Familial hypercholesterolemia is the main genetic cause of premature coronary heart disease, char... more Familial hypercholesterolemia is the main genetic cause of premature coronary heart disease, characterized by serum LDL-cholesterol levels, which result in excess deposition of cholesterol in tissues. FH results from defects in hepatic uptake and degradation of LDL via the LDL receptor pathway. Owing to severe underdiagnosis and undertreatment of FH, there is an urgent worldwide need for diagnostic screeening together with early and aggressive tretment. This position paper aims to improve awareness of the need for early detection and management of FH patients, to determine treatment objectives and to delineate treatment priorities
A survey on knowledge, attitudes, and practice regarding breast and cervical cancer screening was... more A survey on knowledge, attitudes, and practice regarding breast and cervical cancer screening was conducted in Rome on a sample of women aged 18-64 years. Of the 793 interviewees, 31.9% had undergone at least one breast imaging examination; examinations were more frequent in women over 35 and in those familiar with breast self-examination and female pathophysiology. Seventy percent of the women had had at least one Pap smear. Women were classified as Pap smear underusers (26.0%), appropriate users (28.8%), and overusers (45.2%) as compared to standard screening recommendations, according to their age and their lifetime number of smears. Age over 35 was associated with both underuse and overuse. Such inappropriate screening patterns could be related in part to the fact that the women reported that their physicians recommendations for Pap smear frequency were once a year or more in 62%, and once every two or three years in only 2%.
Liver cirrhosis is a chronic disease characterized by a large burden of complications such as asc... more Liver cirrhosis is a chronic disease characterized by a large burden of complications such as ascites, bacterial peritonitis syndrome, bleeding for rupture of esophageal varices, encephalopathy, hepatic failure and hepatocellular carcinoma (HCC). As a consequence a subject affected by this disease requires frequent admission to the hospital, causing a remarkable impact on the national health system resources. Over the last few decades the prevention and management of liver cirrhosis complications have greatly improved, thanks to the large use of non selective beta blockers [1], large volume paracentesis (LVP) with albumin infusion [2], endoscopic band ligation of esophageal varices [3], and the availability of effective drugs for chronic hepatitis C virus (HCV) and chronic hepatitis B virus (HBV) infections [4–5]. Thus, a reduction in the rate of admission to hospitals for liver cirrhosis complications might be expected in more recent years. However, studies addressing this issue are lacking. In this paper the rate of hospital discharge for non-alcoholic liver cirrhosis from the hospitals of Lazio Region during the period 2000–2014 has been evaluated in order to evidence changes, if any, in the rate of admission for this disease. We have focused on non-alcoholic cirrhosis to better evaluate the potential role of the antiviral therapy. Lazio is a region located in central Italy with 5,800,000 inhabitants (including Rome). Like all other Italian regions, universal coverage for health care is provided free of charge to citizens. The outpatient and inpatient treatments and procedures are recorded in a health information system. The completeness and coverage are assured by the reimbursement system that is based on the number of hospital discharges and on the treatments given. Hospital Information System (HIS) of the Lazio Region, active since 1995, routinely collects discharge abstract data from all Lazio public and private hospitals. It includes: admission and discharge dates, discharge status, up to six discharge diagnoses codes using the International Classification of Diseases, Clinical
To develop and validate a predictive model for the identification of patients with Chronic Obstru... more To develop and validate a predictive model for the identification of patients with Chronic Obstructive Pulmonary Disease (COPD) among the resident population of the Lazio region, using information available in the regional administrative systems (SIS) as well as clinical data of a panel of COPD patients. All residents in the Lazio region over 40 years of age in 2007 (2,625,102 inhabitants) The predictive model was developed through record linkage of health care related consumption patterns among 428 panel patients with confirmed COPD diagnosis in 2006 and a control group of patients without COPD (selection from outpatients specialized health care registry, 1:4). Hospital admission for COPD was defined a priori to be sufficient to identify a COPD patient. For all other panel patients and controls, specific drug use (minimum 2 prescriptions during 12 months) and hospitalization for respiratory causes during the past 9 years were retrieved and compared between panel and control patient...
