Influenza outbreaks and hospital bed occupancy in Rome (Italy): current management does not accommodate for seasonal variations in demand

Objective: Our goal was to assess how different hospital wards react to influenza epidemics, and whether related specialties cooperate in coping with winter bed crises.

Study design: The Lazio Hospital Information System (HIS) dataset from July 1998 to June 2001 was used for the study. The HIS collects data on all hospital discharges. We considered diagnosis-related groups (DRG) as the reason for hospital stay and used DRG to classify admissions as influenza related or influenza unrelated. Time series analysis of daily bed occupancy in different specialty areas by influenza-related and influenza-unrelated cases was performed. Generalized additive models (GAMs) were used to take the effect of short-term and seasonal bed occupancy into account on influenza-related occupancy.

Results: Influenza-related bed occupancy ranges from 770 patients/day during the influenza season to 525 patients/day during the rest of the year. Daily occupancy by influenza-related cases represents 2.8% of total hospital occupancy and 7% of general medicine occupancy during the influenza season. When comparing the influenza season with the rest of the year, general medicine occupancy by influenza-related cases increases by 51% versus the 25-32% increase in other specialty wards. Little change in daily occupancy by influenza-unrelated cases was observed in all specialties when comparing the influenza season with the rest of the year.

Conclusions: Hospital specialty wards react poorly and single handedly to a minor and predictable burden. Any winter bed crisis in the Lazio region is probably the result of defective management of available beds more than excess in demand.

Socio-demographic differences in adherence to evidence-based drug therapy after hospital discharge from acute myocardial infarction: a population-based cohort study in Rome, Italy

WHAT IS KNOWN AND OBJECTIVE

Adherence to evidence-based drug therapy after acute myocardial infarction has increased over the last decades, but is still unsatisfactory. Our objectives are to set out to analyse patterns of evidence-based drug therapy after acute myocardial infarction (AMI), and evaluating socio-demographic differences.

METHODS

A cohort of 3920 AMI patients discharged from hospital in Rome (2006-2007) was selected. Drugs claimed during the 12 months after discharge were retrieved. Drug utilization was defined as density of use (boxes claimed/individual follow-up; chronic use = 6+ boxes/365 days) and therapeutic coverage, calculated through Defined Daily Doses (chronic use: ≥80% of individual follow-up). Patterns of use of single drugs and their combination were described. The association between poly-therapy and gender, age and socio-economic position (small-area composite index based on census data) was analysed through logistic regression, accounting for potential confounders.

RESULTS AND DISCUSSION

Most patients used single drugs: 90·5% platelet aggregation inhibitors (antiplatelets), 60·0%β-blockers, 78·1% agents acting on the renin-angiotensin system (ACEIs/ARBs), 77·8% HMG CoA reductase inhibitors (statins). Percentages of patients with ≥80% of therapeutic coverage were 81·9% for antiplatelets, 17·8% for β-blockers, 64·4% for ACEIs/ARBs and 76·1% for statins. The multivariate analysis showed gender and age differences in adherence to poly-therapy (females: OR = 0·84; 95% CI 0·72-0·99; 71-80 years age-group: OR = 0·82; 95% CI 0·68-0·99). No differences were observed with respect to socio-economic position.

WHAT IS NEW AND CONCLUSION

The availability of information systems offers the opportunity to monitor the quality of care and identify weaknesses in public health-care systems. Our results identify specific factors contributing to non-adherence and hence define areas for more targeted health-care interventions. Our results suggest that efforts to improve adherence should focus on women and older patients.

Cyclic fluctuations in hospital bed occupancy in Roma (Italy): supply or demand driven?

