Global survival trends for brain tumors, by histology: analysis of individual records for 556,237 adults diagnosed in 59 countries during 2000-2014 (CONCORD-3)

BACKGROUND

Survival is a key metric of the effectiveness of a health system in managing cancer. We set out to provide a comprehensive examination of worldwide variation and trends in survival from brain tumors in adults, by histology.

METHODS

We analyzed individual data for adults (15-99 years) diagnosed with a brain tumor (ICD-O-3 topography code C71) during 2000-2014, regardless of tumor behavior. Data underwent a 3-phase quality control as part of CONCORD-3. We estimated net survival for 11 histology groups, using the unbiased nonparametric Pohar Perme estimator.

RESULTS

The study included 556,237 adults. In 2010-2014, the global range in age-standardized 5-year net survival for the most common sub-types was broad: in the range 20%-38% for diffuse and anaplastic astrocytoma, from 4% to 17% for glioblastoma, and between 32% and 69% for oligodendroglioma. For patients with glioblastoma, the largest gains in survival occurred between 2000-2004 and 2005-2009. These improvements were more noticeable among adults diagnosed aged 40-70 years than among younger adults.

CONCLUSIONS

To the best of our knowledge, this study provides the largest account to date of global trends in population-based survival for brain tumors by histology in adults. We have highlighted remarkable gains in 5-year survival from glioblastoma since 2005, providing large-scale empirical evidence on the uptake of chemoradiation at population level. Worldwide, survival improvements have been extensive, but some countries still lag behind. Our findings may help clinicians involved in national and international tumor pathway boards to promote initiatives aimed at more extensive implementation of clinical guidelines.

Rehabilitation pathway for Covid and post-Covid patients

 

A hospital rehabilitation service has been implemented in the Hospital of Cittadella, ULSS 6 Euganea - Health Trust (District of Padua) to offer hospitalized Covid and post-Covid patients a tailored rehabilitation pathway in the treatment of the different phases of the disease. The SARS-CoV-2 pandemic has determined the admission of a large number of acute patients in Intensive Care Units (ICU), Semi-Intensive Care Units (S-ICU) and non-critic hospital wards. Patients recovering from COVID-19 experience a wide range of impairments requiring the implementation of multidisciplinary rehabilitation care protocols; these include the assessment for anticipated impairments (especially for patients admitted to ICU, older patients, and patients showing indications of impairment); patients who had severe-critical disease usually require a period of inpatient rehabilitation. Between October 2020 and April 2021 at Cittadella Hospital 450 patients (ICU, S-ICU, non-critic hospital wards) were enrolled in the Rehabilitation pathway and followed daily by a team made by physiatrists, physiotherapists and speech therapists. Referral options (hospitalization, community based rehab or discharge with follow up), based on the conditions of the patients, were assessed. The reduction of surgery and orthopedics patients to rehabilitate and the decrease of outpatient rehab services during Covid emergency made it possible to convert Rehabilitation ward (20 beds) to Covid Rehabilitation; according to epidemiological scenarios, patients admitted to Rehabilitation ward were initially SARS-CoV-2 positive with mild, moderate and severe symptoms, then post-Covid SARS-CoV-2 negative discharged from Covid wards. The definition of a tailored rehabilitation pathway in the treatment of the different phases of Covid disease has represented an important professional and organizational challenge for the Hospital. Rehabilitation plays a pivotal role in the management of Covid and post-Covid patients.

Key messages

Patients recovering from COVID-19 experience a wide range of impairments requiring the implementation of multidisciplinary rehabilitation care protocols. The definition of a tailored rehabilitation pathway in the treatment of the different phases of Covid disease has represented an important professional and organizational challenge for the Hospital.

Correcting the Completeness BIAS of Observed Prevalence

Aims and Background

The cancer prevalence in given areas can be estimated on the basis of data supplied by cancer registries. As the obtained estimate of prevalence depends on the length of the cancer registry's observation period, it is generally lower than the total prevalence in the considered area. In the present work we propose a method to calculate a correction factor of this bias in order to obtain an approximation to the total prevalence.

Methods & Study Design

The method is based on the relationship between relative survival and incidence by age for a specific cancer site.

Results and Conclusions

We provide values of the correction factor, the completeness index R, relative to the most important cancer sites, for specific ages and periods of observation of the cancer registries in Italy. In addition, we provide indications for extended use of the index when substantial variations from the basic pattern of relative survival are observed in practical situations. Furthermore, we give helpful suggestions to obtain approximate values of the correction factor to be used for ages and periods of observation that are intermediate between the ones presented in this paper.

