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Biomedical subjects

Marina Davoli

Publications and source records attributed to Marina Davoli.

15 recordsLinked to original sources
PubMed2006

Heroin maintenance treatment for chronic heroin-dependent individuals: a Cochrane systematic review of effectiveness.

The provision of prescribed heroin to chronic heroin-dependent individuals failing other treatments has been supported during the last 70 years on the ground that the first goal of interventions on drug users is to keep them in treatment to protect them from criminal activities and to promote social integration. To assess heroin prescription effectiveness, we conducted a Cochrane systematic review of all relevant randomized controlled trials. We searched MEDLINE, EMBASE, CINAHL, and the Cochrane Library and contacted leading researchers for ongoing studies. We found 19 eligible studies, of which 4 met our inclusion criteria (577 patients). In 1 study, patients in the heroin arm remained in treatment longer than those in the methadone arm (n = 96, RR = 2.82, 95% CI = 1.70-4.68); in 2 studies, there was no difference; and in 1 study, patients given heroin left the study earlier than those given methadone (n = 235, RR = 0.79, 95% CI = 0.68-0.90). Heroin was more effective than methadone in refraining people from using street heroin in 2 studies (n = 96, RR = 1.10, 95% CI = 0.79-1.53; n = 51, RR = 0.33, 95% CI = 0.15-0.72). In 1 study, heroin reduced the risk of being charged (RR = 0.32, 95% CI = 0.14-0.78); 2 studies showed no difference, and another 2 studies adopted a multidomain outcome enclosing criminal offense and social functioning and found improvements with heroin + methadone over methadone only. It is unclear if heroin attracts people in treatment; those in treatment use less street heroin and are likely to have less criminal activities. This review systematizes and compares studies showing some inconsistencies between their aims, their adopted outcomes, and their conclusions drawn from results.

Chronic Disease↗
PubMed2006

VEdeTTE, a longitudinal study on effectiveness of treatments for heroin addiction in Italy: study protocol and characteristics of study population.

The aim of this study was to provide a methodological overview of the study design of the national evaluation large-scale study VEdeTTE and a description of the VEdeTTE study population and to compare enrollments with refusals and the study population with the overall clients at the National Health System (NHS) treatment centers. VEdeTTE is a longitudinal study of heroin addicts recruited in 115 NHS treatment centers in Italy, 1998-2001; 11,903 people were enrolled, 3876 refused to participate; data were analysed on 10,454. Information from refusals was compared to enrollments. The characteristics of the cohort were compared to those of all patients treated in 1999 in Italy. Refusals had a lower educational level and less regular occupational status than those enrolled. Fourteen percent of enrolled patients were women; heroin users in the VEdeTTE study were older than patients attending all NHS treatment centers in Italy; incident cases were less represented. The majority of participants had more than 8 years of education, 33.5% were regularly employed, and only 2% did not have a fixed address. Injectors were 72.3%; 40.6% had a previous overdose, and 14.3% had been imprisoned for life; 15.7% shared injection equipment during the previous 6 months. The proportion of participants reporting heroin use approximately halved from the beginning of the current treatment to the time of the interview. The VEdeTTE study is the biggest cohort of heroin addicts attending treatment centers in Europe. The Italian heroin-addicted population under treatment seems to have low level of education but good social integration. Compared with men, women show a higher severity. Participants show a beneficial effect of treatment.

Adult↗
PubMed2006

Methadone treatment in clinical practice in Italy: need for improvement.

BACKGROUND: Methadone at appropriate doses has been demonstrated to be the most effective means for retaining patients in treatment and suppressing heroin use. AIM: To describe the modalities of day-to-day provision of methadone maintenance treatments (MMT) in Italian public health centres and to analyze the duration of MMTs by dose and by association with psychosocial treatments. PATIENTS AND METHODS: We analyzed 8,378 subjects, 18 years of age or over, enrolled between September 1998 and March 2001 in one of 115 public treatment centres for heroin dependence in Italy. Treatment data were collected for each subject from enrolment to the end of the study period (maximum of 18 months). RESULTS: Of the total of 29,495 treatments delivered, 21.0% were methadone maintenance, and 34.4% were methadone detoxification. Fifty percent of MMTs offered had a mean dose less than or equal to 40 mg/day, and only 19% had doses higher than or equal to 60 mg/day; treatments with doses higher than 60 mg/day lasted longer than treatments with lower doses. Differences in treatment length were observed between MMTs associated with a psychosocial treatment and those offered alone, only for doses <60 mg/day. CONCLUSIONS: In Italy, MMTs are delivered at inappropriate doses in more than 80% of the cases. The increase of methadone doses to adequate levels as indicated by the literature is necessary to ensure proper and effective use of MMTs in public treatment centres for heroin users.

