AB0520 FIVE-YEAR RATE OF HOSPITALIZATIONS IN ANCA-ASSOCIATED VASCULITIDES IN THE ITALIAN REGION OF FRIULI VENEZIA GIULIA (2013-2017)

Background:

ANCA-associated vasculitides (AAV) are a group of systemic vasculitis carrying a high risk of hospitalization because the multiorgan involvement, the acute nature of some clinical manifestations, the chronic but very disabling course of some other manifestations and finally the risk of severe infections due to chronic glucocorticoid and immunosuppressor administration. However, data on hospitalization due to ANCA-associated vasculitis are still scarce.

Objectives:

to estimate the rate of the first hospitalization or the death in patients suffering from AAV in the Italian region of Friuli Venezia Giulia (about 1,200,000 inhabitants) from year 2013 to 2017.

Methods:

integration of the information coming from many administrative databases were used to this end. The Regional Health Information System of Friuli Venezia Giulia was used as the source of information for this retrospective cohort study. The system covers the entire regional population and includes various electronic health administrative databases that can be linked with one another on an individual basis through a unique encrypted identifier. In particular, the following databases were matched: the database of the regional potential health care beneficiaries (including demographic information and the residential history of all of the subjects living in the region), the hospital discharge database, the database of exemptions from medical charges were used for this study, the database of the different regional laboratories. The population under study was selected based on the following inclusion criteria: patients were residents in Friuli Venezia Giulia and they had to carry the exemption code for AAV, including Granulomatosis with Polyangiitis (GPA), or Eosinophilic Granulomatosis with Polyangiitis (EGPA), or Microscopic Polyangiitis (MPA). This population was observed from 2013 to 2017. The coded event was the occurrence of the first hospitalization or the death. Also, all the hospitalization and their main discharge diagnoses were registered.

Results:

103 patient with AAV were identified. The number of patients with at least one hospitalization/death was 74/103 (71,8%). Seven patients died during the observation period (6,6%). The whole number of hospitalizations was 285 in 74 patients. 55/74 (74,3%) patients experienced more than one hospitalization. In the majority of the hospitalizations (119/285, 41,7%), the cause of hospitalization was directly attributable to the disease itself, while the second cause of hospitalization was the infections (26/285, 9,1%). In 10/103 patients (9,7%), an end stage renal disease was recorded as event. The presence of at least one positivity for ANCA antibodies was documented in 76/103 patients (73,8%), mainly in patients carrying GPA. Globally, the presence of ANCA antibody seems to be associated with greater likelihood of an event (p=0,07, log-rank test). The first event occurred in 50% of ANCA-positive patients within 180 days from diagnosis, while in 50% of ANCA negative patients in 859 days. 6 out of the 7 deaths occurred in ANCA positive patients.

Conclusion:

the rate of hospitalization in AAV is very high confirming the high health care burden of illness. The disease itself is often the cause of the hospitalization, as well as the infectious complication, highlighting the need for more effective treatments, and glucocorticoid sparing therapies. ANCA antibody may represent a biomarker of a more serious disease.

Disclosure of Interests:

Luca Quartuccio Consultant of: Abbvie, Bristol, Speakers bureau: Abbvie, Pfizer, Elena Treppo: None declared, Salvatore De Vita Consultant of: Roche, GSK, Speakers bureau: Roche, GSK, Novartis, Francesca Valent: None declared

Management of immune-related adverse events: A single-center retrospective analysis in a real-world scenario

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Background: Immune checkpoint inhibitors (ICI), anti CTLA-4 and anti PD-1/PD-L1 agents, have demonstrated an improvement in survival outcome in several malignancies. Therapy with ICI is characterized by immune-related adverse events (irAEs) as a result of exuberant immune system activation. Despite good tolerance for ICI, the potentially severe and life-threatening irAEs underscore the importance of investigating optimal management strategies. Methods: A retrospective series of 130 consecutive patients (pts) treated with ICI from Jan 2012 to Dec 2017 was analyzed. Adverse events with a potential immunological etiology were defined as irAEs and graded according to CTCAE v.4.0. The aim of the study was to evaluate irAEs management in an academic hospital center. Results: Pts with a diagnosis of NSCLC n = 64 (49%), melanoma n = 55 (42%), kidney n = 9 (7%) and others n = 2 (2%) were investigated. Baseline ECOG PS was ≤ 1 in 96% of the pts. ICI represented first line treatment for 27% pts, second line for 57% and third or further line for the remaining 16%. 18% were treated with ipilimumab and 82% with anti PD-1/PD-L1 agents (nivolumab 60%, pembrolizumab 21%, atezolizumab 1%). Overall, 50 (38% of pts) developed an irAE.42% of irAEs were grade 1, 38% grade 2, 14% grade 3 and 6% grade 4. The most frequent irAEs were endocrinopathies in 17 pts (34%), followed by cutaneous toxicity in 9 pts (18%) and colitis and diarrhea in 7 pts (14%). A total of 373 unscheduled accesses were observed, 89 (24%) of them were due to irAEs: 78 were unplanned consultations in the oncology department and 11 in the emergency department. irAEs led to hospitalization in 14 pts for 118 days, cumulatively. Grade ≥ 2 colitis was the most frequent irAE associated with hospitalization, it occurred in 4 pts (29%). Colitis and diarrhea required the longest hospitalization (range 4-31 days). 48% (24 pts) required immunosuppressive treatment. Systemic steroids were the most common immunosuppressive agents used. Only one patient received infliximab as second line immunosuppressive treatment after steroid failure. Totally, irAEs required 67 specialist consultancies and additional diagnostic examinations. 15 pts required ICI discontinuation because of irAEs. Conclusions: In our center prevalence and severity of irAEs were similar to literature data. Considered the complexity of irAEs management, multidisciplinary approach and a trained hospital network plays a key role for a more efficient diagnostic and treatment work-up in pts who received ICI therapy and experienced irAEs.

