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The aim of this study was to assess the prognostic role of co-morbidity in severe chronic obstructive pulmonary disease (COPD). A cohort of 270 COPD patients, mean (+/-SD) age 67+/-9 yrs, consecutively discharged from a University Hospital after an acute exacerbation was studied. Mean (+/-SD) forced expiratory volume in one second (FEV1) was 34+/-16% of predicted and FEV1/forced vital capacity (FVC) was 40.5+/-13.8%. The most common co-morbid diseases were: hypertension (28%), diabetes mellitus (14%), and ischaemic heart disease (10%). Clinical, electrocardiogram (ECG), and respiratory function data taken at the time of discharge were collected from the clinical records. The Charlson's index was used to quantify co-morbidity. Follow-up was conducted by means of telephone calls. Multivariate survival analysis was used to identify the independent predictors of death. The median survival of the cohort was 3.1 yrs. Death was predicted by the following variables: age (hazard rate (HR) 1.04; 95% confidence intervals (95% CI) 1.02-1.05), ECG signs of right ventricular hypertrophy (HR 1.76; 95% CI 1.30-2.38), chronic renal failure (HR 1.79; 95% CI 1.05-3.02), ECG signs of myocardial infarction or ischaemia (HR 1.42; 95% CI 1.02-1.96), FEV1 < 590 mL (HR 1.49; 95% CI 0.97-2.27). A score based upon these variables predicted mortality at 5 yrs with a sensitivity of 63% and a specificity of 77%. Selected co-morbid diseases and electrocardiogram signs of right ventricular hypertrophy play a major prognostic role in advanced chronic obstructive pulmonary disease. The clinical assessment of patients with chronic obstructive pulmonary disease should include these important and easily measurable variables.

OBJECTIVES--Gasoline contains established human carcinogens, such as benzene. The health impact of exposure to this fuel, however, has not been fully elucidated. We report on the mortality of a cohort of 2665 filling station managers from the Latium region (Italy). METHODS--This is the first workplace-based cohort of gas station attendants. However, only self-employed individuals were available for study (about 50% of the whole work force). The follow-up period extended from 1981 through 1992. The mortality experience of the cohort was compared with that of the regional population. RESULTS--The overall analysis for standardized mortality ratios (SMR) showed a significantly decreased mortality from all causes, mainly due to a deficit of cardiovascular diseases and malignant neoplasms. Nonsignificantly increased risks for esophageal cancer [SMR 241, 90% confidence interval (90% CI) 82-551], brain cancer (SMR 195, 90% CI 77-401) and non-Hodgkin's lymphoma (SMR 173, 90% CI 47-448) were found for the men; mortality due to lung cancer and leukemia was lower than expected, and no kidney cancer death was recorded. Among the attendants of small stations (characterized by a small number of employees and high sales of gasoline per full-time employee), the SMR values for esophageal cancer (for men SMR 351, 90% CI 120-803) and brain cancer (for men and women SMR 266, 90% CI 105-559) showed increased values. CONCLUSIONS--Filling station attendants are exposed to gasoline vapors and seem at risk of cancer of various sites. Due to the power limitations of this study, however, a precise estimate of the risk for many causes of death was not achievable. Further cohort studies of greater size are warranted.

In Maryland researchers aimed to determine whether clinical staging using the World Health Organization (WHO) proposed system would predict progression from HIV seropositivity to AIDS. They used product-limit estimates with right censoring to compare time of progression to AIDS among 694 intravenous drug users (IVDUs) in Baltimore who were HIV-positive by January 1992 from each of the WHO proposed systems 1st 3 clinical stages. The researchers used Cox proportional hazard methods to examine the effect of race sex age and baseline injection status on the risk of progression by clinical stage. Most of the participants were Black (95%) poor (legal income of

We estimated the AIDS survival by neighborhood socioeconomic status before (1993-1995) and after (1996-1997) the introduction of highly active antiretroviral therapy in Rome, Italy, in a retrospective cohort of persons with AIDS followed through July 31, 1998. Participants included 1,474 persons with AIDS residing in Rome who were diagnosed in 1993-1997. We calculated hazard ratios (HRs) of death for two diagnostic periods (before and after highly active antiretroviral therapy was introduced) by neighborhood socioeconomic status categorized into four levels (level I = highest socioeconomic status), using the Cox model and adjusting for gender, age, intravenous drug use, CD4 cell count at diagnosis, AIDS-defining disease, and hospital of diagnosis. Thirty-four per cent of persons with AIDS (N = 503) had survived as of mid-1998. For persons with AIDS diagnosed in 1993-1995, we found little difference in the risk of death by neighborhood socioeconomic status. For 1996-1997, the risk of death was greater for persons with lower neighborhood socioeconomic status, especially for levels III and IV [HR = 2.81 (95% confidence interval = 1.38-5.76), and HR = 2.55 (95% confidence interval = 1.27-5.14), respectively, compared with level I]. Stratified analyses showed that the greatest difference was found for women and drug users. In conclusion, even in a country with universal health coverage that provides therapy at no cost, differences in survival of persons with AIDS have emerged by neighborhood socioeconomic status since highly active antiretroviral therapy was introduced. Inequalities in health-care access or in medical management, or poor adherence to treatment, could explain the observed heterogeneity.