The objective of this study was to assess hospital bed occupancy both by planned and unplanned cases, and to assess how supply and demand affect bed occupancy. Data was obtained from the Lazio Hospital Information System (HIS) dataset on all hospital discharges from July 1998 to June 2001. Using Diagnosis Related Groups (DRG) as the reason for hospital stay, admissions were classified into four categories: 'planned stay', 'presumed planned stay', 'presumed unplanned stay', and 'unplanned stay'. Time series analysis of daily bed occupancy by category of stay was performed. Generalized Additive Models (GAMs) were used to asses the effect of weekdays and holidays on bed occupancy. Fluctuations in daily occupancy were observed in all categories of stay-in general, bed occupancy decreased over weekends, on national holidays, and during the major holiday season of August. In comparison with unplanned stays, the largest fluctuations were observed for planned stays while presumed planned and unplanned stays showed lesser fluctuations. It is possible to distinguish planned and unplanned hospital stays by using DRG grouping. Cyclic rigidities in the supply of services rather than the availability of beds or demand for beds seem to dictate hospital use in Roma so that restrictions in services hamper any reallocation of beds for 'planned stay' when demand for 'unplanned stay' beds declines.

[The quality of medical records: a retrospective study in Lazio Region, Italy]

INTRODUCTION

Medical records have an important role in the communication among different care providers and in forensic medicine. In Italy, information on completeness and correctness of medical records is scanty, whereas future hospital accreditation could take into account their quality as a proxy of good medical practice.

PURPOSE

We performed a retrospective study in order to assess the quality of medical records in the Lazio region.

METHODS

From all 37009 hospital discharges for five different diseases in 123 hospitals (acute myocardial infarction (AMI), coronary artery bypass surgery, pneumonia, cerebrovascular disorders, breast surgery), registered in the Regional Hospital Information System, we selected a random sample of 2022 (5.5% of the total). Ten physicians, previously trained, reviewed the relative medical charts and filled in "ad hoc" questionnaires.

RESULTS

A total of 1960 (97% of the target) charts were reviewed. Organization and structure of data recording strongly varied. Important differences were found across the diseases for various items: presence of anamnesis 98.1% (range: from 95.6% for breast surgery to 100% for AMI); presence of physical examination 92.7% (range: from 88.1% for breast surgery to 98.5% for AMI), completeness of the daily medical records was good in 70.8% (range: from 34.2% for pneumonia to 93.9% for cerebrovascular disorders). Variability among different type of hospitals was also observed, being teaching hospitals and some private hospitals more accurate.

CONCLUSIONS

Quality of medical records tended to vary across different type of hospitals and different diseases. Actions for improving the quality should be undertaken as a priority. Efforts have to be done in restructuring charts, creating guidelines and training caregivers. The development and application of computer based health information systems should help solving these problems.

Hysterectomy and socioeconomic position in Rome, Italy

STUDY OBJECTIVE

There exists conflicting evidence regarding the higher risk of hysterectomy among women of a lower educational and economic level. This study aims to assess whether in Italy socioeconomic level is related to hysterectomy undertaken for different medical reasons.

DESIGN

An area based index was used to assign socieconomic status (SES; four levels defined) to 3141 women (aged 35 years or older) who underwent a hysterectomy in 1997 and were residing in Rome. Data were taken from hospital discharge records. Direct age standardised hospitalisation rates by SES level were calculated for overall hysterectomies and for those performed for either malignant or non-malignant causes. Statistical differences were detected using the ratios of standardised rates and the test for linear trend.

MAIN RESULTS

The hysterectomy rate was 36.7 per 10 000 women aged 35 years or more. Hysterectomy for uterine leiomyoma accounted for 41% of all operations and was more frequent among women aged 35-49 years than for those aged 50 years or more (crude rates: 28.6 and 7.7 per 10 000, respectively). The risk of hysterectomy was 35% higher for the lowest SES group, compared with the highest group. No association was found between SES and hysterectomy rates for malignant causes, although less affluent women in age group 35-49 years had 87% higher risk of hysterectomy compared with most affluent women. The inverse association between SES and hysterectomy rates attributable to non-malignant causes was statistically significant for women aged 35-49 years but not for those aged 50 years or more.

CONCLUSIONS

The inverse relation between hysterectomy and SES is largely attributable to benign disorders of the uterus, namely leiomyoma and prolapse. More affluent women may have a greater uptake of less invasive techniques for removing uterine leiomyoma compared with less affluent women, who are more likely to undergo unnecessary hysterectomies irrespective of their reproductive age.

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

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

Coronary artery bypass graft surgery: socioeconomic inequalities in access and in 30 day mortality. A population-based study in Rome, Italy

OBJECTIVES

To evaluate whether coronary artery bypass graft (CABG) surgery is equally provided among different socioeconomic status (SES) groups in accordance with need. To estimate the association between SES and mortality occurring 30 days after CABG surgery.