Cancer Prevalence in Italian Regions with Local Cancer Registries

Objective

To provide estimates and projections of cancer incidence and prevalence for those Italian regions whose population is partially covered by a cancer registry (CR) and to determine to what extent local CRs can be considered representative of the region, thus improving the potential of the information provided by CRs.

Methods

A statistical method, MIAMOD (mortality-incidence analysis model), was used to estimate regional cancer incidence and prevalence from regional cancer mortality data and patient survival data recorded by the cancer registries. Estimates of the cancer incidence and prevalence in the various regions have thus been obtained for a number of major cancer sites. A first and important step in validating the regional estimates has been the comparison of the MIAMOD estimates in the areas covered by the cancer registries with empirical incidence and prevalence observed by CRs, in order to assess the consistency in data, methods and assumptions. Empirical prevalence has been calculated by counting patients with a diagnosis of cancer who were alive on the reference date by PREVAL method. A correction factor has been applied to include patients diagnosed before the period of activity of the registry.

Results

General consistency was found between empirical and estimated (by MIAMOD) incidence and prevalence in the registry areas, which is indicative of the quality and the completeness of all data involved as well as the appropriateness of model choices. The prevalence of all cancers combined for Italian regions with CRs was estimated and projected to the year 2000 as ranging between 1,240 per 100,000 in Sicilia and 2,781 in Emilia-Romagna for men, while for women these figures were 1,765 in Sicilia and 4,019 in Liguria. Comparison of cancer prevalence in CR areas with regional estimates shows quite good consistency for Piemonte, Liguria and Lombardia, which means that the local CRs (of Torino, Genova and Varese, respectively) are representative of their respective regions. Prevalence in Emilia-Romagna appears to be rather well represented by only one, the Parma CR, of the three local CRs. The southern Italian registries of Latina and Ragusa recorded a lower cancer prevalence than was actually estimated in their respective regions.

Discussion

Cancer registries with a longer period of activity showed better agreement between empirical and estimated figures due to the more precise information provided, particularly regarding survival and incidence trends. In conclusion, this work shows the potential of the cancer registries not only to represent their population with respect to cancer morbidity but also as an invaluable tool to extrapolate this information to the larger areas they represent.

Trichobezoars in children: therapeutic complications

Trichobezoars are concretions formed by the accumulation of hair or fibers in the gastrointestinal tract, usually associated with underlying psychiatric disorders in females between 13 and 20 years old. Endoscopy, the gold standard for diagnosis, brings some additional advantages: sample taking, size reducing and, rarely, mass removal. This study shows that endoscopy can cause severe complications resulting in a surgical emergency.

Laparoscopic versus open appendectomy in the management of acute appendicitis in children: a multicenter retrospective study

AIM

Acute appendicitis is one of the most common indications for emergency surgery in children. Open appendectomy (OA) has been the gold standard treatment for over 100 years. In the last three decades, the introduction of minimally invasive techniques, such as laparoscopic appendectomy (LA) and transumbilical laparoscopically assisted appendectomy (TULAA), has changed the approach to the disease. However, there is still no agreement with benefits of these new therapeutic options, especially in children. The aim of this retrospective study is comparing the outcomes of OA, LA and TULAA in the paediatric patient.

METHODS

Children suffering from acute appendicitis were treated with LA or TULAA in the Department of Paediatric Surgery and with OA in the Department of General Surgery. Data were abstracted from database of both centers' archives. Operator, operating time, length of hospitalization (LOH), intra- and postoperative complications and histological finding were analyzed.

RESULTS

We recruited 196 patients: 46 treated with LA, 62 with TULAA and 88 with OA. Operative time was significantly shorter in OA. The three techniques had the same incidence of intraoperative and postoperative complications. The incidence of wound infection was higher with the TULAA approach. LOH was significantly shorter in the TULAA group. There was no correlation between LOH and histological finding.

CONCLUSION

We demonstrated that LA, TULAA and OA are similar in most respects and are equally safe modalities in paediatric patients. Further randomized controlled studies are necessary.

Cancer prevalence in United States, Nordic Countries, Italy, Australia, and France: an analysis of geographic variability

BACKGROUND

The objectives of this study were to quantitatively assess the geographic heterogeneity of cancer prevalence in selected Western Countries and to explore the associations between its determinants.

