[Update and review of the 2011 Italian deprivation index calculated at the census section level]

OBJECTIVES

to produce for the national territory as a whole a deprivation index (ID) at the census section level, based on 2011 census data, in the same way as the Italian index based on the 2001 census, revising the formulation of some indicators.

SETTING AND PARTICIPANTS

the study uses the individual data of the general population and housing census of 2011. For the calculation of the index five conditions were chosen that best describe the multidimensional concept of social and material deprivation: low level of education, being unemployed, living in rent, living in crowded house, living in a single-parent family. The index is calculated as the sum of standardized indicators and is also available categorized into quintiles. Compared to the previous formulation of the ID, the proposed revised ID made use of a low education indicator limited to the age group 15-60; for what concerns single-parent families, only the cohabitations with minor children is considered.

MAIN OUTCOME MEASURES

reformulated ID and comparison measures between the two indices (correlation, kappa statistic).

RESULTS

the revised index, compared with the previous one, a different quintile distribution for a significant share of census sections, with the exception of the first and fifth quintiles (that of the least deprived and the most deprived ones).

CONCLUSION

given that in this field of study should be taken for granted the inexistence of a method that produces results objectively and universally valid, the review of the index proposed in this study starts from the availability of analytical data that allowed to overcome some constraints that had induced the choices of the ID proposed in 2010. Anyway, both the original and the revised index produce reliable and consistent results.

Potentially avoidable hospitalization for asthma in children and adolescents by migrant status: results from the Italian Network for Longitudinal Metropolitan Studies

Background

Global migration toward Europe is increasing. Providing health assistance to migrants is challenging because numerous barriers limit their accessibility to health services. Migrants may be at a greater risk of developing asthma and receiving lower quality healthcare assistance than non-migrants. We aim to investigate whether immigrants as children and adolescents have higher rates of potentially avoidable hospitalization (PAH) for asthma compared to Italians.

Methods

We performed a retrospective longitudinal study using six cohorts of 2–17-year-old residents in North and Central Italy from 01/01/2001 to 31/12/2014 (N = 1,256,826). We linked asthma hospital discharges to individuals using anonymized keys. We estimated cohort-specific age and calendar-year-adjusted asthma PAH rate ratios (HRRs) and 95% confidence intervals (95%CIs) among immigrants compared to Italians. We applied a two-stage random effect model to estimate asthma PAH meta-analytic rate ratios (MHRRs). We analyzed data by gender and geographical area of origin countries.

Results

Three thousand three hundred four and 471 discharges for asthma PAH occurred among Italians and immigrants, respectively. Compared to Italians, the asthma PAH cohort-specific rate was higher for immigrant males in Bologna (HRR:2.42; 95%CI:1.53–3.81) and Roma (1.22; 1.02–1.45), and for females in Torino (1.56; 1.10–2.20) and Roma (1.82; 1.50–2.20). Asthma PAH MHRRs were higher only among immigrant females (MHRRs:1.48; 95%CI:1.18–1.87). MHRRs by area of origin were 63 to 113% higher among immigrants, except for Central-Eastern Europeans (0.80; 0.65–0.98).

Conclusion

The asthma PAH meta-analytic rate was higher among female children and adolescent immigrants compared to Italians, with heterogeneity among cohorts showing higher cohort-specific PAH also among males, with some differences by origin country. Access to primary care for children and adolescent immigrants should be improved and immigrants should be considered at risk of severe asthma outcomes and consequently targeted by clinicians.

[Trends in educational inequalities in premature mortality between 2001 and 2016: results from the Emilian Longitudinal Study]

OBJECTIVES

to describe changes in relative and absolute inequalities in mortality by education level between 2001 and 2016 in the Emilian longitudinal study (SLEm) and to estimate the impact of these inequalities at population level.

DESIGN

closed cohort study based on record-linkage between municipal population registries, Census archives of 2001 and 2011, and the mortality register.

SETTING AND PARTICIPANTS

2001- and 2011-Census respondents >=30 years old residing in Bologna, Modena, or Reggio Emilia followed up to the age of 75 years, death, emigration, or end of follow-up (December 2006 or December 2016).

MAIN OUTCOME MEASURES

premature mortality for all causes and for 16 groups of causes known to be associated with socioeconomic position. In order to capture various aspects of the inequalities, the association with the education level is assessed through summary regression-based indexes (Relative and Slope Index of Inequality) and the Attributable Population Fraction.