DESIGN

Individual socioeconomic index assigned with respect to the characteristics of the census tract of residence (level I = highest SES; level IV = lowest SES). Comparison of age adjusted hospital admission rates of ischaemic heart disease (IHD) and CABG surgery among four SES groups. Retrospective cohort study of all patients who underwent CABG surgery during 1996-97.

SETTING

Rome (2 685 890 inhabitants) and the seven cardiac surgery units in the city.

PARTICIPANTS

All residents in Rome aged 35 years or more. A cohort of 1875 CABG patients aged 35 years or more.

MAIN OUTCOME MEASURES

Age adjusted hospitalisation rates for CABG and IHD and rate of CABG per 100 IHD hospitalisations by SES group, taking level I as the reference group. Odds ratios of 30 day mortality after CABG surgery, adjusted for age, gender, illness severity at admission, and type of hospital where CABG was performed.

RESULTS

People in the lowest SES level experienced an excess in the age adjusted IHD hospitalisation rates compared with the highest SES level (an excess of 57% among men, and of 94% among women), but the rate of CABG per 100 IHD hospitalisations was lower, among men, in the most socially disadvantaged level (8.9 CABG procedures per 100 IHD hospital admissions in level IV versus 14.1 in level I rate ratio= 0.63; 95% CI 0.44, 0.89). The most socially disadvantaged SES group experienced a higher risk of 30 day mortality after CABG surgery (8. 1%) than those in the highest SES group (4.8%); this excess in mortality was confirmed even when initial illness severity was taken into account (odds ratio= 2.89; 95% CI 1.44, 5.80).

CONCLUSIONS

The universal coverage of the National Health Service in Italy does not guarantee equitable access to CABG surgery for IHD patients. Factors related to SES are likely to influence poor prognosis after CABG surgery.

Stress and exacerbation in ulcerative colitis: a prospective study of patients enrolled in remission

OBJECTIVE

We sought to determine whether psychosocial factors influence the course of ulcerative colitis, hypothesizing that high perceived stress among patients with inactive disease will increase the risk of subsequent exacerbation.

METHODS

Sixty-two patients with known ulcerative colitis were enrolled into a prospective cohort study while in clinical remission. Their perceived stress, depressive symptoms, and stressful life events were followed, along with potential confounders, for up to 45 months; exacerbation status was monitored for up to 68 months.

RESULTS

The 27 patients who experienced an exacerbation were compared with those who remained in remission. Having a score in the upper tertile on the long-term (past 2 yr) baseline Perceived Stress Questionnaire significantly increased the actuarial risk of exacerbation (hazards ratio = 2.8, 95% confidence interval 1.1-7.2). At any given study visit, high long-term stress tripled the risk of exacerbation during the next 8 months (risk for the three tertiles, 8.3%, 16.7%, and 26.2%, p = 0.02). Shorter sleep time, briefer remission, histological activity, and use of nonsteroidal antiinflammatory drugs, antibiotics, or oral contraceptives also increased the medium- and/or long-term risk of exacerbation, but adjustment for these variables did not eliminate the associations with stress. Exacerbation was not associated with stressful life events, depressive symptoms, short-term (past month) perceived stress, smoking, disease extent or duration, or severity of recent course.

CONCLUSIONS

Short-term stress does not trigger exacerbation in ulcerative colitis, but long-term perceived stress increases the risk of exacerbation over a period of months to years.

[Socioeconomic inequalities in health care efficacy. Three examples in Lazio region]

There has been a limited number of studies in Italy investigating the relationship between socioeconomic inequalities and efficacy of treatments. This paper reviews three case studies on the association between socioeconomic status and disease outcome in the Lazio Region, Italy. The studies investigated: a) the probability of renal transplantation among patients with endstage renal disease; b) the survival of AIDS patients before and after the introduction of the new antiretroviral therapies; c) the 30-day mortality of patients who underwent coronary artery bypass graft surgery. The three studies demonstrate the complex relationship between socioeconomic status and both access to, and efficacy of, important health interventions.

