wheeze, while bread and butter was associated with shortness of breath with wheeze. Dietary antioxidants in vegetables may reduce wheezing symptoms in childhood, whereas both butter and margarine may increase the occurrence of such symptoms.

Socioeconomic status, number of siblings, and respiratory infections in early life as determinants of atopy in children.

Asthma and allergic disorders have been on the increase in recent decades, especially among children living in affluent countries; some aspects of the “Western” way of life may explain this trend. We evaluated the relation of aeroallergen skin test reactivity with socioeconomic status, number of siblings, and respiratory infections in early life. We examined a total of 2,226 schoolchildren, ages 7–11 years, in three areas of Lazio, Italy. Skin prick tests were performed to assess atopic status, and self‐administered questionnaires were completed by the parents. The prevalence of prick test positivity was greater among children whose fathers were in the highest educational level than among those in the lowest [prevalence ratio (PR) = 1.58; 95% confidence interval (CI) = 1.21–2.06]. There was also a lower prevalence of atopy among larger sibships (PR = 0.38 for subjects with four or more siblings vs those without siblings; 95% CI = 0.14–0.99). A history of bronchitis or bronchiolitis before age 2 years was weakly associated with an increased risk of atopy, whereas a history of pertussis or pneumonia was not. Both the effect of fathers education and the influence of larger sibship size remained when we adjusted for several potential confounding factors, including respiratory infections in early life. We infer that higher socioeconomic status and lower sibling number are determinants of atopy in this Italian population. Protection arising from early severe respiratory infections does not explain this association, although we cannot exclude a role for other viral infections.

Effects of environment on atopic status and respiratory disorders in children

BACKGROUND We investigated whether living in areas with higher air pollution levels increases the prevalence of positive skin reactivity in children and the possible synergic effect of air pollution exposure and atopy on respiratory disorders. METHODS This cross-sectional study was conducted in an urban area, in an industrialized area, and in a rural control area in the Latium region of Italy. A total of 2226 subjects, aged 7 to 11 years, were studied. RESULTS The prevalence of children with positive skin test results did not vary significantly over the areas (urban area = 21.0%, industrialized area = 22.0%, rural area = 20.2%). Children living in polluted areas experienced significantly more cough and phlegm (odds ratio [OR] = 1.5), rhinitis (OR = 1.7), pneumonia (OR = 1.7), and early respiratory infections (OR = 1.4) than control subjects. The pattern of the odds ratios for atopy and air pollution suggested that the two factors were probably additive in affecting asthma and early respiratory infections (synergy index [SI] = 1.04 and 1.27, respectively), whereas they seemed to act synergically in regard to cough and phlegm (SI = 1.59), rhinitis (SI = 3.01), and pneumonia (SI = 2.75). CONCLUSION Environmental air pollution seems not to increase the prevalence of atopic status; it seems, however, to enhance the development of clinical symptoms among already sensitized subjects.

The impact of parental smoking on asthma and wheezing. SIDRIA Collaborative Group. Studi Italiani sui Disturbi Respiratori nell'Infanzia e l'Ambiente.

To evaluate the impact of parental smoking on childhood asthma and wheezing, we studied two random samples of subjects ages 6–7 and 13–14 years in ten areas of northern and central Italy. Standardized questionnaires were completed by parents of 18,737 children and 21,068 adolescents (response rates, 92.8% and 96.3%, respectively) about their smoking habits and the respiratory health of their children. Adolescents were asked about their respiratory health and personal smoking. We compared two groups of cases with healthy subjects: “current asthma” (children, 5.2%; adolescents, 6.2%) and “current wheezing” not labeled as asthma (children = 4.5%, adolescents = 8.5%). Exposure to smoke of at least one parent increased the relative risk of current asthma among children [odds ratio (OR) =.34; 95% confidence interval (CI) = 1.11–1.62] and of current wheezing among adolescents OR = 1.24; 95% CI = 1.07–1.44). Maternal smoking had a stronger effect than paternal smoking. Maternal smoking during pregnancy was associated with current asthma (OR = 1.62; 95% CI = 1.34–1.96) and current wheezing in children (OR = 1.31; 95% CI = 1.06–1.62); the effects were lower among adolescents. Among subjects with a negative history of parental asthma, maternal smoking was associated with current wheezing in both age groups, whereas among those with a positive history of parental asthma it was associated with current asthma in children, but not in adolescents. We estimated that 15% (95% CI = 12–19) of the current asthma cases among children and 11% (95% CI = 8.3–14) of the current wheezing cases among adolescents are attributable to parental smoking in Italy. (Epidemiology 1999;10:692–698)

Socioeconomic Differences in Stroke Incidence and Prognosis Under a Universal Healthcare System