RESULTS

premature mortality declined across all educational level between 2001-2006 and 2011-2016; declines were greater among men than women. Among men, relative inequalities in mortality slightly increased (RII from 1.86 in 2001 to 2.13 in 2011), while absolute inequalities declined (SII from 382.3 to 360.6). Among women, both relative and absolute inequalities increased (RII from 1.23 to 1.65, SII from 73.7 to 137.4). Educational inequalities in lung cancer, respiratory and cerebrovascular diseases mortality decreased among men and increased among women. The proportion of the low educated shrank over time (men: from 40% to 36%; women: from 43% to 35%); nonetheless, the fraction of the deaths attributable to educational inequalities showed an upward tendency (from 18.5% to 21.9% in men and from 9.7% to 15.6% in women); the groups of causes that contribute most to this increase were malignant cancers, especially lung cancer, diseases of the circulatory and respiratory systems, and accidents.

CONCLUSIONS

relative inequalities slightly increased in both genders, while absolute inequalities only in women. A reduction in the population impact could be achieved by tackling educational inequalities in mortality due to lung cancer, diseases of the circulatory and respiratory systems, and accidents.

[Immigrants' health and socioeconomic inequalities of overall population residing in Italy evaluated through the Italian network of Longitudinal Metropolitan Studies]

INTRODUCTION

Describing and monitoring socioeconomic inequalities in health are the prerequisite for planning equity policies. In Italy, some cities have integrated personal information from the municipal registries with Census data and with data from healthcare information systems to set up Longitudinal Metropolitan Studies (LMS). Under the coordination of the Italian National Institute for Health, Migration, and Poverty (NIHMP), six cities in the LMS network have contributed to the present monograph: Turin, Venice, Reggio Emilia, Modena, Bologna, and Rome. MORTALITY RESULTS. Significant socioeconomic differences by level of education were seen in all the participating centres. People who live alone or in single-parent households are more likely to die, as are those living in a substandard dwelling. Immigrants resident in the six cities included in the study showed lower all-cause mortality than Italians (males: MRR 0.83; 95%CI 0.78-0.90 - females: MRR 0.70; 95%CI 0.64-0.77). Sub-Saharan Africans experienced a significant higher mortality than Italians (males: MRR 1.33; 95%CI 1.12-1.59 - females: MMR 1.69; 95%CI 1.31-2.17). Immigrants had a neonatal and post-neonatal mortality risk about 1.5 times higher than Italians (neonatal: OR 1.71; 95%CI 1.22-2.39 - post-neonatal: OR 1.63; 95%CI 1.03-2.57). A difference between Italians and immigrants was also observed for mortality in children aged 1-4 years, though less marked (OR 1.24; 95%CI 0.73-2.11). Excesses concerned particularly immigrants from North Africa and from sub-Saharan Africa as well as those residing in Italy for >5 years. HOSPITALISATION RESULTS. Hospitalisation rates are lower for immigrants than for Italians, except when due to infectious diseases, blood disorders, and, among women, for reasons linked to pregnancy and childbirth. Avoidable hospitalisation rates of adults from low migratory pressure Countries are lower than or equal to those of Italians. On the contrary, adults from low migratory pressure Countries show higher avoidable hospitalisation rates compared to Italians in every cohort, with the exception of Rome (RR 0.81; 95%CI 0.78-0.85), with RR ranging from 1.08 (95%CI 0.96-1.22) in Venice to 1.64 (95%CI 1.47-1.83) in Modena.

CONCLUSIONS

Maternal and child health is the most critical area of health for immigrant population. Considering the importance that the issue of health equity has taken on in the political agenda, the data presented in this volume are a great asset, particularly in light of the long recession and the social crisis that have impacted the Country.

Progress in reducing inequalities in cardiovascular disease mortality in Europe

OBJECTIVE

To assess whether recent declines in cardiovascular mortality have benefited all socioeconomic groups equally and whether these declines have narrowed or widened inequalities in cardiovascular mortality in Europe.

METHODS

In this prospective registry-based study, we determined changes in cardiovascular mortality between the 1990s and the early 2010s in 12 European populations by gender, educational level and occupational class. In order to quantify changes in the magnitude of differences in mortality, we calculated both ratio measures of relative inequalities and difference measures of absolute inequalities.