The increasing demand for comparative evaluation of outcomes requires the development and diffusi... more The increasing demand for comparative evaluation of outcomes requires the development and diffusion of epidemiologic research, the ability to correctly conduct analyses and to interpret results. When healthcare outcomes are used for comparing quality of care across providers, failure to use methods of risk adjustment to account for any variation in patient populations can lead to misinterpretation of the findings. The purpose of this paper is to provide a detailed but easy-reading review of different risk adjustment methodologies to compare health care outcomes. The paper is divided in two parts. Introduction describes the difference between experimental and observational studies, the role of confounding in observational studies and the ways confounding is identified and controlled (propensity adjustment and risk adjustment), Specific part on risk adjustment describes: (1) the methods for constructing the severity measures; (2) the methods that use the severity measures to obtain &q...
Most studies on the effectiveness of rehabilitation consider only particular rehabilitation treat... more Most studies on the effectiveness of rehabilitation consider only particular rehabilitation treatments for particular conditions, and do not give a global vision of the issue. This study evaluated the effectiveness of various types of post acute rehabilitative care in patients with different diagnoses by investigating the association between treatments and functional gain by type of impairment and severity on admission. Information on the characteristics of patients and the rehabilitative treatments was collected using an Italian version of the Minimum Data Set-Post Acute Care. The questionnaire was created and validated by the Centers for Medicare and Medicaid Services, it is divided in various section and was filled in at regular intervals throughout the hospital stay. Patients included in the study were 1918. We used factor analysis to summarize each section in a single continuous variable. The observed functional gain was calculated as the difference between functional status at...
Direct admission to Coronary Care Unit (CCU) on hospital arrival can be considered as a good prox... more Direct admission to Coronary Care Unit (CCU) on hospital arrival can be considered as a good proxy for adequate management in patients with acute myocardial infarction (AMI), as it has been associated with better prognosis. We analyzed a cohort of patients with AMI hospitalized in Rome (Italy) in 1997-2000 to assess the proportion directly admitted to CCU and to investigate the effect of patient characteristics such as gender, age, illness severity on admission, and socio-economic status (SES) on CCU admission practices. Using discharge data, we analyzed a cohort of 9127 AMI patients. Illness severity on admission was determined using the Deyo's adaptation of the Charlson's comorbidity index, and each patient was assigned to one to four SES groups (level I referring to the highest SES) defined by a socioeconomic index, derived by the characteristics of the census tract of residence. The effect of gender, age, illness severity and SES, on risk of non-admission to CCU was inve...
Outpatient care accounts every year for a large share of the National Health Fund spending, howev... more Outpatient care accounts every year for a large share of the National Health Fund spending, however characteristics of supply have not been thoroughly investigated. Objective of the study is the description of the outpatient care system of Lazio region and of the main characteristics of outpatient clinics, through indicators obtained using data from the Outpatient Care Information System (SIAS) for 1999. Outpatient clinics were classified into three categories: ASL managed clinics, private clinics and hospital trusts. Absolute and relative density of supply (respectively DAO and DRO) were used as indicators of clinics distribution in the regional area. Number of specialties, average procedure weight and volume of procedures performed were used as indicators of complexity. Absolute density of supply (DAO = n. of dispatch points/population) is generally high, and a large and statistically significant variability is observed (p < 0.001). The relative density (i.e. the correlation co...
Two cross-sectional surveys have been conducted in Rome in 1990 and 1992 to investigate prevalenc... more 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 po...
The effectiveness of a screening programme for HIV infection among prisoners is discussed, in rel... more 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.