Cohort Studies↗
PubMed2005

Drug-related mortality and its impact on adult mortality in eight European countries.

OBJECTIVE: To estimate the mortality rates from drug-related deaths and other causes among problem drug users and population attributable risk of death due to opiate use in eight study sites in Europe. METHODS: Opiate users were recruited from drug treatment centres during the period 1990-1998 and deaths followed up through national or local mortality registries. Gender-specific overall mortality rate, proportion of deaths by cause (drug-related, HIV, other), standardized mortality ratios (SMRs), and the attributable risk fraction (ARF) were estimated. RESULTS: Crude mortality rates varied from 1 per 100 person-years in the Dublin and London cohorts to 3.8 per 100 person-years in Barcelona. The highest drug-related mortality rate was 10 per 1,000 person-years in Barcelona; the rates were approximately 7 per 1,000 person-years in Denmark, London, Rome, and Vienna, and <3.5 per 1,000 person-years for the others cohorts. The mortality rate for AIDS was <2 per 1,000 person-years in all the cohorts except Lisbon, Rome, and Barcelona, for which it was approximately 6 per 1,000 person-years. The highest SMR among males was 21.1 in Barcelona, and among females the highest SMRs were 53.7 and 37.7 in Barcelona and Rome, respectively. In Denmark the ARF was 5%, whereas it was >10% in all other study sites and 24% in Barcelona. CONCLUSION: Cohort mortality studies, especially in combination with estimates of prevalence, provide useful insights into the impact of opiate use on mortality across European countries and emphasize how preventing overall and drug-related deaths among opiate users can significantly improve the health of the population.

Adolescent↗
PubMed2005

Income inequality and mortality in Italy.

BACKGROUND: The relationship between income inequality and health remains controversial in terms of whether or not it exists and, if so, its extent and the mechanisms involved. This study examines the relationship between income inequality, as indicated by the Gini coefficient, and mortality in Italy. METHODS: Cross-sectional ecological study on the 57,138,489 inhabitants living in the 95 provinces existing in Italy in 1994. Multivariate weighted regression analysis of total and age-specific mortality, income inequality, gender, and interaction between income inequality and median income or geographical area. RESULTS: A positive association between income inequality and total mortality was observed for both genders in provinces with a low per capita income and in Southern and Central Italy. The effect was present for infants and for persons over 24 years of age; it was marked for the elderly, particularly women. A negative association with mortality was observed for males living in the North-west. Interactions between income inequality and median income, and between income inequality and geographical area were found. CONCLUSION: In Italy, the relationship between income inequality and health is mixed and not universal, in so far as a positive association was observed only in provinces with lower absolute income. Elderly persons living in Southern Italy represent the population subgroup most vulnerable to unequal income distribution. Income inequality can, in part, explain the historically higher mortality among women in Southern Italy compared to women in the North. These results indicate that income inequality affects the health of population subgroups differentially.

Adolescent↗
PubMed2005

Determinants of methadone treatment assignment among heroin addicts on first admission to public treatment centres in Italy.

AIMS: To identify factors associated with entering any methadone treatment at first admission at an NHS treatment centre in Italy and to investigate determinants of receiving detoxification or maintenance methadone treatments. METHODS: Data were analysed from 565 heroin addicts who entered for the first time one of 90 NHS treatment centres in 12 Italian regions between September 1998 and March 2001. Subjects were interviewed at admission by the centre's staff and followed-up for 18 months. Details on treatments provided were recorded using a standardised form. Random effects logistic regression analysis was applied. RESULTS: Factors positively associated with any methadone treatment assignment were: being younger than 25 years and using heroin more than twice a day, having been recently incarcerated, and living with a partner. Independent predictors of admission to methadone maintenance were injecting heroin, having sex without a condom in the previous six months, being HIV positive and having been enrolled at a NHS TC where a psychiatrist was present. Using heroin once a day or more and using cocaine were factors associated with enrollment into detoxification treatment. A significant heterogeneity between centres was observed. CONCLUSIONS: Results from this study give an insight into different patient profiles who are enrolled in methadone treatments. The observed heterogeneity between centres indicates the need to develop and implement common guidelines for the access of heroin addicts to substitution treatment.