To investigate temporal changes in survival of persons with AIDS (PWA) diagnosed in Lazio, Italy.Longitudinal study of 2862 PWA registered at the AIDS Surveillance System in the period 1 January 1993 to 30 June 1997 and followed for vital status up to 31 May 1998.Hazard ratios (HR) of death were calculated by year of diagnosis and by year of follow-up, adjusting for gender, age, modality of exposure, CD4 cell count at diagnosis, and AIDS-defining illness, using the Cox proportional regression model.In the period 1 January 1993 to 31 May 1998, 1914 PWA died. The multivariate model showed a decrease of the risk of death for patients diagnosed from 1995 onward compared with patients diagnosed in 1993 [1995: HR 0.82; 95% confidence intervals (CI) 0.73-0.93; 1996: HR 0.44; 95% CI 0.38-0.51; first semester of 1997: HR 0.47; 95% CI 0.37-0.59]. The model with the year of follow-up modeled as time-dependent variable showed a statistically significant decline in the risk of death starting from the first quarter of 1997 (HR 0.62; 95% CI 0.48-0.80) and reached the minimum in the first two quarters of 1998 (first quarter: HR 0.13; 95% CI 0.08-0.21; second quarter: HR 0.14, 95% CI 0.08-0.25). There was a small difference in the magnitude of the risk estimates among genders, with a slower improvement in survival among females [first semester of 1997 for males HR was 0.51 (95% CI 0.39-0.66) whereas for females HR was 0.80 (95% CI 0.51-1.27)].Survival of PWA in a population-based study improved significantly in the era when highly active antiretroviral therapy became available, but such improvement is not homogeneous among genders.

OBJECTIVES: To evaluate whether ceramic workers exposed to silica experience an excess of end stage renal disease. METHODS: On the basis of a health surveillance programme, a cohort of 2980 male ceramic workers has been enrolled during the period 1974-91 in Civitacastellana, Lazio, Italy. For each worker, employment history, smoking data, and x ray film readings were available. The vital status was ascertained for all cohort members. All 2820 people still alive and resident in the Lazio region as in June 1994 were searched for a match in the regional end stage renal diseases registry, which records (since June, 1994) all patients undergoing dialysis treatment in public and private facilities of the region. Expected numbers of prevalent cases from the cohort were computed by applying the rate of patients on dialysis treatment by the age distribution of the cohort. RESULTS: A total of six cases was detected when 1.87 were expected (observed/expected (O/E) = 3.21; 95% confidence interval (95% CI) 1.17 to 6.98). The excess risk was present among non-smokers (O = 2; O/E = 4.34) and smokers (O = 4; O/E = 2.83), as well as among workers without silicosis (O = 4; O/E = 2.78) and workers with silicosis (O = 2; O/E = 4.54). The risk was higher among subjects with < 20 years since first employment (O = 4; O/E = 4.65) than among those employed > 20 years. CONCLUSION: These results provide further evidence that exposure to silica dust among ceramic workers is associated with nephrotoxic effects.