[Differences in in-hospital mortality in patients treated with aortocoronary bypass for cardiopathic ischemia, Rome 1996]

Data from Health Information Systems (HIS) have been used in recent years to evaluate effectiveness and quality of care. We analyzed in-hospital mortality occurring within 30 days following operation among 1984 patients (age > or = 35 yrs, males 84%) who underwent Coronary Artery Bypass Graft (CABG) surgery in seven hospitals in Rome in 1996. Data were extracted from the Lazio HIS run by the Regional Health Authority. The HIS database includes up to four diagnoses and surgical procedures (ICD-9); the following variables were considered a priori risk factors: type of ischemic disease, comorbidities, and others surgical interventions during the same admission. Logistic regression was performed in order to evaluate the association between hospital and risk of mortality after adjusting for potential confounders (ORs and 95% CI). The overall in-hospital mortality was 4.7% (ranged from 0.0 to 14.7%). Predictors of outcome included: older age, acute myocardial infarction, chronic myocardial ischemia, other heart diseases, chronic renal diseases, peripheral vascular diseases, other heart and vascular interventions. Statistically significant variability in mortality was observed across hospitals; taking hospital A as reference, hospitals D and E showed the highest risks (OR = 6.36 and OR = 3.12, respectively). We conclude that the observed differences in mortality rates among hospitals cannot be explained by differences in case mix, nor by varying coding styles. They are likely to reflect differences in currently unknown aspects of patient care.

The changing distribution of HIV infection: HIV surveillance in Lazio, Italy, 1985 through 1994. Lazio HIV Surveillance Collaborative Group

OBJECTIVES

This study sought to describe the human immunodeficiency virus (HIV) surveillance system in Lazio, Italy, and to analyze exposure patterns and time trends of HIV serodiagnoses from January 1985 to December 1994.

METHODS

A linkage procedure made it possible to identify newly diagnosed HIV cases. Anonymous information was collected on demographic and exposure factors for each individual.

RESULTS

Of 35,425 reports, 13,660 were newly diagnosed HIV cases, 70.9% of them in men. The proportion of women increased at the beginning of the study period (the male:female ratio declined from 3.5 in 1985 to 2.6 in 1986) and then remained stable. The proportion of subjects reporting heterosexual exposure, in men and women, respectively, increased from 1.5% and 2.0% in 1985 to 21.2% and 60.8% in 1994. Starting in 1992, heterosexual contact has become the main transmission route for women.

CONCLUSIONS

A changing pattern in the HIV epidemic is emerging, with a shift in the incidence of HIV diagnosis from "core" high-risk groups (drug injectors) to the large low-risk population (the general population) exposed through heterosexual transmission. This is probably occurring in other areas (e.g., large urban centers in the United States) with a similar epidemiological situation.

HIV risk-related behaviors among injection drug users in Rome: differences between 1990 and 1992

Temporal differences in human immunodeficiency virus (HIV) risk-related behaviors among injection drug users in Rome, Italy, were analyzed in 487 drug users recruited in 1990 and 450 recruited in 1992. Sharing of syringes decreased among self-reported HIV-positive drug users between 1990 and 1992, but there was no change in their sexual behavior. Fewer HIV-seronegative drug users reported passing on used syringes in 1992 than in 1990; however, there was no change in the percentage of seronegative subjects using previously used syringes, and a reduction in condom use with primary partners. There still exists a great potential for transmission of HIV infection among injection drug users and from injection drug users to the general population.

[Behavior associated with HIV-1 infection in drug addicts in Rome, 1990-1992]