Background and Purpose— Low socioeconomic position (SEP) is associated with high overall stroke mortality, but its contribution to stroke prognosis is unclear. We evaluated socioeconomic disparities in stroke incidence and poststroke outcomes. Methods— We collected hospital discharge and mortality data for all 35- to 84-year-old Rome residents who had a first acute ischemic or hemorrhagic stroke in 2001 to 2004. We used a small-area SEP index. We calculated age-adjusted incidence rates and rate ratios by SEP for fatal and nonfatal stroke subtypes using Poisson regression. Logistic regression was used to study outcomes by SEP (30-day mortality, and among 1-month survivors: 1-year mortality, hospital readmissions for a successive stroke, and cardiovascular diseases). Results— A total of 10 033 incident strokes (75% ischemic) were observed. Incidence rates (per 100 000) for ischemic and hemorrhagic stroke were: 104 and 34 in men and 81 and 28 in women, respectively. There were socioeconomic disparities in stroke incidence in both genders (rate ratios between extreme SEP categories in ischemic and hemorrhagic stroke: 1.76; 95% CI,1.59 to 1.95; 1.50; 95% CI, 1.26 to 1.80 in men; 1.72; 95% CI, 1.55 to 1.91; 1.37; 95% CI, 1.15 to 1.63 in women). No association was found for SEP and mortality after stroke. Men with low SEP with an ischemic event were more likely to be hospitalized for a new stroke than men with high SEP. Women with low SEP with hemorrhagic stroke were more likely to be hospitalized for cardiovascular disease compared with women with high SEP. Conclusions— Stroke incidence strongly differs between socioeconomic groups reflecting a heterogeneous distribution of lifestyle and clinical risk factors. Strategies for primary prevention should target less affluent people.

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.

Prevalence of preclinical and clinical heart failure in the elderly. A population‐based study in Central Italy

We conducted a population‐based cross‐sectional study to assess the prevalence of both preclinical and clinical heart failure (HF) in the elderly.

Income level and chronic ambulatory care sensitive conditions in adults: a multicity population-based study in Italy

BackgroundA relationship between quality of primary health care and preventable hospitalizations has been described in the US, especially among the elderly. In Europe, there has been a recent increase in the evaluation of Ambulatory Care Sensitive Conditions (ACSC) as an indicator of health care quality, but evidence is still limited. The aim of this study was to determine whether income level is associated with higher hospitalization rates for ACSC in adults in a country with universal health care coverage.MethodsFrom the hospital registries in four Italian cities (Turin, Milan, Bologna, Rome), we identified 9384 hospital admissions for six chronic conditions (diabetes, hypertension, congestive heart failure, angina pectoris, chronic obstructive pulmonary disease, and asthma) among 20-64 year-olds in 2000. Case definition was based on the ICD-9-CM coding algorithm suggested by the Agency for Health Research and Quality - Prevention Quality Indicators. An area-based (census block) income index was used for each individual. All hospitalization rates were directly standardised for gender and age using the Italian population. Poisson regression analysis was performed to assess the relationship between income level (quintiles) and hospitalization rates (RR, 95% CI) separately for the selected conditions controlling for age, gender and city of residence.ResultsOverall, the ACSC age-standardized rate was 26.1 per 10.000 inhabitants. All conditions showed a statistically significant socioeconomic gradient, with low income people being more likely to be hospitalized than their well off counterparts. The association was particularly strong for chronic obstructive pulmonary disease (level V low income vs. level I high income RR = 4.23 95%CI 3.37-5.31) and for congestive heart failure (RR = 3.78, 95% CI = 3.09-4.62). With the exception of asthma, males were more vulnerable to ACSC hospitalizations than females. The risks were higher among 45-64 year olds than in younger people.ConclusionsThe socioeconomic gradient in ACSC hospitalization rates confirms the gap in health status between social groups in our country. Insufficient or ineffective primary care is suggested as a plausible additional factor aggravating inequality. This finding highlights the need for improving outpatient care programmes to reduce the excess of unnecessary hospitalizations among poor people.

The association of socioeconomic disadvantage with postoperative complications after major elective cardiovascular surgery

Background: Understanding the mechanism by which both patient- and hospital level factors act in generating disparities has important implications for clinicians and policy-makers. Objective: To measure the association between socioeconomic position (SEP) and postoperative complications after major elective cardiovascular procedures. Design: Multicity hospital-based study. Subjects: Using Hospital Discharge Registries (ICD-9-CM codes), 19 310 patients were identified undergoing five cardiovascular operations (coronary artery bypass grafting (CABG), valve replacement, carotid endarterectomy, major vascular bypass, repair of unruptured abdominal aorta aneurysm (AAA repair)) in four Italian cities, 1997–2000. Measures: For each patient, a five-level median income index by census block of residence was calculated. In-hospital 30-day mortality, cardiovascular complications (CCs) and non-cardiovascular complications (NCCs) were the outcomes. Odds ratios (ORs) were estimated with multilevel logistic regression adjusting for city of residence, gender, age and comorbidities taking into account hospital and individual dependencies. Main results: In-hospital 30-day mortality varied by type of surgery (CABG 3.7%, valve replacement 5.7%, carotid endarterectomy 0.9%, major vascular bypass 8.8%, AAA repair 4.0%). Disadvantaged people were more likely to die after CABG (lowest vs highest income OR 1.93, p trend 0.023). For other surgeries, the relationship between SEP and mortality was less clear. For cardiac surgery, SEP differences in mortality were higher for publicly funded patients in low-volume hospitals (lowest vs highest income OR 3.90, p trend 0.039) than for privately funded patients (OR 1.46, p trend 0.444); however, the difference in the SEP gradients was not statistically significant. Conclusions: Disadvantaged people seem particularly vulnerable to mortality after cardiovascular surgery. Efforts are needed to identify structural factors that may enlarge SEP disparities within hospitals.