Silvia Bruzzone

Excess mortality for non–AIDS-defining cancers among people with AIDS.

During the period 1999–2006, non–AIDS-defining cancers accounted for 7.4% of deaths among Italian people with AIDS. The risk of death was 6.6-fold higher than in the general population, being particularly elevated for virus-related cancers. The study findings highlighted the importance of monitoring the cancer burden on mortality for people with AIDS.

Survival after AIDS diagnosis in Italy, 1999-2006: a population-based study.

Objectives:To provide survival estimates of Italian people with AIDS (PWA) in the highly active antiretroviral therapy era and to identify prognostic factors at diagnosis and illnesses present at death. Design:Longitudinal study with all-cause mortality as end point. Methods:The vital status and illnesses present at death of the 9662 Italian PWA diagnosed from 1999 to 2005 were evaluated through a record linkage with the Italian mortality database. The survival was estimated through Kaplan-Meier method, whereas hazard ratios were computed to identify prognostic factors in the first 12 months or later. Results:80.6% of PWA survived 1 year, 75.2% 2 years, and 66.4% 5 years. Elevated death risks emerged among older individuals, injection drug users, and those with a CD4+ cell count <200. Non-Hodgkin lymphoma at AIDS diagnosis was the strongest negative prognostic factor, particularly in the first 12 months after AIDS (hazard ratio = 9.2, for primary brain lymphoma). At death, non-AIDS-defining illnesses increased from 38.4% in 1999 to 56.9% in 2006, with non-AIDS-defining cancers rising from 3.7% to 8.7%. Conclusions:Our study documented the prolonged survival of Italian PWA, the strong impact of non-Hodgkin lymphoma on mortality, and the increasing frequency of non-AIDS-defining illnesses at death.

The impact of Kaposi sarcoma and non-Hodgkin lymphoma on mortality of people with AIDS in the highly active antiretroviral therapies era

BACKGROUND Kaposi sarcoma (KS) and non-Hodgkin lymphoma (NHL) have strongly diminished in the HAART era, but their impact on life expectancy of people with AIDS (PWA) needs to be monitored. We aimed at quantifying the burden of KS and NHL on mortality of PWA in the HAART period in Italy. METHODS Death certificates of 3209 PWA diagnosed in 1999-2006 who died as of December 2006 were reviewed to identify those deaths in which KS or NHL was the underlying cause. Standardized mortality ratios (SMR) were computed. RESULTS KS or NHL appeared in 4.3% and 14.6% death certificates, respectively; they were the underlying cause of death in 3.1% and 13.4% of cases. SMR were 8698-fold higher for KS and 349-fold higher for NHL, and tended to decline over the study period. CONCLUSION KS and NHL caused about 16% of deaths of PWA in the HAART era, with 100-fold higher risks of death compared to the Italian general population also in recent years. Clinicians and public health officials should be aware of the persisting negative impact of these cancers on life expectancy of PWA.

Time trends of cancer mortality among elderly in Italy, 1970-2008: an observational study

BackgroundThe aging of the Italian population will unavoidably lead to a growing number of persons diagnosed and living with cancer. A comprehensive description of the burden of cancer mortality among Italian elderly (65-84 years of age) in the last four decades has not been carried out yet. Cancer mortality rates were used to describe time trends between 1970-2008.MethodsMortality counts, provided by the Italian National Institute of Statistics, were grouped according to data availability: in quinquennia from 1970-74 through 1995-99, and in 2000-03 and 2006-08 groups. Age-standardized rates (world population) were computed by calendar periods while annual percent changes (APCs) were computed for elderly and middle aged (35-64 years) people for the period 1995-2008.ResultsThe number of cancer deaths in elderly nearly doubled between 1970-74 (31,400 deaths/year in men, and 24,000 in women) and 2006-08 (63,000 deaths/year in men, and 42,000 in women). Overall cancer mortality rates peaked during the quinquennia 1985-89 and 1990-94 (about 1,500/100,000 in men and 680 in women) and declined thereafter. Throughout 1995-2008 cancer mortality rates decreased by -1.6%/year in men and -0.9%/year in women. These decreases were mainly driven by cancers of the stomach, bladder, prostate, and lung (APC = -3.3%, -2.7%, -2.5%, -2.2%, respectively) in men, and by cancers of the stomach, bladder, and breast (APC = -3.5%, -1.9%, -1.1%, respectively) in women. Conversely, increases in mortality rates between 1995 and 2008 were recorded for lung cancer (APC = +0.6%) in women, cutaneous melanoma (APC = +1.7%) in men, and pancreatic cancer (APC = +0.6% in men and +0.9% in women).ConclusionsOverall favorable trends in cancer mortality were observed among Italian elderly between 1995 and 2008. Early diagnosis, improved efficacy of anti-cancer treatments and management of comorbidities are the most likely explanations of these positive observations. However, enduring preventive interventions against the most common risk factor (e.g. cigarette smoking), early diagnosis, and access to care should be reconsidered and extended to match the reductions of cancer mortality recorded in the elderly with those in the middle aged.