The risk of developing active tuberculosis associated with a different size of induration to purified protein derivative (PPD) has not been prospectively assessed among individuals infected with human immunodeficiency virus (HIV). The quantification of this risk is important to more appropriately identify candidates for preventive therapy for tuberculosis.A prospective, multicenter, cohort study on tuberculosis in HIV-infected patients was conducted in 23 infectious disease units in public hospitals in Italy. Two thousand six hundred ninety-five HIV-infected patients were enrolled in the study. Of these, 1054 patients who were nonanergic at the time of entry were included in the present analysis. The median duration of follow-up was 102 weeks. The main outcome measure was a diagnosis of active tuberculosis confirmed by the isolation of Mycobacterium tuberculosis in culture.Among the 252 patients with PPD reactivity, patients with an induration to PPD of 2 to 4 mm had a median CD4+ lymphocyte count of 0.34 x 10(9)/L (interquartile [IQ] range, 0.14 x 10(9)-0.56 x 10(9)), those with a response of 5 to 9 mm had a median count of 0.38 x 10(9)/L (IQ range, 0.24 x 10(9)-0.56 x 10(9)), and those with a response of 10 mm or higher had a median count of 0.37 x 10(9)/L (IQ range, 0.23 x 10(9)-0.52 x 10(9)) (P = .38). Compared with the 802 nonanergic PPD-negative patients, hazard ratios of tuberculosis were 2.1 (95% confidence interval [CI], 0.2-18.3) among the 55 patients with a response to PPD of 2 to 4 mm, 5.7 (95% CI, 1.6-19.8) among the 128 patients with a response to PPD of 5 to 9 mm, and 23.1 (95% CI, 7.8-68.6) among the 69 patients with a response to PPD of 10 mm or higher.Among nonanergic HIV-infected patients, the degree of response to tuberculin does not appear to reflect the degree of immunosuppression and is strongly correlated with the subsequent incidence of tuberculosis. To identify HIV-infected patients who are at an increased risk of tuberculosis and may benefit from preventive therapy, a response to PPD of 5 mm appears to be an appropriate cutoff point.

Objective of this study was to assess the mortality experience of a cohort of chemical workers at a plant located in central Italy. Subjects employed for any time between 1954 and 1970 at the chemical plant were included in the cohort and followed up to June 1991. The workers were classified as having ever/never worked in one of the following work processes: organic chemicals, acid mixtures, cleansing agents and insecticides. Mortality experience of the cohort was compared with that of the regional population by computing SMRs (standardized mortality ratios) and 90% CI (confidence intervals). Vital status was ascertained for 96% of the 505 cohort members. All causes of mortality for the entire cohort were lower than expected (Obs: 176; SMR: 0.90; 90% CI: 0.79-1.03). Analysis by work process revealed an increased mortality for lymphatic and hematopoietic tissue neoplasm in the cleansing agents department (Obs: 3; SMR: 5.00; 90% CI: 1.36-12.9); peritoneum and retropertioneum neoplasm in the organic compounds production (Obs: 2; SMR: 13.33; 90% CI: 2.37-42.0), and bladder cancer in the insecticides process (Obs: 3; SMR: 3.53; 90% CI: 0.96-9.12). Although the study had a low statistical power, the increased cancer risks detected are consistent with previous observations and may be of etiologic interest.

To assess the rate of needlestick injury in hospital personnel in an Italian region. To identify risk factors potentially amendable to correction.Hospital workers undergoing hepatitis B prevaccination testing in 1985 through 1986 were interviewed regarding needlestick injury in the previous year, job category, area of work, years of employment, and other pertinent information.Of the 98 public hospitals of the Latium region, 68 participated in the survey: 32 of 55 with less than 200 beds, 20 of 25 with 200 to 300 beds, 11 of 13 with 400 to 900 beds, and all of the 5 with more than 1,000 beds.All healthcare workers providing direct patient care or environmental services as well as student nurses were invited by the hospital directors to undergo hepatitis B prevaccination testing and vaccination, if eligible.Of 30,226 hospital workers of the 68 participating hospitals, 20,055 were interviewed (66.3%): 47.7% of the 7,172 doctors, 71% of the 14,157 nurses, 55.9% of the 2,513 technicians, and 71.9% of the 6,384 ancillary workers. Needlestick injury was recalled by 29.3%; the rates were 54.9%, 35.3%, 33.8%, 26.5%, 18.7%, and 14.7% in surgeons, registered and unskilled nurses, physicians, ancillary workers, and technicians, respectively. The recalled injury rate was 39.7% and 34.0% in surgical and intensive care areas; in infectious diseases, it was 16.7%. Rates were lower in hospitals with 200 to 300 beds (25.6%). The needlestick injury rate declined from 32% in those with less than 5 years of employment to 28% in those with more than 20 years (p less than .01). Prevalence of HBV infection was higher in student nurses and young workers recalling a needlestick exposure (14.3% and 15.8%, respectively), versus 10.1% and 12.8% in those not exposed (p less than .01 and less than .05, respectively).Parenteral exposure to blood-borne infectious agents is a relevant risk among healthcare workers in our region, particularly in defined job categories and hospital areas (surgeons, nurses, surgical, and intensive care areas). Immunization and educational efforts should be made along with better designs of devices to reduce the risk of infection.