METHODS

For 20 cancer sites, 5-year cancer prevalence, incidence, and survival were observed and age standardised for the mid 2000s in the United States, Nordic European Countries, Italy, Australia, and France.

RESULTS

In Italy, 5-year crude prevalence for all cancers was 1.9% in men and 1.7% in women, while it was ∼1.5% in all other countries and sexes. After adjustment for the different age distribution of the populations, cancer prevalence in the United States was higher (20% in men and 10% in women) than elsewhere. For all cancers combined, the geographic heterogeneities were limited, though relevant for specific cancers (e.g., prostate, showing >30% higher prevalence in the United States, or lung, showing >50% higher prevalence in USA women than in other countries). For all countries, the correlations between differences of prevalence and differences of incidence were >0.9, while prevalence and survival were less consistently correlated.

CONCLUSION

Geographic differences and magnitude of crude cancer prevalence were more strongly associated with incidence rates, influenced by population ageing, than with survival rates. These estimates will be helpful in allocating appropriate resources.

Comparison of stomach cancer incidence and survival in four continents

The aim of this study was to compare stomach cancer incidence and survival rates between four very distinct areas: Campinas (Brasil), Latin America, Iowa (USA), Northern America, Varese (Italy), Europe and Osaka (Japan) in Asia, and determine which of the differences are due to variations in the case mix and which are due to the care received. A proportional hazards regression method was applied to the relative survival rates to obtain geographical differences that were adjusted for age, gender, period of diagnosis, sub-site and stage. Age, gender, period and stage explained most of the variability between the areas (50-100% excess risk of death with respect to Osaka) in the survival rates for stomach cancer patients. In Iowa and Varese, information on the sub-site fully explained the remaining variability. The large survival differences between the four areas were almost totally due to the different case mixes of the stomach cancer patients. The importance of stage indicates that diagnostic delay may be a major clinical factor affecting survival.

Incidence and prevalence of all cancerous diseases in Italy

The burden of cancer in ageing populations is causing great concern, particularly in Italy with Europe's fastest growing elderly population. Studying all cancers combined in one group, although of limited medical value, is of great interest from the viewpoints of public health, epidemiology and the economy. Using mortality data and an estimate of cancer patients' survival we have estimated and projected incidence and prevalence in Italy of all cancers combined in one group. Five major phenomena are highlighted in the paper: (1) the decrease in the age-adjusted cancer mortality rates among females and the stable mortality rates among males since 1990; (2) the changing pattern of cancer incidence since 1990, it has started to decrease for females and is stabilising for males; (3) the decrease in cancer incidence among males and females born after 1940; (4) the increase in the proportion of cancer patients that are cured with calendar years of diagnosis; (5) the increase in the total and the healthy life expectancy (i.e. cancer-free) among the Italian population since 1970. The declining and flat trends in age-adjusted cancer incidence and mortality rates since 1990 is the combined effect of survival improvements and cancer risk reduction for younger cohort groups, after 1940. These favourable trends contribute to the increase in healthy life expectation, thus supporting the idea that we live longer and healthier.

Utilization of percutaneous transluminal coronary angioplasty for quality assurance in health care from 1983 to 1996

OBJECTIVES

To examine the distribution of interventional cardiac catheterization laboratories, their case load, the time trends, and the regional variation of percutaneous transluminal cutaneous angioplasty (PTCA) utilization in Italy.

METHODS

Analysis of data was provided by the annual reports of the Italian Group of Studies and Interventional Cardiology over the period from 1983 to 1996.

RESULTS

The number of PTCA facilities and their use steadily increased, mainly in the North. In 1996 the utilization rate was 34 per 100,000 population, but only 60% of labs performed 200 or more procedures.

CONCLUSIONS

Dramatic time trends and regional variations often took place without an epidemiology and technology assessment-based planning process.

Cancer prevalence estimates based on tumour registry data in the Surveillance, Epidemiology, and End Results (SEER) Program

BACKGROUND

The Connecticut Tumor Registry (CTR) has collected cancer data for a sufficiently long period of time to capture essentially all prevalent cases of cancer, and to provide unbiased estimates of cancer prevalence. However, prevalence proportions estimated from Connecticut data may not be representative of the total US, particularly for racial/ethnic subgroups. The purpose of this study is to apply the modelling approach developed by Capocaccia and De Angelis to cancer data from the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute to obtain more representative US site-specific cancer prevalence proportion estimates for white and black patients.