Comparing ICD-9 and ICD-10: The impact on intentional and unintentional injury mortality statistics in Italy and Norway

BACKGROUND The international classification of diseases (ICD) provides guidelines for the collection, classification and dissemination of official cause-of-death statistics. New revisions of the ICD can potentially disrupt time trends of cause-of-death statistics and affect between-country comparisons. The aim of this study was to measure how switching from ICD-9 to ICD-10 affected mortality statistics for external causes of death, i.e. intentional and unintentional injuries, in Italy and Norway. METHODS A sample of death certificates (N=454,897) were selected in Italy from the first year the ICD-10 was implemented (2003) and reclassified from ICD-10 to ICD-9 by the Italian National Institute of Statistics. A sample of death certificates was also selected in Norway (N=10,706) from the last year the ICD-9 was used (1995) and reclassified according to ICD-10 by Statistics Norway. The reclassification (double-coding) was performed by special trained personal in governmental offices responsible for official mortality statistics. Although the reclassification covered all causes of death (diseases and injuries) in the sample, our analysis focused on just one ICD chapter XX. This was external causes of mortality (injury deaths), and covered 15 selected categories of injuries. RESULTS The switch from ICD-9 to ICD-10 had a significant net impact on 8 of the 15 selected categories. In Italy, accidental falls decreased by 76%; traffic accidents decreased by 9%; suicide by hanging decreased by 3%; events of undetermined intent decreased by 69%; and overall injury deaths decreased by 4%. These net decreases reflect the moving of death records from injury categories in ICD-9 to other injury or disease categories in ICD-10. In Norway, the number of records in three categories decreased significantly: transport accidents, 9%; traffic accidents, 13%; and suicide by self-poisoning, 18%. No statistically significant differences (net changes) were observed in the total number of accidents, suicides and homicides in either country. CONCLUSIONS Switching to ICD-10 did not change the overall trends for accidents, homicides and suicides in either country. However, the number of records in some injury subcategories e.g. accidental falls and traffic accidents, decreased. Changing classification can thus affect the ranking of causes of injury mortality, with consequences for public health policy.

Elevated risks of death for diabetes mellitus and cardiovascular diseases in Italian AIDS cases

After the introduction of highly active antiretroviral therapies (HAART), an increased incidence of insulin resistance, diabetes mellitus (DM), and cardiovascular diseases has been described. The impact of such conditions on mortality in the post-HAART era has been also assessed in various modes in the literature. In this paper, we report on the death risks for DM, myocardial infarction, and chronic ischemic heart diseases that were investigated among 9662 Italian AIDS cases diagnosed between 1999 and 2005. Death certificates reporting DM, myocardial infarction, and chronic ischemic heart diseases were reviewed to identify the underlying cause of death, and to compare the observed numbers of deaths with the expected ones from the sex- and age-matched, general population of Italy. Person-years at risk of death were computed from date of AIDS diagnosis up to date of death or to December 31, 2006. Standardized mortality ratios (SMR) and their 95% confidence intervals (CI) were computed. DM and cardiovascular diseases were the cause of death for 43 out of 3101 deceased AIDS cases (i.e., 1.4% of all deaths). In comparison with the general population, the risks of death were 6.4-fold higher for DM (95% CI:3.5-10.8), 2.3-fold higher for myocardial infarction (95% CI:1.4-3.7) and 3.0 for chronic ischemic heart diseases (95% CI: 1.5-5.2).

Protection of health information in Italy: a step too far?