The burden of inflammatory bowel diseases, including Crohn&amp;amp;amp;amp;amp;amp;amp;amp;am... more The burden of inflammatory bowel diseases, including Crohn&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s disease and ulcerative colitis, has never been estimated in Italy using administrative data sources. Our objective was to measure the occurrence of inflammatory bowel diseases in the Lazio region (Italy) using administrative data and to test the sensitivity of the Crohn&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s disease case-finding algorithm with respect to clinical diagnosis. We conducted a population-based cross-sectional study identifying prevalent and incident cases. We estimated occurrence rates of inflammatory bowel diseases using hospital discharges or activation of copayment exemptions. Sensitivity was calculated from 2358 subjects with clinical diagnosis of Crohn&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s disease. Exemptions identified more than 20% of the cases. Prevalence rates (per 100,000) on December 31, 2009 for males and females were 177 and 144 for ulcerative colitis and 91 and 81 for Crohn&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s disease, respectively. The incidence rates during the years 2008-2009 were 14.5 and 12.2 for ulcerative colitis and 7.4 and 6.5 for Crohn&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s disease for males and females, respectively. The sensitivity of the administrative sources was 82.2%. Health and population data sources allow the estimation of inflammatory bowel diseases occurrence. The age-specific peaks of diagnosis were consistent with those reported in other studies. Sensitivity may be affected by temporal changes in the quality of the data sources.
Data gathered through the Latium HIV Surveillance System were used in conjunction with a compartm... more 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.
Purpose There are some methodological concerns regarding results from observational studies about... more Purpose There are some methodological concerns regarding results from observational studies about the effectiveness of evidence-based (EB) drug therapy in secondary prevention after myocardial infarction. The present study used a nested case-control approach to address these major methodological limitations. Methods A cohort of 6880 patients discharged from hospital after acute myocardial infarction (AMI) in 2006-2007 was enrolled and followed-up throughout 2009. Exposure was defined as adherence to each drug in terms of the proportion of days covered (cutoff ≥ 75%). Composite treatment groups, that is, groups with no EB therapy or therapy with one, two, three, or four EB drugs), were analyzed. Outcomes were overall mortality and reinfarction. Nested case-control studies were performed for both outcomes, matching four controls to every case (841 deaths, 778 reinfarctions) by gender, age, and individual follow-up. The association between exposure to EB drug therapy and outcomes was analyzed using conditional logistic regression, adjusting for revascularization procedures, comorbidities, duration of index admission, and use of the study drugs prior to admission. Results Mortality and reinfarction risk decreased with the use of an increasing number of EB drugs. Combinations of two or more EB drugs were associated with a significant protective effect (p < 0.001) versus no EB drugs (mortality: 4 EB drugs: OR adj = 0.35; 95%CI: 0.21-0.59; reinfarction: 4 EB drugs: OR adj = 0.23; 95%CI: 0.15-0.37). Conclusions These findings of the beneficial effects of EB polytherapy on mortality and morbidity in a population-based setting using a nested case-control approach strengthen existing evidence from observational studies.
Define patients treated with evidence-based drugs in a cohort discharged after acute myocardial i... more Define patients treated with evidence-based drugs in a cohort discharged after acute myocardial infarction (AMI) in absence of prescribed daily doses (PDD). To compare different drug use measures and analyze their impact on the effect estimate of risk factors related to drug use. AMI patients discharged in Rome during 2006-2007 were selected from the Hospital Information System. Drugs claimed during the 12 months after discharge were retrieved. Measures of drug use were defined as: &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;continuity&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; (one prescription each follow-up quarter-year) and the &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;proportion of days covered&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; calculated by defined daily doses (DDDs) or pill counts (PCs) (≥ 80% of individual follow-up). Poly-therapy was defined through the same drug use measure for all drug groups. Kappa index was calculated to analyze the concordance between measures. For each measure we estimated the effect of age, gender and Percutaneous Transluminal Coronary Angioplasty (PTCA) on poly-therapy. Poly-therapy rates varied between 11.5 and 37.8% in the cohort and between 17.3 and 56.9% in patients with at least one prescription for all drugs. Concordance between all measures was high for antiplatelets (k=0.74) and very low for beta-blockers (k=0.22). According to measures used, gender and older age effects slightly varied, while PTCA remained a strong determinant of drug use. Different measures of exposure to drug treatment may affect the estimate of the proportion of treated patients and the effect estimates of risk factors. Drug dispense registries are useful, but it is necessary to develop and validate methodologies in absence of PDD.