METHODS

Incidence and relative survival were modelled and used to obtain estimated completeness indices of SEER prevalence proportions for all cancer sites combined, stomach, cervix uteri, skin melanomas, non-Hodgkin's lymphomas, lung and bronchus, colon/rectum, female breast, and prostate. For validation purposes, modelled completeness indices were computed for Connecticut and compared with empirical completeness indices (the ratio of Connecticut based prevalence proportion estimates using 1973-1993 data to 1940-1993 data). The SEER-based modelled completeness indices were used to adjust SEER prevalence proportion estimates for white and black patients.

RESULTS

Model validation showed that the adjusted SEER cancer prevalence proportions provided reasonably unbiased prevalence proportion estimates in general, although more complex modelling of the completeness indices is necessary for female cancers of the colon, melanoma, breast, cervix, and all cancers combined. The SEER-based cancer prevalence proportions are incomplete for most cancer sites, more so for women, whites, and at older ages. For all cancers combined, prevalence proportions tended to be higher for whites than blacks. For the site-specific cancers this was true for stomach, prostate, cervix uteri, and lung and bronchus (men only). For colon/rectal cancers the prevalence proportions were higher for blacks through ages 59 (men) and 64 (women), and then for the remaining ages they were higher for whites. Prevalence proportions were lowest for stomach cancer and highest for prostate and female breast cancers. Men experienced higher prevalence proportions than women for skin melanomas, non-Hodgkin's lymphomas, lung and bronchus, and colon/rectal cancers.

CONCLUSION

The modelling approach applied to SEER data generally provided reasonable estimates of cancer prevalence. These estimates are useful because they are more representative of cancer prevalence than previously obtained and reported in the US.

Will elderly patients stand aside for younger patients in the queue for cardiac services?

BACKGROUND

Fair management of queues for hospital-based services requires consideration of clinical need, but there is no information on public attitudes towards non-clinical factors such as age or work status as determinants of priority.

METHODS

We asked elderly residents of Padova, Italy, whether, if they were awaiting cardiac surgery or an outpatient cardiology consultant, they would give up their place in line for a younger or self-employed individual. We also elicited responses from a convenience sample of younger health workers asked to imagine themselves as elderly persons facing the same choices.

FINDINGS

The eligible response rate was 72% (443/616). About half deemed it right to give up their place in line for cardiac surgery to a 45-year-old (51%, 95% CI 46-56) or self-employed person (47%, 95% CI 42-51) Proportions were significantly higher for an outpatient consultation (68%, 95% CI 63-72). In multivariate analyses, married respondents, those closer to age 65, university graduates, and those who were formerly self-employed were significantly less likely to respond affirmatively. In significant contrast for all four scenarios (p<0.0001), the overwhelming majority of non-elderly respondents refused to give up their places in line.

INTERPRETATION

The majority of elderly citizens were hypothetically willing to cede priority in accessing cardiac care to younger or self-employed persons, but this willingness was attenuated among the "young" elderly and more privileged respondents. Non-elderly respondents were much less self-sacrificing, suggesting that ageing baby-boomers may be more assertive about their continuing rights to health care.

The prognostic role of gender in survival of adult cancer patients. EUROCARE Working Group

Many observations indicate that women have a much longer expectancy of life than men. Some population-based studies on cancer patients support the idea of the role of gender in predicting survival. However, the data are somewhat contrasting and inconclusive. The purpose of this paper was to evaluate the prognostic role of gender for cancer patients, making use of the large set of survival data made available by the EUROCARE II project for the period 1985-1989. By applying a multivariate approach the major confounders such as age, geographical area and cancer site were considered in analysing survival data on more than 1 million cancer cases collected by 45 population-based cancer registries in 17 European countries. The results were consistent with the general observation that in the industrialised countries women tend to survive longer than men. The multivariate analysis showed better survival from cancer in women than in men, estimated as an overall 2% lower relative risk of dying. The female advantage was particularly evident in young cases, reduced in patients in middle age groups and in the oldest patients completely reversed so that at this age men had the better prognosis. Longer survival for women was not present immediately after diagnosis, but the major advantage was seen after 3 years of follow-up. The risk of death for women was significantly lower for cancer of the head and neck, oesophagus, stomach, liver and pancreas. For bladder cancer, the risk of death was significantly greater for women. These results can be explained by gender differences in sub-site distributions (head and neck and stomach) and by the differences in the stage at diagnosis (presumably bladder). However, the consistency of the data, evident only when a vast set of data is analysed, suggest that women may be intrinsically more robust than men in coping with cancer.