A recent appeal by a group of Italian obstetricians and neonatologists, advocating full resuscitation of extremely preterm infants independently from parental opinion, raised a debate on the rationale and consequences of such proposal. Whether or not the appeal will modify practices, there is no doubt that careful assessment of outcome for these very special infants is called for. However, this is currently impossible at national level in Italy. Following a change in legislation, the time-honoured system of births monitoring by the Italian National Institute of Statistics (ISTAT) was dismantled in 1998 and later rebuilt entrusting it to the Ministry of Health, while ISTAT remains in charge of deaths registry. Both are public institutions; yet for privacy protection the transfer of birth certificates from the Ministry to ISTAT is only permitted after deletion of personal identifiers. Thus, the individual matching of birth certificates, containing crucial information such as birthweight, gestational age and vitality, to the corresponding infant death data (if any) becomes more difficult. Results of an attempt of statistical record linkage performed on the 2003 birth cohort are shown in Table 1. Variables used as keys to record linkage were infant’s gender, plurality, date and place of delivery and maternal date of birth. Overall, only 598 of the 1539 deaths (38.9%) could be successfully linked, and proportions decreased from 56.6% in the North to 32% in the Centre and South, to only 15% in the Islands. Both missing birth certificates and records incompleteness on linkage variables contributed to these results. The lower proportion of valid death records determined linking difficulties in Central Italy, while missing birth certificates were the main issue in the South and especially Islands. At the light of the North-to-South trend of neonatal and infant mortality traditionally reported in Italy, lack of information from the Southern regions is particularly troubling. As stated by the Europeristat project, neonatal and infant mortality stratified by birthweight and gestational age are ‘core’ indicators to be recorded by all European Union countries to assess the quality of perinatal care and monitor the effects of policy changes. Voluntary collection of data by Neonatal Intensive Care Units, as developing today in Italy and other countries for benchmarking purposes, is a useful but inadequate substitute, being based on the selected subgroup of neonates surviving to admission to tertiary Centres. Solutions are urgently needed to reconcile privacy protection with timely population-based monitoring of neonatal and infant outcomes stratified by birthweight and gestational age.

Epidemiology of Fatal Trauma in Italy in 2002 Using Population-Based Registries

Background:Population-based registries have been proposed for epidemiologic studies and quality assessment in trauma care because they consider the entire population of a given geographic area.Patients and Methods:Trauma mortality in pre-hospital and in-hospital settings and death time from injury have been calculated for Italy during 2002 by cross-analyzing two national databases: the death certificates register (DCD) and the hospital discharge register (HDR). All diagnosis codes from 800.0 to 939.9 and from 950.0 to 959.9 in both the DCD and the HDR, with the exclusion of femur fractures (820.0 and 821.9) if older than 65, have been included.Results:The total number of people who died during 2002 as a consequence of trauma in Italy was 15,456; of these, 43.5% were older than age 64, and 35.9% belonged to the 15–44 age group. The overall incidence rate of trauma death was 27.23 per 100,000 inhabitants/ year, with a relative risk to men vs. women of 2.3. An analysis of the time distribution of the trauma deaths showed that 46.8% were pre-hospital mortalities, 18% of the deaths occurred within 48 h after hospital admission (acute mortality), 11.2% of the deaths occurred between three and seven days after admission (early mortality), and 24.0% of the patients died more than seven days after admission (late mortality). Patients who died before they arrived at hospital were younger and the proportion of men was higher than for the deaths that occurred after hospital arrival.Conclusion:The use of population-based registries proved to be effective in our study because it allowed us to use currently available data to obtain information useful for trauma system planning and design.

Association between mobile phone traffic volume and road crash fatalities: A population-based case-crossover study

Use of mobile phones while driving is known to cause crashes with possible fatalities. Different habits of mobile phone use might be distracting forces and display differential impacts on accident risk; the assessment of the relative importance is relevant to implement prevention, mitigation, and control measures. This study aimed to assess the relationship between the use of mobile phones at population level and road crash fatalities in large urban areas. Data on road crashes with fatalities were collected from seven Italian metropolitan areas and matched in time and space with high resolution mobile phone traffic volume data about calls, texts, Internet connections and upload/download data. A case-crossover study design was applied to estimate the relative risks of road accident for increases in each type of mobile phone traffic volumes in underlying population present in the small areas where accidents occurred. Effect modification was evaluated by weekday/weekend, hour of the day, meteorological conditions, and street densities. Positive associations between road crashes rates and the number of calls, texts, and Internet connections were found, with incremental risks of 17.2% (95% Confidence Interval [CI] 7.7, 27.6), 8.4% (CI 0.7, 16.8), and 54.6% (CI 34.0, 78.5) per increases (at 15 min intervals) of 5 calls/100 people, 3 text/100 people, and 40 connections/100 people, respectively. Small differences across cities were detected. Working days, nighttime and morning hours were associated with greater phone use and more road accidents. The relationship between mobile phone use and road fatalities at population level is strong. Strict controls on cellular phone in the vehicle may results in a large health benefit.

Italian supercentenarians: Age validation of deaths from 1969 to 2000

This report describes the first stage of the age validation process of Italian supercentenarians. The process is still in progress and to date has only concerned supercentenarians deceased in the period 1969-2000. Of 35 potential supercentenarians included in the Italian National Institute of Statistics (Istituto nazionale di statistica, or Istat) database, 21 cases (three males and 18 females) are fully validated, seven cases refer to false supercentenarians—the error often being a misreported date of birth—and seven cases still remain unverified. The maximum age reached by the validated supercentenarians is 111, and the first case is recorded in 1973. In Italy supercentenarians have become a significant phenomenon only in the last few years.