The aim was to quantify all cause mortality among injecting drug users.This was a retrospective analysis of 1989 data on injecting drug users and mortality obtained from three independent agencies: the Procurator Fiscal's Office, the General Register Office, and the Scottish HIV-test register.Greater Glasgow, Scotland.Drug injectors, estimated population 9424.81 names were found using the three sources to identify deaths. After removing duplicates, 51 deaths were found. This represented a mortality rate of 0.54% in the estimated population. Among female injectors the mortality rate was 0.85%, significantly higher than the rate of 0.42% among male injectors (95% CI for the true difference in mortality rates between female and male injectors was 0.31%-0.55%). Over 90% of deaths were attributed to overdose or suicide. Although AIDS caused only one death, 19% of cases (5/27) whose HIV antibody status could be ascertained were positive. The mortality rate among HIV positive injectors (3.8%) was significantly higher than among HIV negative injectors (0.49%).Comprehensive coverage using three data sources revealed a far greater annual number of all cause deaths among injectors than would have been expected from previous research. The observed mortality rate was lower than in previous studies where the denominators used to calculate rates had an element of underenumeration. For the foreseeable future it is unlikely that AIDS will have much impact on mortality among injectors in Glasgow, because of the low prevalence of HIV infection among injectors in the city, and because HIV positive injectors are dying for reasons other than AIDS; rather, overdose and suicide will continue to be the main causes of death.

This case-referent study evaluated cancer risks among farmers in central Italy. Cancer cases (N = 1674, 17 sites) were selected from all deceased men aged 35-80 years; a random sample of 480 decedents formed the reference series. Farmers had a decreased risk of lung and bladder cancer and melanoma and nonsignificant excess risks for stomach, rectal, kidney, and nonmelanoma skin cancer. Stomach and kidney cancer were significantly increased among the farmers with > 10 years' experience, and stomach, rectal, and pancreatic cancer were increased among licensed pesticide users with > 10 years' experience. Possible relationships emerged between specific crops and cancer: fruit and colon and bladder cancer, wheat and prostate cancer, olives and kidney cancer, and potato and kidney cancer. The results regarding stomach, pancreatic, lung, bladder, and prostate cancer and melanoma congrue with earlier results. The kidney cancer excess, the association of colon and bladder cancer with orchard farming, and the excess of rectal cancer among licensed farmers are new and unexpected findings.

The aim of this study was to evaluate whether risk factors associated with cardiovascular or respiratory diseases and lung cancer occur differently among nonsmoking women in Italy with and without exposure to environmental tobacco smoke (ETS) from husbands that smoke. We performed a cross-sectional study of 1,938 nonsmoking women in four areas of Italy. Data on respiratory and cardiovascular risk factors and on diet were collected using self-administered questionnaires. Medical examinations and blood tests were administered; urine cotinine levels were measured. Nonsmoking women ever exposed to husbands' smoking were compared with unexposed women for several factors: education, husband's education, household crowding, number of children, current or past occupation, exposure to toxic substances at work, parental diseases, self-perceived health status, physician-diagnosed hypertension, hypercholesterol, diabetes, osteoporosis, chronic respiratory diseases, blood pressure medications, lifestyle and preventive behaviors, dietary variables, systolic and diastolic blood pressure, body mass index, waist-hip ratio, triceps skin folds, plasma antioxidant (pro-) vitamins (- and ss-carotene, retinol, l-ascorbic acid, -tocopherol, lycopene), serum total and HDL cholesterol, and triglycerides. Women married to smokers were more likely to be less educated, to be married to a less educated husband, and to live in more crowded dwellings than women married to nonsmokers. Women married to smokers were significantly less likely to eat cooked [odds ratio (OR) = 0.72; 95% confidence interval (CI), 0.55-0.93] or fresh vegetables (OR = 0.63; CI, 0.49-0.82) more than once a day than women not exposed to ETS. Exposed women had significantly higher urinary cotinine than unexposed subjects (difference: 2.94 ng/mg creatinine). All the other variables were not more prevalent among exposed compared to unexposed subjects. The results regarding demographic factors are easily explained by the social class distribution of smoking in Italy. A lower intake of vegetables among exposed women in our study is consistent with the available literature. Overall, our results do not support previous claims of more frequent risk factors for cardiovascular and pulmonary diseases among ETS-exposed subjects. In Italy, as elsewhere in Europe and North America, women who have never smoked but are married to smokers are likely to be of lower social class than those married to never-smokers. However, once socioeconomic differences are considered, the possibility of confounding in studies on the health effects of ETS is minimal.