[Coronary angiography in two defined populations: Padua and Citadella]

BACKGROUND

Coronary angiography is an invasive procedure that is relatively expensive and that requires an appropriate indication.

METHODS

Utilization rate and the appropriateness of the use of the coronary angiography have been compared in two defined populations, namely residents from the city of Padua (group A), and subjects from the local health unit of Cittadella (group B), who underwent coronary angiography between June 1, 1992 and May 31, 1993. Appropriateness was evaluated both by comparison with the AHA/ACC guidelines and by observation of the outcome following diagnosis one year after the coronary angiogram was performed.

RESULTS

One hundred and seventy-one patients in group A and 100 patients in group B underwent coronary angiography: both groups had similar age and sex distribution. Utilization rate was 8 per 10,000 inhabitants in group A, and 10 per 10,000 inhabitants in group B. Appropriate coronary angiography, evaluated by comparison with the AHA/ACC guidelines, was 69.9% in group A and 68% in group B. Coronary angiogram showed at least one stenosis > or = 50% in 133 patients from group A and in 66 patients from group B. These patients were followed up for at least 12 months. Of 13 deaths, 12 occurred as fatal cardiac events, while of the 147 surviving patients who had complete follow-up data, 114 (77%) improved. The outcome was measured through symptoms and stress test. In addition, subjective improvement was measured in group A using the "Nottingham Health Profile".

CONCLUSIONS

Criteria of appropriateness for an invasive diagnostic procedure such as coronary angiography, which is a determinant "entry point" for revascularization procedures, is based on common clinical knowledge that may be evolving with time. Based on these data, it seems that the current guidelines could be modified, especially for indications within the setting of myocardial infarction.

Comparisons of colon-cancer survival among European countries: The Eurocare Study

Under the aegis of EUROCARE, a European Union project to assemble survival data from population-based cancer registries and analyze them according to standardized procedures, we have investigated and compared colon-cancer survival in 10 European countries. We analyzed 68,283 colon-cancer cases diagnosed between 1978 and 1985 and followed for at least 6 years. After calculating relative survival, putative factors prognostic for survival were investigated by univariate and multiple-regression analyses. Important intercountry colon-cancer survival differences exist within Europe, which are not explained by methodological differences, nor by demographic confounders. In patients aged 60 to 69, the mean European 5-year cumulative relative survival was 40%. Switzerland, Finland and The Netherlands had significantly higher 5-year relative survival, while one area in the UK and Cracow in Poland had significantly lower survival than this European estimate. Prognosis improved over time: from 1978 to 1985, the risk of death was reduced by about 4% per year in all countries studied. Age at diagnosis is inversely related to prognosis. Differences in health provision and hence in quality of care and stage at presentation seem largely responsible for the differences in colon-cancer survival found in the EUROCARE countries.

An age and period reconstruction of the HIV epidemic in Italy

BACKGROUND

The majority of AIDS cases in Italy are among intravenous drug users (68%) and homosexual men. An age, period and cohort (APC) model is presented and used to reconstruct the HIV epidemics in Italy. Projections of AIDS-related conditions (ARC) and AIDS cases are attempted based on a hypothesis of minima and an endemic hypothesis.

METHODS

The model is a generalization of the usual back-calculation method which considers age, competitive mortality, susceptible population and therapy effects. Estimates of the HIV epidemic in Italy are obtained using Italian AIDS counts (corrected for delay in reporting), and an incubation time distribution (estimated from data of an Italian cohort), which was found to be dependent on the age at infection. The impact of AZT therapy, introduced in Italy in mid1987, is evaluated using a modification of the incubation time distribution dependent on period of infection.

RESULTS

The estimated number of new infections in Italy declined after 1987, although the number of new AIDS cases has continued to rise, albeit less steeply in recent years. When delay in the progression to AIDS due to therapy is taken into account, the estimated number of people infected in mid1990 increases from 52,000 to 67,000, with approximately 12% of subjects already in the ARC stage. The age at maximum risk of infection is 25 years in males and 23 years in females.

CONCLUSIONS

Using a hypothesis of no more HIV infections after 1990, AIDS counts would be still rising in Italy up to 1993 as a result of past infections and of the long incubation period.

[The distribution and activities of hemodynamic laboratories in Italy: the implications for the quality of services]

BACKGROUND

The diffusion of cardiac catheterization laboratories in Italy has been increasing in the last decade, often without a rational planning process evaluating costs, safety, concentration and case loads.