We evaluated the disease management of transient ischemic attack in patients admitted to Lazio ho... more We evaluated the disease management of transient ischemic attack in patients admitted to Lazio hospitals from July 1997 to June 1998. We assessed the effects of patient characteristics including chronic comorbidities on the use of diagnostic procedures, endarterectomy, and on the risk of adverse cerebrovascular outcome or death. There were 2,608 patients in the study who were followed up over a 18- to 30-month period. Carotid surgery was performed on 1.15% of the subjects, total mortality was 34.7 per 1,000 person-years and adverse cerebrovascular outcome was observed in 38.1 per 1,000 person-years. Chronic comorbidities did affect the mortality rate and the rate of adverse outcome, but not the rate of endarterectomies. Carotid surgery was infrequently performed in study subjects. It seems that this potentially stroke-preventive treatment was not offered to suitable candidates in many instances.
Background: Coronary care units (CCUs) currently treat a variety of diseases, but little is known... more Background: Coronary care units (CCUs) currently treat a variety of diseases, but little is known about the effectiveness of CCUs on heart conditions other than acute myocardial infarction. Objectives: The objectives of this study were to evaluate the association between direct admission to CCUs and the risk of inhospital death in patients with heart disease, to investigate factors affecting direct admission to a CCU, and to assess the effect of CCU admission on the use of invasive procedures in patients with arrhythmias. Research Design: We conducted a retrospective analysis of discharge-abstract data from Lazio, Italy, hospitals. We used logistic regression, propensity score, and instrumental variable analysis to compare inhospital risk of death between patients admitted to CCUs and to ordinary wards in 13 different groups of heart disease. We used linear regression to study the association between the rate of CCU admission and the relative risk of death. Results: The study included 181,049 heart disease admissions, of which 8620 were admitted to CCUs (4.8%). Risk of death was significantly lower in patients admitted directly to CCUs for "acute myocardial infarction" (odds ratio [OR], 0.57), "acute ischemic heart disease" (OR, 0.55), and "other arrhythmias" (OR, 0.56). Mortality ORs were inversely related to the rate of CCU admission. CCU patients with arrhythmias received more invasive procedures (OR, 2.70) than non-CCU patients. Conclusion: Direct admission to a CCU is associated with a decrease in mortality for patients with "acute myocardial infarction," "acute heart ischemia," and "other arrhythmias." Patients most likely to benefit from CCU care are preferentially admitted to CCUs. CCUs make larger use of invasive procedures than ordinary wards.
The measures of clinical status used to predict costs must pay the most attention possible to med... more The measures of clinical status used to predict costs must pay the most attention possible to medical conditions and clinical complexity. Length of stay (LOS), which has been used as a proxy for resource consumption, is not a direct measure of costs. Classification and regression trees, which are used in defining iso-resource groups, can be affected by overfitting and are based on a priori choices of the splitting attributes. Finally, current approaches are mainly concerned in estimating average group costs and do not attempt to estimate individual case costs. We sought to define comprehensive measures of clinical status and detailed measures of resource consumption. We also sought to predict individual inpatient rehabilitation costs through multiple regression models. A prospective analysis was conducted of all rehabilitation cases admitted to 5 Italian inpatient facilities during a period of 12 months. All admissions underwent repeated Minimum Data Set-Post Acute Care (MDS-PAC) schedules to collect information on clinical status and treatment provided. We used factorial analysis to yield continuous variables representing clinical characteristics, and we priced treatments to obtain cost of stay. We used linear regression models to predict cost of stay and validated the model-based cost predictions by data-splitting. We collected 9720 MDS-PAC schedules from 2702 hospital admissions. The multivariate regression models fitted costs reasonably well with r(2) values of at least 0.34. On cross-validation, the ability of the regression models to predict cost was confirmed. We were able to estimate actual rehabilitation costs and define reliable regression models to predict costs from individual patient characteristics. Our approach identifies the contribution of any single patient characteristic to rehabilitation cost and tests the assumptions of the analysis.
To clarify the interactions between stressful life events and other risk factors in the developme... more 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&#39;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.