Incremental oncology workload generated by immunotherapy in the first-year of treatment

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Background: The rapid development of immunotherapy (IO) has transformed the cancer therapy landscape with growing impact on oncology workload. Given the few data on this topic, we conducted a study to estimate the shift in workload generated by any new metastatic cancer patient treated with IO and referred to the Oncology Department of the Academic Academic Cancer Center of Udine, Italy, within the 12 months of first consultation. Methods: We collected from our “Data Warehouse” electronic accountability system all new diagnosis of metastatic cancer between 01.01.2017 and 31.12.2018, resulting in a first consultation and leading to a second clinical episode during the following year, in order to assess the oncology workload. The population was divided into patients that received IO (anti-CTLA-4/PD-1/PDL1) versus patients treated with “other treatments”. Mean number per patient and standard deviation were calculated for clinical episodes (first consultations, treatment sessions, unplanned presentations, hospitalizations, re-evaluations, follow-up and inpatient oncology advices). The total number of patients treated and the number of episodes were recorded. Mean numbers of episodes in the IO group and “other treatments” group were compared using Student’s t-test (significance p < 0.005). Follow-up data was collected up to 31.12.2019. Results: A total number of 969 patients were considered (854 “other treatments” group and 115 IO group), resulting in a total of 12407 clinical episodes over the period of 12 months (first consultations excluded). Compared to “other treatments” group, patients in the IO group generated a greater workload in terms of treatment sessions (9.59 vs 6.83 per patient, p < 0.0001), re-evaluations (2.55 vs 1.88, p = 0.0002), and unplanned presentations (2.19 vs 1.51, p = 0.08). On the other hand, follow-up visits workload was greater for “other treatments” group (0.83 vs 0.63, p = 0.0002). No differences were found regarding hospitalizations and inpatient oncology advices. Further analysis will be presented. Conclusions: IO represents a new frontier in oncology landscape, leading to outcome’s improvement and longer lasting treatment periods. The estimate of oncology workload generated by new diagnosis of metastatic cancer requiring IO, is crucial for implementing more sustainable systems and for planning clinical activities.

Prevalence of COVID-19 among patients with chronic inflammatory rheumatic diseases treated with biologic agents or small molecules: A population-based study in the first two months of COVID-19 outbreak in Italy

Objective

The aim of this study is to determine the prevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease 2019 (COVID-19) among adult patients treated with biologic agents or small molecules for chronic inflammatory rheumatic diseases, in particular for chronic inflammatory arthritides.

Methods

To this end, a population-based study, in the province of Udine (466,700 inhabitants, with age > 15 years old, Friuli Venezia Giulia region, Italy) was planned. The primary outcome was the prevalence of COVID-19 in the first two months of the outbreak. All the rheumatic patients treated with biologic agents or small molecules in the last 6 months in our province were included (N = 1051).

Results

From February 29 to April 25, 2020, 4 adult patients (4/1051, i.e. 3.8/1000, 95% Confidence Interval 1.5–9.7/1000) were registered as swab test positive by PCR for COVID-19. Overall, a total of 47/1051 (4.5%) cases were tested for COVID-19 by PCR in the same period, and 15 of them due to symptoms compatible with COVID-19. In the general population, the prevalence was 937 cases/466700 (2/1000, 95% Confidence Interval 1.9–2.1/1000, P-value = 0.33, chi square test), and 20,179/466,700 (4.3%) swab tests for COVID-19 were performed.

Conclusion

The risk of COVID-19 in rheumatic patients under biologic agents or small molecules does not appear different from that observed in the general population. Patients should be informed to safely proceed with their treatment and follow the rules for self-protection to COVID-19.