Two cross-sectional surveys have been conducted in Rome in 1990 and 1992 to investigate prevalence and temporal differences of risk behaviours among drug injectors. A total of 487 drug injectors in 1990, and 450 in 1992 have been interviewed both in the street and in treatment services. Twenty-four percent of the subjects interviewed in 1990 reported having used second-hand syringes in the preceding 6 months, as compared to 14% in 1992; in the two years 29% and 13%, respectively, reported having passed a second-hand syringe to other drug injectors. Fifty-six percent (46% in 1992) of primary partners of drug injectors interviewed were not drug users themselves, while the prevalence of non drug using occasional partners was 34% and 43% in the two surveys. In 1990 condom use with primary partner was reported by 48% of drug injectors, and by 41% in 1992; condom use with occasional partners was 56% and 64% in the two years. The differences in sharing behaviours were observed for HIV-1 positive subjects, while HIV-1 negatives reported the same prevalence of use of second-hand syringes in 1990 and 1992; no statistically significant differences have been found for sexual behaviours among the HIV-1 positives, while the HIV-1 negatives reported a lower prevalence of condom use with primary partner. The observed differences in the two years remain also adjusting for the socio-demographic characteristics of the two populations in a multiple logistic regression model. Prevalence of HIV-1 related risk behaviours among drug injectors is still too high.(ABSTRACT TRUNCATED AT 250 WORDS)

Indirect estimates of lung cancer death rates in Italy not attributable to active smoking

We used a model, originally applied in the context of occupational cohort studies to evaluate confounding from smoking, to estimate lung cancer death rates in the Italian population not attributable to active smoking (background rates). Relevant parameters were the percentages of current and former smokers in the population, as derived from national interview surveys, and rate ratios for lung cancer and smoking. We studied differences over time (1956-1958 to 1987-1989) and place (urban/rural) in the background lung cancer death rates while allowing for changes in the average daily amount of tobacco consumption and in duration of smoking. We applied two functions proposed by Whittemore to obtain rate ratios for smokers: one assumes a linear relation between cumulative number of cigarettes smoked and lung cancer death rates; the other is closer to the multistage carcinogenesis theory. All our calculations indicate that the estimated background rates increased in Italy from the period 1956-1958 to the period 1987-1989; the increase was stronger in males than in females. In 1980-1982, higher background rates were observed in heavily urbanized areas than in rural areas. The results did not change when we considered cohort effects in smoking prevalence and when the key parameters were perturbed in a sensitivity analysis. It appears that factors other than smoking play an important role in causing lung cancer in Italy.

[Reproducibility of pediatric information collected with various methods: postal/telephone questionnaire and direct interview]

The paper reports on a research aimed to evaluate the repeatability of some paediatric data obtained from the parents by using different collection instruments: telephone interview, mail questionnaire, in-person interview. The study included 699 children consecutively born in the Policlinico Universitario "A. Gemelli" from September to November 1983. After 3 years a questionnaire containing questions about measles, anti measles immunization, age at which the baby started to walk, disease delaying the walking, and orthopaedic examinations was sent by mail to 149 families; the other 550 families were searched for by telephone and, if found, asked the same questions. All the contacted families were invited for a paediatric check-up, during which the same data were collected through direct interview. For each question crude agreement and K statistic (which controls for the agreement attributable to chance) were computed with respect to both the phone/direct and mail direct comparisons. 391 families (56%) were traced for the first interview, due to the high number of them which had moved home. Among these 289 (74%) attended the paediatric check-up. On the whole, rather high values of K statistic were observed, ranging from 0.59 (question on diseases delaying the walking, comparison phone/direct) to 0.93 (question on anti-measles immunization, comparison mail/direct). Due to the small sample size, the estimates concerning the comparison mail/direct are rather imprecise. Although its potential is limited by the low response rate, the study brings good evidence that the information considered is not sufficiently reliable when reported retrospectively by parents. However, the keeping of a prospective individual record containing data of medical interest should be encouraged.

The epidemic dynamics of HIV-1 in Italy: modelling the interaction between intravenous drug users and heterosexual population