Familial hypercholesterolemia is the main genetic cause of premature coronary heart disease, char... more Familial hypercholesterolemia is the main genetic cause of premature coronary heart disease, characterized by serum LDL-cholesterol levels, which result in excess deposition of cholesterol in tissues. FH results from defects in hepatic uptake and degradation of LDL via the LDL receptor pathway. Owing to severe underdiagnosis and undertreatment of FH, there is an urgent worldwide need for diagnostic screeening together with early and aggressive tretment. This position paper aims to improve awareness of the need for early detection and management of FH patients, to determine treatment objectives and to delineate treatment priorities
A survey on knowledge, attitudes, and practice regarding breast and cervical cancer screening was... more A survey on knowledge, attitudes, and practice regarding breast and cervical cancer screening was conducted in Rome on a sample of women aged 18-64 years. Of the 793 interviewees, 31.9% had undergone at least one breast imaging examination; examinations were more frequent in women over 35 and in those familiar with breast self-examination and female pathophysiology. Seventy percent of the women had had at least one Pap smear. Women were classified as Pap smear underusers (26.0%), appropriate users (28.8%), and overusers (45.2%) as compared to standard screening recommendations, according to their age and their lifetime number of smears. Age over 35 was associated with both underuse and overuse. Such inappropriate screening patterns could be related in part to the fact that the women reported that their physicians recommendations for Pap smear frequency were once a year or more in 62%, and once every two or three years in only 2%.
Liver cirrhosis is a chronic disease characterized by a large burden of complications such as asc... more Liver cirrhosis is a chronic disease characterized by a large burden of complications such as ascites, bacterial peritonitis syndrome, bleeding for rupture of esophageal varices, encephalopathy, hepatic failure and hepatocellular carcinoma (HCC). As a consequence a subject affected by this disease requires frequent admission to the hospital, causing a remarkable impact on the national health system resources. Over the last few decades the prevention and management of liver cirrhosis complications have greatly improved, thanks to the large use of non selective beta blockers [1], large volume paracentesis (LVP) with albumin infusion [2], endoscopic band ligation of esophageal varices [3], and the availability of effective drugs for chronic hepatitis C virus (HCV) and chronic hepatitis B virus (HBV) infections [4–5]. Thus, a reduction in the rate of admission to hospitals for liver cirrhosis complications might be expected in more recent years. However, studies addressing this issue are lacking. In this paper the rate of hospital discharge for non-alcoholic liver cirrhosis from the hospitals of Lazio Region during the period 2000–2014 has been evaluated in order to evidence changes, if any, in the rate of admission for this disease. We have focused on non-alcoholic cirrhosis to better evaluate the potential role of the antiviral therapy. Lazio is a region located in central Italy with 5,800,000 inhabitants (including Rome). Like all other Italian regions, universal coverage for health care is provided free of charge to citizens. The outpatient and inpatient treatments and procedures are recorded in a health information system. The completeness and coverage are assured by the reimbursement system that is based on the number of hospital discharges and on the treatments given. Hospital Information System (HIS) of the Lazio Region, active since 1995, routinely collects discharge abstract data from all Lazio public and private hospitals. It includes: admission and discharge dates, discharge status, up to six discharge diagnoses codes using the International Classification of Diseases, Clinical
To develop and validate a predictive model for the identification of patients with Chronic Obstru... more To develop and validate a predictive model for the identification of patients with Chronic Obstructive Pulmonary Disease (COPD) among the resident population of the Lazio region, using information available in the regional administrative systems (SIS) as well as clinical data of a panel of COPD patients. All residents in the Lazio region over 40 years of age in 2007 (2,625,102 inhabitants) The predictive model was developed through record linkage of health care related consumption patterns among 428 panel patients with confirmed COPD diagnosis in 2006 and a control group of patients without COPD (selection from outpatients specialized health care registry, 1:4). Hospital admission for COPD was defined a priori to be sufficient to identify a COPD patient. For all other panel patients and controls, specific drug use (minimum 2 prescriptions during 12 months) and hospitalization for respiratory causes during the past 9 years were retrieved and compared between panel and control patient...