Effects of the growing prevalence in oncology: A real-world study on the estimated workload

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Background: The increasing prevalence of cancer patients due to new effective treatments is leading to a growing demand in oncology activities, thus requiring a re-modelling towards more sustainable systems. The aim of this study is to estimate the workload generated by each new cancer patient referred to the Oncology Department of the Academic Cancer Center of Udine, Italy, within the two years from first consultation. Methods: We have utilised our electronic “Data Warehouse” accountability system to retrieve anonymous aggregate data of the 2-year oncology workload generated by each new diagnosis, leading to an initial consultation, occurring between 01.01.2012 and 31.12.2017. Initial consultations with no clinical episode in the following 12 months were excluded. Mean value per patient and standard deviations were calculated for the following clinical activities: treatment sessions, unplanned presentations, hospitalisations, re-assessments, follow-up visits and inpatient oncology advices. The total number of patients treated and of episodes were recorded. Follow-up data was collected up to 31.12.2019. Results: During the observation period, 7,454 newly diagnosed patients were referred to our Oncology Unit, resulting in a total of 92,830 clinical activities occurring over an 8-year period. In 1,788 pts (24.0%) only follow-up was needed; 3,152 pts (42.3%) were referred for adjuvant treatment and 2,514 (33.7%) for advanced disease management. Overall, the mean number of clinical activities per patient within the first 2 years was: 6.04 pre-treatment evaluations (52.9%; SD 8.81; 45,003 total episodes), 2.00 follow-up visits (17.5%; SD 1.89; 14,922 total episodes), 0.42 hospitalisations (3.7%; SD 1.21; 3,141 total episodes), 0.36 inpatient oncology advices (3.2%; SD 0.83; 2,705 total episodes), 1.57 re-assessments (13.8%; SD 2.28; 11,723 total episodes) and 1.02 unplanned presentations (8.9%; SD 2.17; 7,601 total episodes). Subgroup analysis in the different tumors and settings are ongoing. Conclusions: The landscape of cancer care is changing due to the growing prevalence of cancer patients that experience longer overall survival. Trying to estimate the amount of clinical activities generated by any new diagnosis is crucial for implementing new models of oncology management and for programming an adequate workforce supply.

The impact of prior chemotherapy (PrC) on immunotherapy outcomes in non-small cell lung cancer (NSCLC) patients: Real data from a mono-institutional study

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Background: Immunotherapy has changed the paradigm on NSCLC treatment. No widespread and reproducible predictive biomarkers have been established. We analyzed how PrC could affect ICI outcomes. Methods: We conducted a retrospective observational study and analyzed all NSCLC patients (pts) treated with ICI (nivolumab or atezolizumab or pembrolizumab) in our institution from 2015 to 2018 and followed until January 2020. All pts had received at least one PrC. We recorded clinical features of pts both before and after ICI treatment. Results: A total of 83 pts were included, with a median age of 69 (range, 47-82). Sixty pts (73%) were male, 74 (89%) were smokers and 81 (97%) had ECOG PS 0-1. Thirteen (15.7%) pts had a immune-related toxicity (iRT, G1-G2 76.9% and G3-G4 23.1%) and 21 (25.3%) continued ICI therapy beyond progression disease (PD). Patients with a PD as best response to PrC had more probability to reach a PD with ICI (p = 0.06). Median Progression-Free Survival (PFS) on ICI was 2.9 months (interquartile range, 1.9-9.4) with no statistical difference between pts with oligo- or diffuse progression (≤ or > 5 metastasis) during PrC (p = 0.42). Corticosteroids use was associated with worse PFS (p < 0.01). Median Overall Survival (OS) was 9.1 months (interquartile range, 3.3-26.5), with a benefit for pts with a stable disease (SD) or partial response (PR) to PrC (p = 0.02), for pts who experimented iRT (p = 0.04) and who didn’t receive corticosteroids (p < 0.01). In multivariate analysis liver or brain metastases (HR 8.8, 95% CI 2.9-26.8 and HR 2.2, 95% CI 0.6-8.1), coticosteroids use (HR 3.7, 95% CI 1.3-10.5) or previous cisplatin-based chemotherapy (HR 8.4, 95% CI 2.3-30.1) were associated with worse OS. Instead, pts whit iRT (HR 0.4, 95% CI 0.1-1.3) and PR as best response to PrC (HR 0.8, 95% CI 0.3-2.0) had a better OS. Conclusions: Our study confirms literature data and suggests that PrC could affect ICI outcomes. Tumor burden seems not to influence ICI outcomes, unlike response rate to PrC. Systemic corticosteroids use and iRT predicts ICI outcomes.