RESULTS

Cardiovascular mortality has declined rapidly among lower and higher socioeconomic groups. Relative declines (%) were faster among higher socioeconomic groups; absolute declines (deaths per 100 000 person-years) were almost uniformly larger among lower socioeconomic groups. Therefore, although relative inequalities increased over time, absolute inequalities often declined substantially on all measures used. Similar trends were seen for ischaemic heart disease and cerebrovascular disease mortality separately. Best performer was England and Wales, which combined large declines in cardiovascular mortality with large reductions in absolute inequalities and stability in relative inequalities in both genders. In the early 2010s, inequalities in cardiovascular mortality were smallest in Southern Europe, of intermediate magnitude in Northern and Western Europe and largest in Central-Eastern European and Baltic countries.

CONCLUSIONS

Lower socioeconomic groups have experienced remarkable declines in cardiovascular mortality rates over the last 25 years, and trends in inequalities can be qualified as favourable overall. Nevertheless, further reducing inequalities remains an important challenge for European health systems and policies.

[Long-term health effects of earthquakes: outlining the features of an epidemiological surveillance system in Italy.]

The major earthquakes occurred in Italy in the past 10 years (L'Aquila, Emilia and Amatrice) have resulted in 679 death, displacement of more than 120,000 people and economic losses for more than 20 billion euros. In a recent review, we found that earthquakes are associated to multiple health conditions in the long term. Because of Italy's high seismic risk, it is likely that establishing a post-earthquake surveillance system would enable early detection of many deleterious effects and mitigation of damages. In this editorial, we outline the possible features of such a surveillance system. Firstly, it should be cost-effective, capitalising on routinely collected health data. Secondly, it should be coordinated centrally by a compact multidisciplinary team, to enable harmonised procedures and analysis. Thirdly, based on current evidence, it should be able to follow-up populations for least 7 years and capture both physical and mental health diseases. Finally, it should gather sufficient information to enable stratified analysis and identify at-risk subgroups that may need specific interventions.

Medium- and long-term health effects of earthquakes in high-income countries: a systematic review and meta-analysis

Background

Accurate monitoring of population health is essential to ensure proper recovery after earthquakes. We aimed to summarize the findings and features of post-earthquake epidemiological studies conducted in high-income countries and to prompt the development of future surveillance plans.

Methods

Medline, Scopus and six sources of grey literature were systematically searched. Inclusion criteria were: observational study conducted in high-income countries with at least one comparison group of unexposed participants, and measurement of health outcomes at least 1 month after the earthquake.

Results

A total of 52 articles were included, assessing the effects of 13 earthquakes that occurred in eight countries. Most studies: had a time-series (33%) or cross-sectional (29%) design; included temporal comparison groups (63%); used routine data (58%); and focused on patient subgroups rather than the whole population (65%). Individuals exposed to earthquakes had: 2% higher all-cause mortality rates [95% confidence interval (CI), 1% to 3%]; 36% (95% CI, 19% to 57%) and 37% (95% CI, 29% to 46%) greater mortality rates from myocardial infarction and stroke, respectively; and 0.16 higher mean percent points of glycated haemoglobin (95% CI, 0.07% to 0.25% points). There was no evidence of earthquake effects for blood pressure, body mass index or lipid biomarkers.

Conclusions

A more regular and coordinated use of large and routinely collected datasets would benefit post-earthquake epidemiological surveillance. Whenever possible, a cohort design with geographical and temporal comparison groups should be used, and both communicable and non-communicable diseases should be assessed. Post-earthquake epidemiological surveillance should also capture the impact of seismic events on the access to and use of health care services.

Cohort profile: the Italian Network of Longitudinal Metropolitan Studies (IN-LiMeS), a multicentre cohort for socioeconomic inequalities in health monitoring

PURPOSE

The Italian Network of Longitudinal Metropolitan Studies (IN-LiMeS) is a system of integrated data on health outcomes, demographic and socioeconomic information, and represents a powerful tool to study health inequalities.

PARTICIPANTS

IN-LiMeS is a multicentre and multipurpose pool of metropolitan population cohorts enrolled in nine Italian cities: Turin, Venice, Reggio Emilia, Modena, Bologna, Florence, Leghorn, Prato and Rome. Data come from record linkage of municipal population registries, the 2001 population census, mortality registers and hospital discharge archives. Depending on the source of enrolment, cohorts can be closed or open. The census-based closed cohort design includes subjects resident in any of the nine cities at the 2001 census day; 4 466 655 individuals were enrolled in 2001 in the nine closed cohorts. The open cohort design includes subjects resident in 2001 or subsequently registered by birth or immigration until the latest available follow-up (currently 31 December 2013). The open cohort design is available for Turin, Venice, Reggio Emilia, Modena, Bologna, Prato and Rome. Detailed socioeconomic data are available for subjects enrolled in the census-based cohorts; information on demographic characteristics, education and citizenship is available from population registries.