METHODS

Data have been provided by the 1990 annual report of the Italian Group of Hemodynamic Studies and Interventional Cardiology which includes, following the best estimates, about 90% of public and private labs. These data include all cardiac catheterization visits. In analysis, PTCA's have been separately considered.

RESULTS

In 1990, 85 laboratories with 101 rooms were active. The distribution of the labs was 58% in the north, 14% in the middle and 28% in the south of the country. The number of labs per million inhabitants was 1.9, 1.1 and 1.2 respectively, with a national average of 1.5. The percentage of labs performing fewer than 300 visits per year was 33% in the country. Within the areas, such percentages were 33%, 17% and 42% respectively. A total of 48,518 exams were performed (61%, 18% and 21% in the three areas) with a rate per 100,000 of 115, 82 and 51 (national rate 86). 5,145 PTCA's were carried out in the same year, about 80% of which were in the north area.

CONCLUSIONS

Even if data could be underestimated, a great difference in geographical distribution of labs was confirmed. This might be explained by morbidity, population age and mobility of patients across the country. The percentage of labs performing fewer than 300 studies is relevant, in particular in the south and in the Isles. Planning for future requirements should include the amelioration of utilization rates (in a perspective of cost containment and patient safety), a thorough evaluation of demographic and morbidity trends, and an estimate of the proportion of inappropriate procedures.

[Coronary angiography in a defined population: a pilot study of the residents of Padua]

In recent years there has been a steady increase in number of coronary angiography procedures and coronary angioplasty. Since these interventions are relatively expensive, we tried to evaluate the appropriateness of coronary angiography indications. A retrospective pilot study was undertaken on all residents in Padua who had had a coronary angiography performed in 1988. In order to take into account patients who, although resident in Padua, had a coronary angiography performed outside Padua or even abroad, all Italian Hemodynamic Centers and the Office for Foreign Cures Authorization of ULSS 21 were contacted. Follow-up was stopped on April, 1991. Patients were first checked if living by consulting the Register's Office of the Community of Padua; they were then interviewed by letter on state of health. One hundred twenty-four patients underwent 138 coronary angiography. Utilization rate is 5.6 per 10,000 people (CI 4.6-6.6). This figure is lower than the present USA utilization rate, and is similar to the rate of late 70's. From patient records, 3 out 8 groups emerged as predominant indication for coronary angiography: unstable angina (37%), valvular heart disease (20%) and recent myocardial infarction (20%). According the ACC/AHA guidelines, indication was considered "appropriate" in 69%, "inappropriate" in 7%, "doubtful" in 20% and impossible to evaluate in 5% of cases. Although this classification may have been built up with incomplete information, it is note-worthy that the percentage of inappropriate indication is comparable to that of other reports. A further observation is that not in every case the treatment assigned at the time of diagnostic angiography was really carried out on the patients.(ABSTRACT TRUNCATED AT 250 WORDS)

The quality improvement system in the hospitals of Padua (Italy)

A quality improvement system has been established in 1989 in the hospital network of Padua and its organization is described. Three selected experiences are reported. (1) Appropriateness of the use of human albumin. After the assessment of the clinical policy, new guidelines were experimentally introduced and an evaluation after 3 months has shown a decrease of the total number of prescriptions (25%) and of inappropriate indications (9% vs 40.1%). (2) Urinary Tract Infections (UTI) and indwelling catheterization. The study showed 49% of conditions related to UTI and some corrigible inadequacies in the process of care: 37.2% of indications were probably not justified; 40% of patients who did not undergo urineculture had indications and 13% who underwent urineculture had no indications to the test. Guidelines for appropriate indications and a continuing education programme have been introduced. (3) Falls by hospitalized patients. The patient fall rate was 0.3/1000. As the reporting system showed inaccuracies (for example, the severity of injury was not collected in 34% of cases), a new notification form was introduced in 1991.

Rate of growth of AIDS epidemic in Europe: a comparative analysis

Estimates of the rate of increase of the AIDS epidemic for each of 18 European countries are obtained by fitting a Poisson process with exponential rate of growth to data. A linear regression model of these estimates on the proportion of cases that are intravenous drug users, homosexuals/bisexuals and heterosexuals, was estimated and suggested that the rates of growth of the epidemics amongst these groups are different and in increasing order. Empirical Bayes estimates of the rates are obtained for each country.