[Emergency department visits for interpersonal violence injuries in Udine (Friuli Venezia Giulia Region, Northern Italy)]

OBJECTIVES

to describe frequency, characteristics, and consequences of intentional injuries due to interpersonal violence visited at the Emergency Rooms of Udine and Cividale del Friuli (Friuli Venezia Giulia Region, North-Eastern Italy).

DESIGN

analysis of the administrative database of the Emergency Department.

SETTING AND PARTICIPANTS

in the two Emergency Departments of Udine and Cividale del Friuli, serving a 250,000-inhabitant area, all the visits due to injuries from interpersonal violence in the years 2015-2017 were analysed.

MAIN OUTCOME MEASURES

number of visits because of injuries from interpersonal violence, distribution of demographic characteristics of patients, of characteristics of the events (place of occurrence, mechanism, relation with patient's occupation, involvement of persons known to the victims), of consequences (discharge diagnosis, Emergency Department management times).

RESULTS

in three years, 1,741 visits of violence victims were recorded in the Emergency Department of the Udine area; 8.7% of patients were assigned a triage yellow tag and 1.0% a red tag. Almost one third of victims were non-Italian citizens; 14.2% of events were work-related; more than one third occurred in the home; in one third of cases, the aggressor was known to the victim; 96 people were diagnosed with fractures. The average time from start of medical care and Emergency Room discharge ranged from half an hour among white triage tags to more than three hours among yellow tags. More than 100 people experiences more than one violent episode.

CONCLUSIONS

this is the first description of frequency, characteristics, and health impact of violence in the area of Udine, providing information useful for a targeted prevention. It also highlights the central role of the Emergency Department not only for the registration of the phenomenon, but also for the management of the acute episodes and for the prevention of recurrent events.

Who is discharged to intermediate care facilities? An Italian study in the population of Udine

The objective of this study was to assess complexity of patients discharged from hospital to intermediate care facility in an Italian setting. Multiple anonymous health-related databases were linked at the individual patient level through a stochastic key to study patients discharged from the University Hospital of Udine, Italy, from 2010 to 2019. Patient complexity was measured through diagnosis related group (DRG) relative weight of each hospitalization, number of chronic conditions and annual use of health resources. 12,674 intermediate care facility admissions were recorded in the study period. Mean DRG weight was 1.54±1.05 with variations depending on the discharging hospital ward. Patients discharged to intermediate facilities had higher DRG weight, had more comorbidities and consumed more health resources than the others, particularly in case of patients discharged from surgical wards. Patients discharged to intermediate care facilities are particularly complex, have high use of health resources, and may be difficult to manage.

Glycaemic control, antidiabetic medications and influenza vaccination coverage among patients with diabetes in Udine, Italy

Objective

The objectives of this study were to estimate influenza vaccination coverage among patients with diabetes mellitus in an Italian 250 000-inhabitant area in the 2017-2018 season and to assess whether glycaemic control and pharmacological treatment were associated with the likelihood of being vaccinated.

Design

In this cross-sectional study, we analysed anonymous health administrative databases, linked with each other at the individual patient level through a stochastic key: diabetes mellitus registry, vaccinations, drug prescriptions and laboratory database.

Setting

The study was conducted in the catchment area of the University Hospital of Udine ('the Udine area'), a 250 000-inhabitant area in the northeast of Italy.

Participants

The study included all subjects included in the regional registry of patients with diabetes mellitus, living in the Udine area as of 1 October 2017.

Main outcome measures

Vaccination coverage in the 2017-2018 influenza season was calculated. The association between patients' characteristics and the likelihood of being vaccinated was assessed through multivariate log binomial regression.

Result

53.0% of 15 900 patients with diabetes living in the area were vaccinated. Coverage increased with age, approaching 75% at ≥85 years. Patients lacking recent glycated haemoglobin testing were less likely to be vaccinated (43.4% vaccination coverage), as were those not treated pharmacologically (44.4% vaccination coverage). Patients treated with both insulin, metformin and other antidiabetic medications were more likely to be vaccinated than those treated with metformin alone (58.1% vaccination coverage; adjusted relative risk=1.07, 95% CI 1.01 to 1.14).

Conclusion

Influenza vaccination coverage was suboptimal in this Italian population of patients with diabetes. Strategies to improve diabetes management could in turn positively affect influenza coverage.

Polypharmacy in the general population of a Northern Italian area: analysis of administrative data

INTRODUCTION

The aim of this study was to estimate the prevalence and assess patient-related determinants of polypharmacy in the general population of the Italian area around Udine.

MATERIALS AND METHODS

A retrospective cohort study was conducted using administrative databases: drug prescriptions, hospital discharges, ambulatory care prescriptions, exemptions from medical charges. Various definitions of polypharmacy were adopted (co-prescription of multiple medications, use of multiple medications for overlapping time periods). The role of patient's characteristics on polypharmacy was assessed through regression analyses.