The increasing demand for comparative evaluation of outcomes requires the development and diffusi... more The increasing demand for comparative evaluation of outcomes requires the development and diffusion of epidemiologic research, the ability to correctly conduct analyses and to interpret results. When healthcare outcomes are used for comparing quality of care across providers, failure to use methods of risk adjustment to account for any variation in patient populations can lead to misinterpretation of the findings. The purpose of this paper is to provide a detailed but easy-reading review of different risk adjustment methodologies to compare health care outcomes. The paper is divided in two parts. Introduction describes the difference between experimental and observational studies, the role of confounding in observational studies and the ways confounding is identified and controlled (propensity adjustment and risk adjustment), Specific part on risk adjustment describes: (1) the methods for constructing the severity measures; (2) the methods that use the severity measures to obtain &q...
Most studies on the effectiveness of rehabilitation consider only particular rehabilitation treat... more Most studies on the effectiveness of rehabilitation consider only particular rehabilitation treatments for particular conditions, and do not give a global vision of the issue. This study evaluated the effectiveness of various types of post acute rehabilitative care in patients with different diagnoses by investigating the association between treatments and functional gain by type of impairment and severity on admission. Information on the characteristics of patients and the rehabilitative treatments was collected using an Italian version of the Minimum Data Set-Post Acute Care. The questionnaire was created and validated by the Centers for Medicare and Medicaid Services, it is divided in various section and was filled in at regular intervals throughout the hospital stay. Patients included in the study were 1918. We used factor analysis to summarize each section in a single continuous variable. The observed functional gain was calculated as the difference between functional status at...
Direct admission to Coronary Care Unit (CCU) on hospital arrival can be considered as a good prox... more Direct admission to Coronary Care Unit (CCU) on hospital arrival can be considered as a good proxy for adequate management in patients with acute myocardial infarction (AMI), as it has been associated with better prognosis. We analyzed a cohort of patients with AMI hospitalized in Rome (Italy) in 1997-2000 to assess the proportion directly admitted to CCU and to investigate the effect of patient characteristics such as gender, age, illness severity on admission, and socio-economic status (SES) on CCU admission practices. Using discharge data, we analyzed a cohort of 9127 AMI patients. Illness severity on admission was determined using the Deyo's adaptation of the Charlson's comorbidity index, and each patient was assigned to one to four SES groups (level I referring to the highest SES) defined by a socioeconomic index, derived by the characteristics of the census tract of residence. The effect of gender, age, illness severity and SES, on risk of non-admission to CCU was inve...
Outpatient care accounts every year for a large share of the National Health Fund spending, howev... more Outpatient care accounts every year for a large share of the National Health Fund spending, however characteristics of supply have not been thoroughly investigated. Objective of the study is the description of the outpatient care system of Lazio region and of the main characteristics of outpatient clinics, through indicators obtained using data from the Outpatient Care Information System (SIAS) for 1999. Outpatient clinics were classified into three categories: ASL managed clinics, private clinics and hospital trusts. Absolute and relative density of supply (respectively DAO and DRO) were used as indicators of clinics distribution in the regional area. Number of specialties, average procedure weight and volume of procedures performed were used as indicators of complexity. Absolute density of supply (DAO = n. of dispatch points/population) is generally high, and a large and statistically significant variability is observed (p < 0.001). The relative density (i.e. the correlation co...
Two cross-sectional surveys have been conducted in Rome in 1990 and 1992 to investigate prevalenc... more 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 po...
The effectiveness of a screening programme for HIV infection among prisoners is discussed, in rel... more 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.