FINDINGS TO DATE

The first IN-LiMeS application was the study of differentials in mortality between immigrants and Italians. Either using a closed cohort design (nine cities) or an open one (Turin and Reggio Emilia), individuals from high migration pressure countries generally showed a lower mortality risk. However, a certain heterogeneity between the nine cities was noted, especially among men, and an excess mortality risk was reported for some macroareas of origin and specific causes of death.

FUTURE PLANS

We are currently working on the linkage of the 2011 population census data, the expansion of geographical coverage and the implementation of the open design in all the participating cohorts.

[Medium- and long-term health effects of the L'Aquila earthquake (Central Italy, 2009) and of other earthquakes in high-income Countries: a systematic review]

OBJECTIVES

to compare the methodological characteristics of the studies investigating the middle- and long-term health effects of the L'Aquila earthquake with the features of studies conducted after other earthquakes occurred in highincome Countries.

DESIGN

a systematic comparison between the studies which evaluated the health effects of the L'Aquila earthquake (Central Italy, 6th April 2009) and those conducted after other earthquakes occurred in comparable settings.

METHODS

Medline, Scopus, and 6 sources of grey literature were systematically searched. Inclusion criteria comprised measurement of health outcomes at least one month after the earthquake, investigation of earthquakes occurred in high-income Countries, and presence of at least one temporal or geographical control group.

RESULTS

out of 2,976 titles, 13 studies regarding the L'Aquila earthquake and 51 studies concerning other earthquakes were included. The L'Aquila and the Kobe/Hanshin- Awaji (Japan, 17th January 1995) earthquakes were the most investigated. Studies on the L'Aquila earthquake had a median sample size of 1,240 subjects, a median duration of 24 months, and used most frequently a cross sectional design (7/13). Studies on other earthquakes had a median sample size of 320 subjects, a median duration of 15 months, and used most frequently a time series design (19/51).

CONCLUSIONS

the L'Aquila studies often focussed on mental health, while the earthquake effects on mortality, cardiovascular outcomes, and health systems were less frequently evaluated. A more intensive use of routine data could benefit future epidemiological surveillance in the aftermath of earthquakes.

Impact of socioeconomic status and district of residence on cutaneous malignant melanoma prognosis: a survival study on incident cases between 1991 and 2011 in the province of Ferrara, northern Italy

The aim of this study was to analyse the impact of socioeconomic status (SES) on the prognosis of patients with invasive malignant melanoma (MM) incident from 1991 to 2011 in the province of Ferrara, northern Italy. A total of 750 patients provided by the Area Vasta Emilia Centrale Cancer Registry were included in this retrospective cohort study. Prognosis was analysed in terms of overall survival and specific survival. The study determinants were the patients' SES and district of residence. The confounding effect of sex, age, period and TNM stage at diagnosis was evaluated. In the study population, neither overall survival nor specific survival showed significant differences among different layers of SES and districts of residence. The risk for death from MM was lower for the female sex [hazard risk (HR)=0.68, 95% confidence interval (CI): 0.50-0.94] and for diagnoses made in the most recent period (2005-2011: HR=0.56, 95% CI: 0.36-0.89 with respect to 1991-1997). A worse prognosis was observed in patients older than 70 years at the time of diagnosis (HR=2.33, 95% CI: 1.39-3.91 with respect to the <40-year age group) and in patients with more than pT1 tumours (up to 20 times for pT4 tumours). SES and district of residence did not constitute prognostic factors for MM patients residing in the province of Ferrara. Homogeneity in MM staging, treatment and follow-up strategies due to the relatively small extent of the study area and the presence of a single university hospital of reference, as well as less marked social and economic differences among the study patients in comparison with other previously analysed populations, may account for this finding.