RESULTS

In 2017, 63.7% of the general population received at least one drug prescription. 25 218 persons were co-prescribed ≥ 5 medications at least once. The prevalence of co-prescriptions among persons ≥ 65 years was 31.7%. 20 793 persons used ≥ 60 DDDs of ≥ 5 medications. The prevalence of all these phenomena was much higher in the elderly than in children and adults. The number of comorbidities significantly affected all types of polypharmacy.

CONCLUSIONS

In this area, the prevalence of polypharmacy is high, particularly among the elderly. Age and comorbidities significantly affect the risk. Further research will aim at evaluating the health effects and appropriateness of polyphamacy.

Reasons for non-participation in public oncological screening programs in the Italian region Friuli Venezia Giulia

OBJECTIVES

In the Italian region Friuli Venezia Giulia, public screening is offered for cervical cancer, breast cancer, and colorectal cancer. Participation of the target population is lower than 70%. Our aim was to investigate reasons for non-participation.

STUDY DESIGN

This is a qualitative survey.

METHODS

A telephone survey was conducted in 2018 on a random sample of persons not adhering in 2017. Only one question about the reason for non-participation was asked. The answers were transcribed verbatim with no personal identifiers and no additional information. The transcribed anonymous answers were then read and classified into mutually exclusive macrocategories and subcategories.

RESULTS

A total of 4456 non-adhering persons were surveyed. Personal practical issues were the most common type of barrier reported in all three screening programs, followed by personal beliefs. Program-related issues were more common in cervical cancer screening than in the others. Almost half of the women not participating in the public breast cancer screening and 40% of those not adhering to the public cervical cancer screening had mammography or Pap test out of the public program.

CONCLUSIONS

In this region, practitioners should work to overcome practical barriers and discuss personal beliefs. Surveys of non-participants in other geographic areas would be important to adequately inform local policymaking.

Peer education for medical students on health promotion and clinical risk management

CONTEXT

Health promotion (HP) and clinical risk management (CRM) topics are seldom discussed during medical school lessons. Peer-assisted learning (PAL) has long occurred informally in medical education, and interest in this method has recently grown, as it is considered a valuable technique for both tutors and tutees.

AIMS

The aim was to evaluate the impact of HP and CRM PAL intervention on medical students' (tutees) knowledge level.

SETTINGS AND DESIGN

A PAL intervention has been implemented at Udine University medical school during 2017. It was composed of lectures and practical activities conducted by ten near-peer tutors.

METHODS

The effectiveness has been evaluated by giving tutees: (1) a knowledge multiple-choice questionnaire, before and after the intervention; (2) a satisfaction questionnaire; and evaluating (3) tutees' group assignments.

STATISTICAL ANALYSIS USED

We performed descriptive analysis; then McNemar, Wilcoxon signed rank, Wilcoxon Mann-Whitney, and t-tests were applied.

RESULTS

The number of students addressed by PAL intervention was 62. Difference in total correct answers among pre- and post-intervention questionnaires showed a statistically significant improvement (P < 0.0001), both when analyzing it globally and by area (HP/CRM). Students' satisfaction for CRM was greater than for HP area (P = 0.0041).

CONCLUSIONS

This educational intervention based on PAL showed its effectiveness producing a statistically significant improvement in students' knowledge. Our findings confirm that PAL could be a feasible method for HP and CRM topics.

Data linkage analysis of giant cell arteritis in Italy: Healthcare burden and cost of illness in the Italian region of Friuli Venezia Giulia (2001-2017)

Giant cell arteritis (GCA) is the most common vasculitis in adults. However, comprehensive analyses of the healthcare burden are still scarce. The aim of the study is to report the healthcare burden and cost of illness of GCA in the Friuli Venezia Giulia (FVG) region of Italy, based on a data linkage analysis. To this end, a retrospective study was conducted through the integration of many administrative health databases of the FVG region as the source of information. Cases were identified from two verified, partially overlapping sources (the rare disease registry and medical exemption database). From 2001 to 2017, 208 patients with GCA were registered. The prevalence of GCA in the population aged ⩾ 45 years as of December 31, 2017 was 27.2/100,000 inhabitants (95% CI 23.5-31.4). The mean time of observation was 4.5 ± 3.6 years. A total of 3182 visits (338 per 100 patient-years) was recorded. The most frequent specialty visits were rheumatology (n = 610, 19.2%), followed by internal medicine (n = 564, 17.7%). A total of 287 hospitalizations (30 per 100 patient-years) were reported. A total of 13,043 prescriptions (1386 per 100 patient-years) were registered. More than half of the patients were prescribed an immunosuppressive agent. The overall estimated direct healthcare cost was €2,234,070, corresponding to €2374 per patient-year. Overall, GCA is a rare disease which implies a high healthcare cost.