Adult↗
PubMed2005

An overview of systematic reviews of the effectiveness of opiate maintenance therapies: available evidence to inform clinical practice and research.

AIM: To summarize the major findings of the five Cochrane reviews on substitution maintenance treatments for opioid dependence. METHODS: We conducted a narrative and quantitative summary of systematic review findings. There were 52 studies included in the original reviews (12,075 participants, range 577-5894): methadone maintenance treatment (MMT) was compared with methadone detoxification treatment (MDT), no treatment, different dosages of MMT, buprenorphine maintenance treatment (BMT), heroin maintenance treatment (HMT), and l-alpha-acetylmethadol (LAAM) maintenance treatment (LMT). MEASUREMENTS: Outcomes considered were retention in treatment, use of heroin and other drugs during treatment, mortality, criminal activity, and quality of life. FINDINGS: Retention in treatment: MMT is more effective than MDT, no treatment, BMT, LMT, and heroin plus methadone. MMT proved to be less effective than injected heroin alone. High doses of methadone are more effective than medium and low doses. Use of heroin: MMT is more effective than waiting list, less effective than LAAM, and not different from injected heroin. No significant results were available for mortality and criminal activity. CONCLUSIONS: These findings confirm that MMT at appropriate doses is the most effective in retaining patients in treatment and suppressing heroin use but show weak evidence of effectiveness toward other relevant outcomes. Future clinical trials should collect data on a broad range of health outcomes and recruit participants from heterogeneous practice settings and social contexts to increase generalizability of results.

Buprenorphine↗
PubMed2004

Effectiveness of interventions on opiate withdrawal treatment: an overview of systematic reviews.

AIM: To provide an overview of 5 Cochrane reviews of different approaches for treating opioid withdrawal. DESIGN: Narrative and quantitative summary of review findings. PARTICIPANTS: There were 46 studies included in the original reviews with a total of 3350 participants (range 18-300). INTERVENTION: The 5 reviews considered 46 studies covering seven different comparisons, the major ones being methadone compared with alpha2-adrenergic agonists and other opioid agonists, different alpha2-adrenergic agonists compared with each other and to antagonist-induced withdrawal and buprenorphine. MEASUREMENTS: The outcomes considered were signs and symptoms of withdrawal, retention in treatment, completion rate, relapse rate and side effects. FINDINGS: Methadone detoxification results in higher retention in treatment, lower relapse rate and fewer side effects when compared with adrenergic agonists. No difference was observed when comparing different adrenergic agonists; buprenorphine appears to have an advantage over adrenergic agonists on withdrawal symptoms and side effects. CONCLUSIONS: Despite the considerable number of trials that have been carried out on this topic, they are very heterogeneous as far as the comparisons and outcomes considered. This prevented many of them from being incorporated into a quantitative meta-analysis. Consensus in measurements and results should be reached among researchers involved in the evaluation of the effectiveness of treatments for opiate addiction in order to produce consistent outcomes in the measuring and reporting of results from clinical trials.

Adrenergic alpha-Agonists↗
PubMed2002

A systematic review on the efficacy of naltrexone maintenance treatment in opioid dependence.

AIM: To evaluate the efficacy of naltrexone maintenance treatment in preventing relapse in opioid addicts after detoxification. DESIGN: A systematic review according to the methodology developed by the Cochrane Collaboration based on either randomized controlled trials (RCTs) or controlled clinical trials (CCTs). PARTICIPANTS: Seven hundred and seven heroin dependent in- and out-patients, or former heroin addicts dependent on methadone and participating in a naltrexone treatment programme; 89% were male. INTERVENTION: Maintenance treatments on opiate dependent people after detoxification, comparing naltrexone with placebo, pharmacological or behavioural treatments. MEASUREMENTS: The outcomes considered were successfully completed treatment, opioid use under treatment (re)-incarcerations during the study period, mean duration of treatment. FINDINGS: The outcomes tended to be slightly although not significantly in favour of the naltrexone groups. Use of naltrexone in addition to behavioural treatment significantly decreased the probability of (re-)incarceration (OR=0.30; 95% CI 0.12, 0.76). The difficulties in producing a quantitative analysis were due mainly to the heterogeneity of the included studies. CONCLUSIONS: From the available clinical trials performed up to this time, there is insufficient evidence to justify the use of naltrexone in maintenance treatment of opioid addicts.