Differences in mortality by immigrant status in Italy. Results of the Italian Network of Longitudinal Metropolitan Studies

Despite a rapid increase in immigration from low-income countries, studies on immigrants' mortality in Italy are scarce. We aimed to describe differences in all and cause-specific mortality among immigrants and Italians residing in Turin and Reggio Emilia (Northern Italy), two cities participating in the Italian Network of Longitudinal Metropolitan Studies (IN-LiMeS). We used individual data from the municipal population registers linked to the cause of death registers. All people aged 1-64 years residing between 2001 and 2010 were enrolled (open cohort) and followed up until 2013. The mortality of citizens from high migratory pressure countries (as a whole, and for each macro-area group) was compared with that of Italians; differences were estimated by Poisson regression adjusted by age and calendar year mortality rate ratios (MRRs), and by age-standardized mortality ratios for the analysis of cause-specific mortality. Compared with Italians, immigrants had lower overall mortality (MRR for men: 0.82, 95 % CI: 0.75-0.90; for women: 0.71, 95 % CI: 0.63-0.81). Sub-Saharan Africans experienced a significant higher mortality than Italians (MRR for men 1.29, 95 % CI: 1.03-1.61; for women: 1.70, 95 % CI: 1.22-2.36). Higher mortality for immigrants compared to Italians was observed for infectious diseases, congenital anomalies, some site-specific tumours and homicide mortality. Our study showed heterogeneity in mortality across the macro-areas of origin, and in particular Sub-Saharan Africans seemed to be a vulnerable population. The extension to other cohorts of IN-LiMeS will allow the health status of immigrants and vulnerable groups to be studied and monitored in more depth.

Short-Term Effects of Nitrogen Dioxide on Mortality and Susceptibility Factors in 10 Italian Cities: The EpiAir Study

BACKGROUND

Several studies have shown an association between nitrogen dioxide (NO2) and mortality. In Italy, the EpiAir multicentric study, "Air Pollution and Health: Epidemiological Surveillance and Primary Prevention," investigated short-term health effects of air pollution, including NO2.

OBJECTIVES

To study the individual susceptibility, we evaluated the association between NO2 and cause-specific mortality, investigating individual sociodemographic features and chronic/acute medical conditions as potential effect modifiers.

METHODS

We considered 276,205 natural deaths of persons > 35 years of age, resident in 10 Italian cities, and deceased between 2001 and 2005. We chose a time-stratified case-crossover analysis to evaluate the short-term effects of NO2 on natural, cardiac, cerebrovascular, and respiratory mortality. For each subject, we collected information on sociodemographic features and hospital admissions in the previous 2 years. Fixed monitors provided daily concentrations of NO2, particulate matter ≤ 10 μm in aerodynamic diameter (PM10) and ozone (O3).

RESULTS

We found statistically significant associations with a 10-μg/m3 increase of NO2 for natural mortality [2.09% for lag 0-5; 95% confidence interval (CI), 0.96-3.24], for cardiac mortality (2.63% for lag 0-5; 95% CI, 1.53-3.75), and for respiratory mortality (3.48% for lag 1-5; 95% CI, 0.75-6.29). These associations were independent from those of PM10 and O3. Stronger associations were estimated for subjects with at least one hospital admission in the 2 previous years and for subjects with three or more specific chronic conditions. Some cardiovascular conditions (i.e., ischemic heart disease, pulmonary circulation impairment, heart conduction disorders, heart failure) and diabetes appeared to confer a strong susceptibility to air pollution.

CONCLUSIONS

Our results suggest significant and likely independent effects of NO2 on natural, cardiac, and respiratory mortality, particularly among subjects with specific cardiovascular preexisting chronic conditions and diabetes.

[The Italian deprivation index at census block level: definition, description and association with general mortality]

OBJECTIVE

the study is aimed at developing a nationwide deprivation index at municipality and census block level, based on the 2001 Census data, and meeting epidemiological needs.

SETTING AND PARTICIPANTS

The study uses data drawn from the 2001 General Census of Population and Housing. From the 280 variables defined at census block level (352,605 census tracts with average number of inhabitants 169, standard deviation 225; and average area 0.6 km², sd 2.4 km²) five traits that operationally combine to represent the multidimensionality of the social and material deprivation concept have been selected; these are: low level of education, unemployment, non-home ownership, one parent family and overcrowding. The index is calculated by summing standardized indicators and it is also available as categorical by quintiles of population. The same procedure is applied to aggregate frequency data at municipality level. The correlation between mortality and deprivation has been evaluated using 2000-2004 general mortality.

RESULTS

considering national data, a strong north-south gradient in deprivation was observed. The municipality deprivation index 2001 is highly correlated to the index likewise calculated on the basis of the previous 1991 Census (r=0.91). General mortality was positively correlated to the index (in particular in population up to 64 years and in larger size municipalities).