Association of nationality and education with oral health: a screening programme in Northern Italy

Background

Socioeconomic status (SES) has been proposed as an important determinant of oral health outcomes. The aim of this project is to assess the association between nationality, parents’ educational level and oral health in a sample of children in Udine, Italy.

Methods

Between February and May 2018, in the context of a screening programme carried out to evaluate the oral health status in 6-year-old children, parents filled out a questionnaire investigating behavioural, socioeconomic and demographical factors. For each child the number of decayed, missing and filled deciduous teeth (dmft) and caries prevalence (CP) were assessed.

Results

The screening was conducted on 976 children, 705 (72%) Italian (I) and 271 (28%) foreign residents (F). Not-Italian nationality significantly increased the CP (F: 59.32%; I: 32.74%; RR: 1.81 [95% CI: 1.57-2.10]; Risk Difference: 26.59 [95% CI: 19.98-33.19]) and dmft median value (F: 2±5; I:0±1; p &lt; 0.0001). Stratified by level of education, the differences between I and F were significant when both parents had low educational level (CP: RR = 1.62 [95%; CI: 1.00-2.62]; dmft: F = 5±5; I = 0±3; p &lt; 0.05) and when both parents had high school education (CP: RR = 1.45 [95%; CI: 1.14-1.84]; dmft: F = 2±6; I = 0±2; p &lt; 0.001). Otherwise, when both parents had university degree, nationality did not increase significantly the outcome (CP: RR = 1.17 [95%; CI: 0.91-1.50; p &gt; 0.1]; dmft: F = 0±2; I = 0±0; p &gt; 0.1).

Conclusions

The analyses suggest that being a foreign resident is a risk factor for lower child oral health. Moreover, parents’ educational level seems to be an effect modifier: when parents had a university degree there was no significant difference between Italians and foreign residents, otherwise the lower the level of education, the greater the difference between the categories. These data may help to identify particularly vulnerable groups and to develop preventive strategies.

Key messages

These findings confirmed the presence of a vulnerable population (foreign residents) in which socioeconomic factors had stronger associations to oral health than Italian citizens. Further research may be useful to identify both protective and risk factors associated with different nationality, in order to evaluate specific interventions in low-SES groups.

Effect of rotavirus vaccination offer to children observed in Italy between 2010-2018

Background

Rotavirus (RV) is the most common cause of gastroenteritis (GE) among children under 5 years. Since 2012 Friuli Venezia Giulia (FVG) Region (Italy) has offered free RV vaccination to low birthweight preterm and other at-risk babies. Starting from 2018, the offer has been extended to all newborns. Aim of the study is to investigate the effectiveness of RV vaccination offer on coverage and GE-related hospital admissions among FVG children under 1 year between 2010-2018.

Methods

With a retrospective analysis we identified FVG Region children &lt;1y with at least one dose of RV vaccine and children &lt;1y admitted to hospital with a diagnosis of Non-Specific GE (NSGE; ICD9-CM codes 001-009) and RVGE (008.61) from 2010 to 2018. Vaccination coverage and hospitalization risk in each annual child cohort were calculated. Hospitalization and vaccination data were also linked using a univocal anonymous stochastic key.

Results

Of 77,330 children (51% males) born in FVG during 2010-2018, 8209 (11%) were vaccinated for RV. Coverage progressively increased from 0.2% in 2010 (22/9736) to 23% in 2017 (1782/7747) and then almost tripled in 2018 reaching 67% (5006/7425). During the 9 years observed, 414 children were hospitalized for NSGE (0.5%) and 172 for RVGE (0.2%). NSGE hospitalizations started from 48 (0.5%) in 2010 and reached 58 (0.8%) in 2018. Admissions for RVGE were 27 (0.3%) in 2010 and decreased to 15 (0.2%) in 2018. Annual hospitalization rate fluctuated with no clear pattern. In the observation period, 11 RV vaccinated children were admitted to hospital for NSGE (2.6% of total NSGE admissions), 1 of them specifically with RVGE.

Conclusions

The offer of RV vaccination to newborns results to be effective to gain vaccine coverage among children under 5 years. The impact of this offer on GE-related hospital admission and RVGE in particular cannot be properly evaluated yet, as not enough time has passed since the implementation of free offer to all newborns.

Key messages

Defining and implementing an appropriate vaccination offer is essential to ensure adequate levels of coverage against Rotavirus among children under 5 years. The evaluation of the effect of Rotavirus vaccination on hospital admissions for NSGE and RVGE needs a careful and continuous assessment in next years.

Epidemiology of paraneoplastic neurological syndromes: a population-based study

BACKGROUND

The epidemiology of paraneoplastic neurological syndromes (PNS) remains to be defined. We present here the first population-based incidence study and report the clinical spectrum and antibody profile of PNS in a large area in Northeastern Italy.