The burden of inflammatory bowel diseases, including Crohn&amp;amp;amp;amp;amp;amp;amp;amp;am... more The burden of inflammatory bowel diseases, including Crohn&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s disease and ulcerative colitis, has never been estimated in Italy using administrative data sources. Our objective was to measure the occurrence of inflammatory bowel diseases in the Lazio region (Italy) using administrative data and to test the sensitivity of the Crohn&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s disease case-finding algorithm with respect to clinical diagnosis. We conducted a population-based cross-sectional study identifying prevalent and incident cases. We estimated occurrence rates of inflammatory bowel diseases using hospital discharges or activation of copayment exemptions. Sensitivity was calculated from 2358 subjects with clinical diagnosis of Crohn&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s disease. Exemptions identified more than 20% of the cases. Prevalence rates (per 100,000) on December 31, 2009 for males and females were 177 and 144 for ulcerative colitis and 91 and 81 for Crohn&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s disease, respectively. The incidence rates during the years 2008-2009 were 14.5 and 12.2 for ulcerative colitis and 7.4 and 6.5 for Crohn&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s disease for males and females, respectively. The sensitivity of the administrative sources was 82.2%. Health and population data sources allow the estimation of inflammatory bowel diseases occurrence. The age-specific peaks of diagnosis were consistent with those reported in other studies. Sensitivity may be affected by temporal changes in the quality of the data sources.
Data gathered through the Latium HIV Surveillance System were used in conjunction with a compartm... more 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.
Purpose There are some methodological concerns regarding results from observational studies about... more Purpose There are some methodological concerns regarding results from observational studies about the effectiveness of evidence-based (EB) drug therapy in secondary prevention after myocardial infarction. The present study used a nested case-control approach to address these major methodological limitations. Methods A cohort of 6880 patients discharged from hospital after acute myocardial infarction (AMI) in 2006-2007 was enrolled and followed-up throughout 2009. Exposure was defined as adherence to each drug in terms of the proportion of days covered (cutoff ≥ 75%). Composite treatment groups, that is, groups with no EB therapy or therapy with one, two, three, or four EB drugs), were analyzed. Outcomes were overall mortality and reinfarction. Nested case-control studies were performed for both outcomes, matching four controls to every case (841 deaths, 778 reinfarctions) by gender, age, and individual follow-up. The association between exposure to EB drug therapy and outcomes was analyzed using conditional logistic regression, adjusting for revascularization procedures, comorbidities, duration of index admission, and use of the study drugs prior to admission. Results Mortality and reinfarction risk decreased with the use of an increasing number of EB drugs. Combinations of two or more EB drugs were associated with a significant protective effect (p < 0.001) versus no EB drugs (mortality: 4 EB drugs: OR adj = 0.35; 95%CI: 0.21-0.59; reinfarction: 4 EB drugs: OR adj = 0.23; 95%CI: 0.15-0.37). Conclusions These findings of the beneficial effects of EB polytherapy on mortality and morbidity in a population-based setting using a nested case-control approach strengthen existing evidence from observational studies.
Define patients treated with evidence-based drugs in a cohort discharged after acute myocardial i... more Define patients treated with evidence-based drugs in a cohort discharged after acute myocardial infarction (AMI) in absence of prescribed daily doses (PDD). To compare different drug use measures and analyze their impact on the effect estimate of risk factors related to drug use. AMI patients discharged in Rome during 2006-2007 were selected from the Hospital Information System. Drugs claimed during the 12 months after discharge were retrieved. Measures of drug use were defined as: &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;continuity&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; (one prescription each follow-up quarter-year) and the &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;proportion of days covered&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; calculated by defined daily doses (DDDs) or pill counts (PCs) (≥ 80% of individual follow-up). Poly-therapy was defined through the same drug use measure for all drug groups. Kappa index was calculated to analyze the concordance between measures. For each measure we estimated the effect of age, gender and Percutaneous Transluminal Coronary Angioplasty (PTCA) on poly-therapy. Poly-therapy rates varied between 11.5 and 37.8% in the cohort and between 17.3 and 56.9% in patients with at least one prescription for all drugs. Concordance between all measures was high for antiplatelets (k=0.74) and very low for beta-blockers (k=0.22). According to measures used, gender and older age effects slightly varied, while PTCA remained a strong determinant of drug use. Different measures of exposure to drug treatment may affect the estimate of the proportion of treated patients and the effect estimates of risk factors. Drug dispense registries are useful, but it is necessary to develop and validate methodologies in absence of PDD.