Data gathered through the Latium HIV Surveillance System were used in conjunction with a compartmental mathematical model to describe the transmission dynamics of HIV-1 in Italy. In the Latium region, as in the rest of Italy, fewer than 1 in 5 cumulative cases of AIDS are attributable to male homosexual transmission, while 55-60 per cent of the cases have been observed among intravenous drug users (IVDUs). Moreover, the number of non-drug-using heterosexual cases is increasing (14 per cent of cumulative cases). Anonymous notification of positive HIV-1 tests, mandatory in Latium since 1985, were used to produce a time series of new HIV-1 diagnoses; just over 400 new cases of infection per quarter were diagnosed from mid 1989 to mid 1990, with no evidence of increasing incidence. A minimum of 6009 and a maximum of 10,000 individuals with HIV-1 as of the end of 1989 were estimated, 80 per cent of adult cases occurring among IVDUs. The model included two main subgroups: IVDUs and non-drug-using heterosexuals, both with behavioural heterogeneities. Sharing of needles among IVDUs and heterosexual contact were considered as possible ways of transmitting HIV-1. A mathematical framework was developed to reproduce different mixing patterns within and between subgroups. A scenario analysis of the model showed incident cases of HIV-1 among IVDUs peaking early, then declining dramatically and stabilising at low values, with a stable-state prevalence higher than 0.75. Heterosexual interaction with IVDUs resulted in a significant, but non-self-sustaining, virus spread in the general population, affecting females more than males. The extent of this spread is associated with the assortativeness of the sexual mixing pattern adopted. The qualitative features of the Italian epidemic are well represented by the model, which highlights the role of IVDUs as an infection reservoir. However, the need emerges for more accurate information on the key parameters influencing the transmission dynamics of HIV-1.

Life events, personality, and physical risk factors in recent-onset duodenal ulcer. A preliminary study

To clarify the interactions between stressful life events and other risk factors in the development of duodenal ulcer disease, we studied 33 patients with active ulcer, symptomatic for less than or equal to 6 months and untreated during the previous year, using the Paykel Interview for stressful life events, the Minnesota Multiphasic Personality Inventory (MMPI), and Zung's Anxiety and Depression scales. MMPIs were abnormal in 64% of the patients, and 61% showed some degree of depression. The 16 patients whose symptoms had been preceded by severe stress and more pathological MMPIs, especially on paranoia and dependency scales; were more depressed; and had used less nonsteroidal anti-inflammatory drugs than those without (p less than 0.05). They were somewhat more likely to be single, to be of low social class, and to have recently increased use of cigarettes, alcohol, or coffee (though their absolute level of alcohol consumption was low). Anxiety levels did not differ between stress and nonstress groups. Correspondence analysis yielded four clusters of patients, characterized by (a) alcohol/cigarette use, personality disorder, chronicity; (b) early onset, neurosis; (c) depression, life events; (d) late onset, psychosocial stability. The analysis changed little according to whether life events were or were not considered in cluster formation. We conclude that ulcer patients who become ill under stress from a distinct subgroup, that depressed mood and stress-related increases in use of alcohol and cigarettes may mediate between stress and ulcer formation, and that life events are a quantitatively minor factor in ulcerogenesis.

[Mandatory test for HIV infections in prison population: evaluation of the efficacy of a screening program]

The effectiveness of a screening programme for HIV infection among prisoners is discussed, in relation to validity of screening test, natural history ad modalities of transmission of the infection, hypothetical objectives of the programme, in comparison with alternatives prevention programmes. The association between HIV infection, e.v. drug abuse and sexual behaviours is analyzed. On the basis of available evidences the hypothesis of lack of effectiveness and possible harmfulness of this screening programme is proposed.

[Evaluation of the effectiveness of a premarital program for HIV infection screening]

The effectiveness of premarital screening program for HIV infection is discussed, in relation to hypothetical objectives: improvement of individual health, prevention of transmission of HIV infection and estimate of prevalence among sexually active population. Taking into account validity of screening test, natural history of HIV infection, availability of effective early treatment and possible social outcomes, the hypothesis of lack of effectiveness of this program is held.

Years of potential life lost (YPLL) before age 65 in Italy

The Italian death rates and years of potential life lost (YPLL) for all causes and for 12 selected aggregations of causes are reported for 1979 and 1983, with the latter compared to United States data. Cancer is the leading cause of YPLL in Italy (23.8 per cent of total YPLL), followed by unintentional injuries (16.3 per cent) and heart disease (11.2 per cent). Rates of YPLL for all causes decreased 12.0 per cent from 1979 to 1983, the strongest declines in absolute terms being observed for prematurity and unintentional injuries, and in percentage decline for pneumonia and influenza, and infectious diseases; during the same period, YPLL for diabetes increased. The rates of YPLL are higher for males than for females (rate ratio = 1.9) especially for causes related to lifestyle factors. Premature mortality is lower in Italy than in the USA, because of the striking difference in mortality from injuries and heart diseases.