CONCLUSION

the pattern described by the deprivation index was coherent with what is already known about geographic distribution of poverty and its impact on mortality. Such outcome bears out the index use for epidemiological purposes.

[Air pollution and mortality in ten Italian cities. Results of the EpiAir Project]

OBJECTIVE

the relationship between air pollution and mortality has been well established in national and international scientific literature. This study reports the results of the EpiAir Project relative to the effect of air pollution on mortality in 10 Italian cities during 2001-2005. The association between particulate matter (PM10) and gases (nitrogen dioxide, NO2, and ozone, O3), and all natural mortality, as well as cardiac, cerebrovascular and respiratory mortality, is presented. Specific issues have been investigated, such as the latency of the air pollution-mortality effects and the identification of individual demographic characteristics and clinical conditions that result in greater susceptibility to the effects of particulate matter.

METHODS

the study population consisted of 276,205 subjects aged 35+ years old, resident in one of the 10 Italian cities studied, which died in the city between 2001-2005. For each subject, information was collected on cause of death, location of death, demographical variables and hospital discharge diagnoses in the previous 2-year period. The statistical analysis was adjusted for the relevant temporal and meteorological factors using the case-crossover approach. The results for ozone are limited to the warm semester (April through September). An analysis of the association between air pollution and mortality was conducted for each city, and the city-specific estimates were meta-analyzed on a second level to obtain a pooled result, and reported inter-city heterogeneity.

RESULTS

a short-term effect of PM10 on mortality has been detected for all the groups of causes considered, with latencies ranging from lag 0 for cerebrovascular mortality to lag 0-3 for respiratory mortality. The association between NO2 and mortality displays strong and similar effects for all death causes, with prolonged effects (lag 0-5) for all groups of causes. The results for O3 are similar to those found for NO2, with prolonged latency (lag 0-5) for all causes of death with the exception of cerebrovascular mortality, for which a delayed effect (lag 3-5) was identified. Individual susceptibility factors of the PM10-natural mortality association include age, as elderly subjects are especially vulnerable to the effects of particles.

CONCLUSIONS

the main results of the study suggest that the air pollution originated by vehicular traffic is the most relevant environmental problem in Italian cities from a public health viewpoint.

[Air pollution and urgent hospital admissions in nine Italian cities. Results of the EpiAir Project]

INTRODUCTION

the relationship between air pollution and hospital admissions has been well studied. In this study, the results of the Italian EpiAir Project are reported on the effect of air pollution on hospital admissions in 9 Italian cities during 2001-2005. The association between particulate matter (PM10) and gases (NO2 and O3) and hospital admissions for cardiac, cerebrovascular, respiratory conditions, pulmonary embolism and diabetes has been evaluated.

MATERIAL AND METHODS

The study population consists of 701,902 hospital admissions of subjects residents in nine Italian cities and hospitalized in the city in the period 2001- 2005. We used a case-crossover approach and the statistical analysis considered the relevant temporal and meteorological factors for confounding adjustment. The results for ozone refer to the warm semester. The analysis of the association between air pollution and admissions was conducted for each city, and the city-specific estimates were meta-analyzed to obtain pooled results.

RESULTS

we found an immediate effect of PM10 and NO2 (lag 0) for cardiac diseases as a group and for specific conditions (coronary syndrome and heart failure). No effect of ozone was observed. For cerebrovascular diseases we did not observe a positive effect of the three pollutants. An effect of NO2 on pulmonary embolism was detected. The association between air pollutants and hospitalization for respiratory diseases (respiratory infections, COPD and asthma) showed different lags for the three pollutants: the effect of PM10 was immediate at lag 0-1 while the effects of NO2 and ozone were prolonged at lag 0-5. The strongest association was between NO2 and asthma admissions, especially in children. No effects on diabetes were found.

CONCLUSIONS

the main results of the present study confirm the deleterious short term impact of air pollution on cardiovascular and respiratory morbidity in Italian cities.

[Environmental indicators in ten Italian cities (2001-2005): the air quality data for epidemiological surveillance]

OBJECTIVE

to produce environmental indicators suitable for an epidemiological surveillance in 10 Italian cities part of the EpiAir Project (2001-2005).