METHODS

We performed a 9-year (2009-2017) population-based epidemiological study of PNS in the provinces of Udine, Pordenone and Gorizia, in the Friuli-Venezia Giulia region (983,190 people as of January 1, 2017). PNS diagnosis and subgroups were defined by the 2004 diagnostic criteria. Age- and sex-adjusted incidence rates were calculated.

RESULTS

We identified 89 patients with a diagnosis of definite PNS. Median age was 68 years (range 26-90), 52% were female. The incidence of PNS was 0.89/100,000 person-years. PNS incidence rates increased over time from 0.62/100,000 person-years (2009-2011), 0.81/100,000 person-years (2012-2014) to 1.22/100,000 person-years (2015-2017). The prevalence of PNS was 4.37 per 100,000. Most common PNS were limbic encephalitis (31%), cerebellar degeneration (28%) and encephalomyelitis (20%). Among antibody (Ab)-positive cases, most frequent specificities included: Yo (30%), Hu (26%), and Ma2 (22%), while the most frequent associated tumors were lung (17%) and breast cancer (16%), followed by lymphoma (12%). PNS developed in 1 in every 334 cancers in our region. Statistically significant associations were observed between cancer type and Ab-specificity (P < 0.001), and between neurological syndrome and Ab-specificity (P < 0.001).

CONCLUSIONS

This first population-based study found an incidence of PNS that approximates 1/100,000 person-years and a prevalence of 4/100,000. Moreover, the incidence of PNS is increasing over time, probably due to increased awareness and improved detection techniques.

Value of the Rare Disease Registry of the Italian Region Friuli Venezia Giulia

BACKGROUND

The lack of epidemiological and clinical data is a major obstacle in health service planning for rare diseases. Patient registries are examples of real-world data that may fill the information gap.

OBJECTIVE

We describe the Rare Disease Registry of the Friuli Venezia Giulia region of Italy and its potential for research and health planning.

METHODS

The Rare Disease Registry data were linked with information on mortality, hospital discharges, ambulatory care, and drug prescriptions contained in administrative databases. All information is anonymous, and data linkage was based on a stochastic key univocal for each patient. Average annual costs owing to hospitalizations, outpatient care, and medications were estimated.

RESULTS

Implementation of the Registry started in 2010, and 4250 participants were registered up to 2017. A total of 2696 patients were living in the region as of January 1, 2017. The overall raw prevalence of rare diseases was 22 per 10,000 inhabitants, with higher prevalence in the pediatric population. The most common disease groups were congenital malformations, chromosomal and genetic syndromes, and circulatory and nervous diseases. In 2017, 30 patients died, 648 were hospitalized, and 2355 received some type of ambulatory care. The total annual estimated cost was approximately €6.5 million, with great variability in the average patient cost across diseases.

CONCLUSIONS

The possibility of following the detailed real-world care experience of patients with each specific rare disease and assessing the costs related to each step in their care path represents a unique opportunity to identify inefficiencies, optimize care, and reduce waste of resources.

Hospital discharge diagnoses in patients with positive blood cultures in an Italian academic hospital

OBJECTIVE

To assess the sensitivity of hospital discharge diagnoses for identifying sepsis in patients with blood culture confirmation.

METHODS

A cross-sectional study was conducted at the Italian 1000-bed University Hospital of Udine. The administrative databases of the Hospital were used as the source of information. Laboratory data were linked with hospital discharge data. We estimated the proportion of hospitalizations with at least 2 positive blood culture tests in which at least one discharge diagnosis indicated bloodstream infection.

RESULTS

From 2011 to 2017, 3571 hospitalizations (1.2%) had positive blood culture tests. Of them, only 49.5% had at least one ICD-9-CM discharge diagnosis code of sepsis, with lower proportions in surgical than in medical wards.

CONCLUSIONS

The sensitivity of ICD-9-CM discharge codes for sepsis is low as compared with the blood culture gold standard. Using discharge codes for epidemiological estimates of sepsis, health planning and risk management may yield biased results. Audits and ICD coding training are needed.

Why we should take care of the competing risk bias in survival analysis: A phase II trial on the toxicity profile of radiotherapy for prostate cancer

Aim

The aim of the present study is to evaluate and quantify the bias of competing risks in an Italian oncologic cohort comparing results from different statistical analysis methods.

Background

Competing risks are very common in randomized clinical trials and observational studies, in particular oncology and radiotherapy ones, and their inappropriate management causes results distortions widely present in clinical scientific articles.

Materials and methods

This is a single-institution phase II trial including 41 patients affected by prostate cancer and undergoing radiotherapy (IMRT-SIB) at the University Hospital of Udine.Different outcomes were considered: late toxicities, relapse, death.Death in the absence of relapse or late toxicity was considered as a competing event.