We evaluated the disease management of transient ischemic attack in patients admitted to Lazio ho... more We evaluated the disease management of transient ischemic attack in patients admitted to Lazio hospitals from July 1997 to June 1998. We assessed the effects of patient characteristics including chronic comorbidities on the use of diagnostic procedures, endarterectomy, and on the risk of adverse cerebrovascular outcome or death. There were 2,608 patients in the study who were followed up over a 18- to 30-month period. Carotid surgery was performed on 1.15% of the subjects, total mortality was 34.7 per 1,000 person-years and adverse cerebrovascular outcome was observed in 38.1 per 1,000 person-years. Chronic comorbidities did affect the mortality rate and the rate of adverse outcome, but not the rate of endarterectomies. Carotid surgery was infrequently performed in study subjects. It seems that this potentially stroke-preventive treatment was not offered to suitable candidates in many instances.
Background: Coronary care units (CCUs) currently treat a variety of diseases, but little is known... more Background: Coronary care units (CCUs) currently treat a variety of diseases, but little is known about the effectiveness of CCUs on heart conditions other than acute myocardial infarction. Objectives: The objectives of this study were to evaluate the association between direct admission to CCUs and the risk of inhospital death in patients with heart disease, to investigate factors affecting direct admission to a CCU, and to assess the effect of CCU admission on the use of invasive procedures in patients with arrhythmias. Research Design: We conducted a retrospective analysis of discharge-abstract data from Lazio, Italy, hospitals. We used logistic regression, propensity score, and instrumental variable analysis to compare inhospital risk of death between patients admitted to CCUs and to ordinary wards in 13 different groups of heart disease. We used linear regression to study the association between the rate of CCU admission and the relative risk of death. Results: The study included 181,049 heart disease admissions, of which 8620 were admitted to CCUs (4.8%). Risk of death was significantly lower in patients admitted directly to CCUs for "acute myocardial infarction" (odds ratio [OR], 0.57), "acute ischemic heart disease" (OR, 0.55), and "other arrhythmias" (OR, 0.56). Mortality ORs were inversely related to the rate of CCU admission. CCU patients with arrhythmias received more invasive procedures (OR, 2.70) than non-CCU patients. Conclusion: Direct admission to a CCU is associated with a decrease in mortality for patients with "acute myocardial infarction," "acute heart ischemia," and "other arrhythmias." Patients most likely to benefit from CCU care are preferentially admitted to CCUs. CCUs make larger use of invasive procedures than ordinary wards.
The measures of clinical status used to predict costs must pay the most attention possible to med... more The measures of clinical status used to predict costs must pay the most attention possible to medical conditions and clinical complexity. Length of stay (LOS), which has been used as a proxy for resource consumption, is not a direct measure of costs. Classification and regression trees, which are used in defining iso-resource groups, can be affected by overfitting and are based on a priori choices of the splitting attributes. Finally, current approaches are mainly concerned in estimating average group costs and do not attempt to estimate individual case costs. We sought to define comprehensive measures of clinical status and detailed measures of resource consumption. We also sought to predict individual inpatient rehabilitation costs through multiple regression models. A prospective analysis was conducted of all rehabilitation cases admitted to 5 Italian inpatient facilities during a period of 12 months. All admissions underwent repeated Minimum Data Set-Post Acute Care (MDS-PAC) schedules to collect information on clinical status and treatment provided. We used factorial analysis to yield continuous variables representing clinical characteristics, and we priced treatments to obtain cost of stay. We used linear regression models to predict cost of stay and validated the model-based cost predictions by data-splitting. We collected 9720 MDS-PAC schedules from 2702 hospital admissions. The multivariate regression models fitted costs reasonably well with r(2) values of at least 0.34. On cross-validation, the ability of the regression models to predict cost was confirmed. We were able to estimate actual rehabilitation costs and define reliable regression models to predict costs from individual patient characteristics. Our approach identifies the contribution of any single patient characteristic to rehabilitation cost and tests the assumptions of the analysis.
To clarify the interactions between stressful life events and other risk factors in the developme... more 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&#39;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.
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Papers by Massimo Arcà