Controlled Clinical Trials as Topic↗
PubMedDate not supplied

[Summary of systematic revisions of the efficacy of smoking cessation therapy].

Smoking cessation can be considered the most effective strategy to reduce smoking related mortality at medium term. The aim of this study is to conduct an overview of systematic reviews of effectiveness of smoking cessation interventions in the general population. Medline, Embase and the Cochrane Library for the years 1990-march 2001 have been searched for those systematic reviews of primary studies evaluating the effectiveness of smoking cessation interventions in the general population, adult smokers. The outcome measure was abstinence from smoking at 6 months after the start of the intervention. Thirty papers were found, 15 Cochrane reviews and 15 other systematic reviews. The present overview focuses on Cochrane reviews, because they were more recent and followed a standardised methodology. The interventions which proved to be successful were: the simple medical advice, a structured intervention from nurses, individual counselling, group therapy, nicotine replacement therapy, and bupropion. There is not enough evidence yet that one strategy is better than another. Even though there is evidence that it is possible to quit smoking without any intervention, we can recommend that every physician register the smoking habits of his patients, encourage smokers to quit and offer all the available effective strategies.

Acupuncture Therapy↗
PubMedDate not supplied

[Volume and health outcomes: an overview of systematic reviews].

BACKGROUND: Improving quality and effectiveness of health care is one of the priorities of health policies. Hospital or physician volume of activity may be a measurable variable with a relevant impact on effectiveness of health care. There are several studies and systematic reviews evaluating the association between volume and outcome of health care. The aim of this review is to identify: areas, clinical conditions or interventions (prevention, diagnostic, therapeutic, surgical or clinical) for which an association between volume and outcome has been investigated; those for which an association between volume and outcome has been proved METHODS: Overview of systematic reviews and Health Technology Assessment reports; search of MEDLINE, EMBASE, The Cochrane Library, Web sites of Health Technology Assessment, other HTA Agencies, National guideline Clearinghouse, National Health Care quality tools (1995-february 2005). For each studied area results are described separately for each review due to the heterogeneity of outcomes, volume thresholds and results reported. No metanalysis has been conducted. Completeness of reporting of the systematic reviews has been evaluated using the QUOROM statement. For each review we evaluated the number of studies included and the proportion of studies with statistically significant results (p < 0,05). As far as in-hospital mortality is concerned, the different areas have been classified in the following groups: Strong evidence ofpositive association: areas with > or =10 studies included in the reviews, and high prevalence (> or =50%) of positive studies (p <0. 05) in the majority of reviews. Weak evidence of association: areas with 5 to 9 studies included in the reviews and high prevalence (> or =50%) of positive studies (p <0.05) in the majority of reviews. Weak evidence of lack of association: areas with 5 to 9 studies included in the reviews and high prevalence (>50%) of not statistically significant studies (p >0.05) in the majority of reviews. No suficient evidence of association: areas with less than 5 studies included in the reviews. No evidence of association: areas with > or =10 studies included in the reviews, and high prevalence (>50%) of not statistically significant studies (p >0.05) in the majority of reviews. The same literature search was then applied to identify primary studies published in each considered area following the most recent systematic review published. RESULTS AND DISCUSSION: We identified 21 systematic reviews and included 11 of them analysing 46 different areas. The majority of studies evaluate the effect of specific surgical procedures; the main outcomes considered are hospital mortality and 5 year survival for cancers. Considering in-hospital mortalilty as outcome, in 11 areas there is strong evidence ofassociation between volume of activity and outcome: abdominalaortic aneurysm (unruptured), percutaneous transluminal coronary angioplasty knee arthroplasty coronary artery bypass, surgery for oesophageal and pancreatic cancer, surgery for prostate cancer, colecistectomy, carotid endarterectomy, myocardial infarction, neonatal intensive care. It is never possible however to identify a unique volume threshold. For some of these areas, particularly coronary angioplasty and coronary artery bypass, there are many new studies published following the last systematic review; some specific aspects are being investigated such as the role of temporal changes in the association, the effect of different risk adjustment procedures and the separate role of physician or hospital volume. In some cases, for example knee arthroplasty in-hospital mortality could be an inadequate outcome on which judging the strength of association, in fact, the few studies evaluating other outcomes such as complications provide inconsistent results. For a range of areas the evidence of association is weak: AIDS, appendicectomy, cardiac catheterization, surgery for breast, lung, stomach cancer, hernia repair, hip fracture, hysterectomy and injuries. As far as AIDS is concerned, the few number of studies found is probably due to the lack of studies published after the introduction of effective therapies. All the included studies show an evidence of association between volume and in-hospital mortality. In no case we found weak evidence of lack of association while we identified three conditions for which the number of studies included in the reviews together with the prevalence of non significant studies do suggest lack of association; these are abdominal aortic aneurysm (ruptured), hip arthroplasty and surgery for colorectal cancer. In the case of hip arthroplasty as well, inhospital mortality could be an inadequate outcome, but only one old study found a positive association with risk of complications. Eventually there is a group of areas (n=22) for which there is not enough evidence to draw conclusions about the association between volume and outcome due to a small number of studies. In some cases, such as transplants, this could be due to the low rate of events; in this case all the few published studies show positive results. There are some limitations which should be taken into account in the interpretation of these results: despite the overall good completeness of reporting of the included reviews, the majority of studies included in the reviews themselves are cross-sectional studies representing a very weak study design to evaluate causality of the investigated association. Moreover the methodology of risk adjustment applied is heterogenous among studies and it is difficult to know the extent to which this can affect the observed results. It is eventually necessary to consider the possible occurrence of publication bias which could lead to an overestimation of the positive effect of volume on health care outcomes attributable to the lack of publication of negative studies. CONCLUSIONS: In some areas the evidence seems strong enough to guide health care organizational choices, although it is not possible to identify well defined volume thresholds. In other areas, particularly for non surgical conditions, where there is not enough evidence, it seems necessary to conduct proper epidemiological studies. Also the evaluation of effectiveness of using volume as an instrument of health policy requires further research. Taking into account the rapid and continuing process of technology development, the definition of standard and prerequisite volumes of care should be specific of each temporal period and health care system. It is therefore a dynamic process requiring a continuous review of the available evidence. In the area of evidence based public health, the limited available evidence should not impair the choice of actions based on limited evidence, but rather it should lead to the application of thefew available evidence on one side and to the planning of proper research in the areas of lack of evidence.