Results

The Kaplan Meier method, compared to cumulative incidence function method, overestimated the probability of the event of interest (toxicity and biochemical relapse) and of the competing event (death without toxicity/relapse) by 9.36%. The log-rank test, compared to Gray's test, overestimated the probability of the event of interest by 5.26%.The Hazard Ratio's and cause specific hazard's Cox regression are not directly comparable to subdistribution hazard's Fine and Gray's modified Cox regression; nonetheless, the FG model, the best choice for prognostic studies with competing risks, found significant associations not emerging with Cox regression.

Conclusions

This study confirms that using inappropriate statistical methods produces a 10% overestimation in results, as described in the literature, and highlights the importance of taking into account the competing risks bias.

[Pharmaceutical prescription of proton pump inhibitors and ranitidine in the general population living in the area of the Healthcare Authority and University of Udine (Friuli Venezia Giulia, Northeastern Italy)]

OBJECTIVES

to describe the use of proton pump inhibitors (PPI) and ranitidine in the general population living in the area of the Healthcare Authority and University of Udine (Friuli Venezia Giulia, Northeastern Italy) and to evaluate whether there are any cases of co-prescription of medications in those classes.

DESIGN

analysis of health-related administrative databases (list of potential healthcare beneficiaries, prescriptions of medications, exemption from medical charges because of chronic conditions, list of general practitioners).

SETTING AND PARTICIPANTS

population of the Italian area of the Healthcare Authority and University of Udine (approximately 250,000 inhabitants) ≥1 year of age as of January 1st, 2016.

MAIN OUTCOME MEASURES

prevalence of PPI or H2RA use (>1 prescription in 2016), overall and stratified by drug, age class and sex; duration of the theoretical period covered by prescriptions; prevalence of co-prescriptions; association of co-prescriptions and clinical and demographic characteristics of patients (odds ratio and 95% confidence intervals).

RESULTS

in 2016, 162 persons per 1,000 used those medications; in particular, 158/1,000 used PPIs. Prevalence of use increased with age, as did the median treatment duration with PPIs. Co-prescription of two medications of the same class were observed in 0.43% of antacid users. The likelihood of receiving co-prescriptions was higher among non-elderly subjects, long-term PPI users, and those with chronical diseases, such asthma.

CONCLUSION

in the considered Italian area, PPIs and ranitidine were frequently used, although less than in the rest of Italy. We observed occasionally non-recommended practices, such as the co-prescription of different medications of the same class or with the same indications.

Hyperechoic bands detected by salivary gland ultrasonography are related to salivary impairment in established Sjögren's syndrome

OBJECTIVES

In primary Sjögren's syndrome (pSS) dryness of eye and mouth is the cardinal referred symptom. Assessing the rate of activity and damage in the salivary glands of pSS patients is essential to improve disease management. Up to now, a differentiation of activity and damage ultrasonographic (US) lesions is an open issue. The aim of this preliminary study was to identify US lesions which better correlate with loss of function of salivary glands in pSS.

METHODS

Salivary glands ultrasonography of consecutive patients with established pSS, fulfilling AECG and ACR/EULAR criteria was performed. The association between sialometry and Visual Analogue Scale (VAS) oral dryness and SGUS lesions was assessed trough univariate and multivariate analysis.

RESULTS

In 75 established pSS patients, mean disease duration 12.4±7.2 years, the hyperechoic bands of parotid gland (PG) and submandibular gland (SMG) were significantly associated with sialometry (p<0.001) and VAS oral dryness (PG p=0.002, SMG p<0.001). The global glandular involvement (scored according to De Vita et al., 1992) was associated with sialometry (PG p=0.025, SMG p<0.001) and with VAS oral sicca (PG p=0.015, SMG p<0.001). The multivariate analysis selected the hyperechoic bands of PG and SMG as the variables independently associated with sialometry and the hyperechoic bands and the homogeneity in the SMG as associated with VAS oral dryness.

CONCLUSIONS

These results indicate that salivary impairment in pSS, as objectively evaluated by sialometry, could be mainly associated with damage (i.e., hyperechoic bands) in established pSS. Additional follow-up studies and improved scoring tools are needed.

Management of reduced vaccine coverage due to 6 years of failure to vaccinate: The Codroipo case, Italy

During 2017 an alert was raised in relation to a possible vaccination failure occurred in Friuli Venezia Giulia Region (Italy) between 2009 and 2015, exposing multiple cohorts of children and the entire community to vaccine preventable diseases outbreak risk. The Codroipo case resulted in 20,441 vaccine doses being in doubt, thus prompting the healthcare system to react in order to revaccinate 5444 children through planning and implementing network actions and multiple channels of communication.