SOCIOECONOMIC INEQUALITY IN PREMATURE MORTALITY IN ITALY: A NATIONAL CENSUS-BASED RECORD LINKAGE STUDY

Background Socioeconomic status (SES) is a well-recognized determinant of health. A high prevalence of risk factors for non-communicable diseases along with reduced access to early diagnosis and effective treatment have historically been thought to be the main mechanisms underlying the relationship between low SES and poor health. However, the phenomenon is more complex and involves also psychosocial factors, such as stress, depression, financial difficulties, lack of social support, and low job control, all risk factors for poor health. Nowadays, inequalities in health represents a major challenge for health policies, having a high social, ethical and economic impact even in high-income countries. This is particularly true during economic recessions, when unemployment and financial problems is expected to affect more people with medium or low SES. However, results on the impact of macroeconomic changes on socioeconomic inequalities in health are controversial and substantial differences exist among European countries with higher inequality in North and East Europe compared to southern European countries. In Europe, the evidence on inequalities in mortality comes mainly from national, longitudinal, census-linked or unlinked studies, whereas in Italy most of the data are based only on urban areas. The lack of national study precludes a comprehensive analysis of socioeconomic inequalities in mortality in Italy which can measure the impact of SES on cause-specific mortality and evaluate within-country geographic differences and the interaction with other variables. Aim The study aimed to quantify socioeconomic inequality in premature mortality in absolute and relative terms in Italy considering also geographic differences and the role of other variables, such as marital status, size of the municipality, and social and material vulnerability of the municipality of residence. Methods The study was based on the record linkage of national administrative databases, including the 2011 census and the mortality registries. Each death occurred in Italy from census date (9 October 2011) onwards was linked to the census using the tax identification number as linkage key. This allowed to conduct a cohort study based on all Italian residents. In this report, the mortality registries for the period 2011-2015 were linked to the 2011 census and the individuals alive on 1 January 2012 were included in the cohort. Education and occupation were used to determine the SES of the individual. Four levels of education were considered: no education or primary school, middle school, high school and university. Occupation-based social class was obtained by using the Erikson-Goldthorpe scheme with the following classes: non-skilled manual, skilled manual workers, farmers, self-employees, routine non-manual and upper non-manual workers. Relative inequality was measured by computing the age-adjusted mortality rate ratio (MRR) and the relative index of inequality (RII), whereas absolute inequality was measured by calculating the slope index of inequality (SII). The MRR and the RII was estimated by fitting multiplicative Poisson regression models, whereas the SII was estimated by fitting additive Poisson models. RII and SII were obtained by regressing the mortality rate of SES groups on a specific measure of their relative position in the social hierarchy: the socioeconomic rank, i.e. the proportion of the population that has a higher position, scaled to take values between 0 (highest rank) and 1 (lowest rank). The level of education was used to obtain the socioeconomic rank. RII and SII express the magnitude of socioeconomic inequality in relative and absolute terms, respectively, by providing a unique estimate of the inequality that can be used for comparisons within the same population or between different populations. The resulting figures can be interpreted as the ratio (for RII) or difference (for SII) of mortality rates between those at the bottom and those at the top of the social hierarchy. RII and SII were used to rank the causes of death by relative and absolute inequality. Results A total of 35,708,445 subjects aged between 30 and 74 years were included in the study. In four years of follow-up, 573,335 deaths were registered over 137,847,954 person-years at risk. Being low educated and having a less prestigious job had a negative effect on overall premature mortality and mortality from most of the causes of death considered in this study. Compared to men with the highest level of education (university graduates), the