Evidence-Based Medicine↗
PubMedDate not supplied

[Potentially avoidable hospitalisation in Bologna, 1997-2000: temporal trend and differences by income level].

OBJECTIVE: To describe the temporal trend of hospitalisations for Ambulatory Care Sensitive Conditions (ACSCs) from 1997 to 2000 in Bologna (Italy) and to analyze the association with the income level. DESIGN AND SETTING: We have selected two panels of ACSCs: eight conditions for the paediatric/young population (<20 years of age) and fourteen for the adult population (> or =20 years of age). All discharges for ACSCs of residents in Bologna from Emilia-Romagna hospitals have been selected in the years 1997-2000. An indicator of social position was computed: the median per capita equivalent income by census block, obtained through record linkage between the Italian Tax Register (income earned in 1998) and the Population Register of Bologna. MAIN OUTCOME MEASURES: The direct age-standardized rates and the rate ratio by income level have been calculated. The Poisson regression model has been used to calculate the relative risk (RR) of hospitalizations for ACSCs. RESULTS: 2359 (17.6% of the total) hospitalisations have been selected among the paediatric/young population and 27822 (11.1% of the total) among the adult population. The annual age-adjusted rate of ACSC is 122.68 per 10000 persons among children and 176.60 among adults. The hospitalisation forACSCs among children is associated with a middle-low level of income (RR 1.55; CI 95% 1.35-1.78 for the lowest level vs. highest level), male gender and age <5 years old. In the adult population the risk of hospitalisation for ACSCs is higher among those with lower levels of income (RR 1.80; CI 95% 1.66-1.95 for the lowest level vs. highest level), moreover the RR is higher for men at every age. The admissions forACSCs among adults show a decreasing temporal trend. CONCLUSIONS: The disadvantaged groups of the population experience the highest risk of hospitalisation for ACSCs, with differences by gender and age groups. Although it is difficult to specifically identify the mechanisms potentially involved in the relationship between socioeconomic status and excess of hospitalisation, the admissions for ACSCs may represent an interesting indicator of quality ofprimary care.

Adult↗