METHODS

the environmental parameters that correlate to relevant health effects are the particles with diameters less than or equal to 10 micrometers (PM10), the nitrogen dioxide (NO2) and the ozone (O3). The necessary meteorological data are: temperature, relative humidity, barometric pressure and apparent temperature.We have identified some criteria to select monitoring stations and have taken standard methods of calculation to produce environmental indicators starting from the daily data available after closely evaluating the completeness of the existing data. Furthermore, we have checked the homogeneity of the selected data to ensure that it represents the population's exposure.

RESULTS

close examination of descriptive statistics shows a critical situation of the considered pollutants. The analysis of the yearly state underlines for PM10 values higher than 40 microg/m3 in the area of Mestre-Venice and in Milan, Turin, Bologna e Taranto. For NO2, values are consistently above 40 microg/m3 in Milan, Turin, Bologna, Florence, Rome and Palermo. For ozone, the concentrations were stable, with the exception of Summer 2003 when we recorded, on average, an increase of 13% compared to the mean value estimated for the ten cities during the study period, especially in Mestre-Venice, Turin and Palermo.

CONCLUSIONS

it is important to ensure the consistency of the methods and instruments in environmental monitoring. To evaluate health effects and perform interventions over the longterm, it is therefore fundamental that the data be homogenous, especially during the periodic reorganizations and rationalizations of air quality management. It is also necessary to include daily meteorological data that influence pollutant dispersion and population health status.

Carotid lesions in outpatients with nonalcoholic fatty liver disease

AIM: To ascertain whether carotid lesions are more prevalent in outpatients with incidental findings of nonalcoholic fatty liver disease (NAFLD) at abdominal ultrasound (US).

METHODS: One hundred and fifty-four consecutive outpatients (age range 24-90 years, both sexes) referred by general practitioners for abdominal US, and drinking less than 20 g alcohol/day, underwent carotid US for an assessment of carotid intima-media thickness (c-IMT) and carotid plaque prevalence. Hepatic steatosis, visceral fat thickness and subcutaneous fat thickness were also assessed at ultrasonography.

RESULTS: Higher c-IMT values were found in the presence of NAFLD (90 patients), even after adjustment for indices of general and abdominal obesity and for the principal cardiovascular risk factors (0.84 ± 0.10 mm vs 0.71 ± 0.10 mm, P < 0.001). The prevalence of carotid plaques was 57.8% in the patients with NAFLD vs 37.5% in the patients without this condition (P = 0.02). The adjusted relative risk of having carotid plaques for patients with NAFLD was 1.85 (95% CI: 1.33-2.57, P < 0.001).

CONCLUSION: An incidental finding of hepatic steatosis may suggest the presence of silent carotid atherosclerotic lesions.

The influence of socioeconomic status on utilization and outcomes of elective total hip replacement: a multicity population-based longitudinal study

OBJECTIVE

In countries with universal health coverage, socioeconomic status is not expected to influence access to effective treatment and its prognosis. We tested whether socioeconomic status affects the rates of elective total hip replacement and whether it plays a role in early and late outcomes.

DESIGN

Multicity population-based longitudinal study.

SETTING AND PARTICIPANTS

From Hospital Registries of four Italian cities (Rome, Milan, Turin, and Bologna), we identified 6140 residents aged 65+ years undergoing elective total hip replacement in 1997-2000.

MAIN OUTCOME MEASURES

An area-based (census block) income index was used for each individual. Poisson regression yielded rate ratios (RR) of population occurrence by income level. Logistic regression estimated odds ratios (OR) of selected outcomes within 90 days. Cox proportional hazard models evaluated effects of income on rates of revision of total hip replacement and mortality up to 31 December 2004. Analyses were adjusted for age, gender, city of residence, and coexisting medical conditions.

RESULTS

Low-income people were less likely than high-income counterparts to undergo total hip replacement [RR = 0.87, 95% confidence interval (CI) 0.81-0.95]; the effect was stronger among those aged 75+ years (RR = 0.76, 95% CI = 0.66-0.86). Low income was associated with higher risk of acute adverse medical events (P trend = 0.05) and of general infections and decubitus ulcer (P trend = 0.02) within 90 days. The effects were even higher among those aged 75+ years. No effects were found either for orthopaedic complications within 90 days or for revision and mortality.

CONCLUSIONS

Total hip replacement is underutilized among elderly deprived individuals. Disadvantaged patients seem more vulnerable to acute adverse medical events after surgery. The evidence of unmet need and poor prognosis of low social class people has important implications for health care policy.