MRR from all causes was 1.30 (95% CI: 1.10-1.53) for men with high school diploma, 1.64 (95% CI: 1.40-1.92) for those with middle school diploma and 1.93 (95% CI: 1.65-2.27) among those with no education or primary school certificate. Compared to women with the highest level of education (university graduates), the MRR from all causes was 1.14 (95% CI: 1.01-1.29) for women with high school diploma, 1.31 (95% CI: 1.16-1.48) for those with middle school diploma and 1.44 (95% CI: 1.28-1.63) among those with no education or primary school certificate. Compared to men in the upper non-manual class, the MRR from all causes was 1.24 (95% CI: 1.18-1.30) among routine non-manual workers, 1.31 (95% CI: 1.24- 1.38) among self-employees, 1.48 (95% CI: 1.35-1.63) among farmers, 1.37 (95% CI: 1.30- 1.45) among skilled manual workers and 1.63 (95% CI: 1.55-1.71) among non-skilled manual workers. In women, all the other classes showed only a slight increase in mortality as compared to upper non-manual workers, with the only exception of farmers who had comparable mortality rates. The MRR was 1.07 (95% CI: 1.02-1.13) among routine non-manual workers, 1.14 (95% CI: 1.06-1.23) among self-employees, 1.03 (95% CI: 0.89-1.19) among farmers, 1.08 (95% CI: 0.98-1.20) among skilled manual workers and 1.09 (95% CI: 1.03-1.16) among non-skilled manual workers. Socioeconomic inequality for all-cause mortality was higher in men than in women, both in relative (RII for men: 2.07, 95% CI: 1.81-2.37, RII for women: 1.51, 95% CI: 1.35-1.68) and absolute terms (SII for men: 373 deaths per 100.000 person-years, 95% CI: 327-419, SII for women: 113 deaths per 100.000 person-years, 95% CI: 88-138). In relative terms, the causes of death with the highest inequality were: laryngeal cancer (RII: 5.69, 95% CI: 4.54-7.15), chronic liver diseases (RII: 5.03, 95% CI: 3.72-6.80), chronic lower respiratory diseases (RII: 4.83, 95% CI: 3.59-6.50) and HIV/AIDS (RII: 4.77, 95% CI: 3.11-7.31) among men, and diabetes (RII: 5.75, 95% CI: 4.48-7.37), HIV/AIDS (RII: 4.33, 95% CI: 2.55-7.38) and chronic liver diseases (RII: 3.47, 95% CI: 2.71-4.44) among women. The causes of death with the highest absolute socioeconomic inequality were: circulatory system diseases (SII: 85 deaths per 100,000 person-years, 95% CI: 76-94) and lung cancer (SII: 58 deaths, 95% CI: 52-64) among men, and circulatory system diseases (SII: 43 deaths, 95% CI: 37-49) and diabetes (SII: 12 deaths, 95% CI: 10; 14) among women. Socioeconomic inequality in all-cause mortality was higher among singles (RII in men: 3.24, 95% CI: 2.68-3.92, RII in women: 2.71, 95% CI: 2.11-3.49), separated or divorced (RII in men: 2.58, 95% CI: 2.30-2.58, RII in women: 1.67, 95% CI: 1.26-1.50) than married individuals (RII in men: 1.80, 95% CI: 1.63-1.98, RII in women 1.42, 95% CI: 1.32-1.53). People living in large municipalities ( 6550,000 residents) showed a higher level of socioeconomic inequality (RII in men: 2.42, 95% CI: 2.09-2.79, RII in women: 1.68, 95% CI: 1.68, 95% CI 1.52-1.86) than those living in small municipalities (<2000 residents) (RII in men: 1.88, 95% CI: 1.66-2.14, RII in women: 1.40, 95% CI: 1.12-1.62). Women living in municipalities with high social and material vulnerability showed higher socioeconomic inequality in overall mortality (RIIs: 1.70, 95% CI: 1.51-1.91 and 1.34, 95% CI: 1.19-1.49 for those living in the last and first fifths of the distribution of the vulnerability index of the municipality of residence, respectively), whereas the estimates among men overlapped. Socioeconomic inequality in mortality from circulatory system diseases and diabetes was greater in women from southern Italy, while there are no substantial geographic differences in men. The RIIs for all circulatory system diseases were: 2.73 (95% CI: 2.39-3.12) in women living in the South, 1.86 (95% CI: 1.55-2.22) in those living in the Center and 2.01 (95% CI: 2.01, 1.72-2.36) in those living in the North. The RIIs for diabetes were: 6.21 (95% CI: 4.80-8.08) in women living in the South, 4.32 (95% CI: 3.33-5.61) in those living in the Center and 3.71 (95% CI: 2.78, 1.72-4.95) in those living in the North of the country. Conclusions The successful linkage of national databases allowed, for the first time, to provide a comprehensive picture of socioeconomic inequality in mortality in Italy. Socioeconomic inequality in premature mortality is still a major public health problem in Italy. It is more pronounced among some groups of the population, such as singles, separated and divorced individuals, those living in large municipalities, and women living in southern Italy or in municipalities with high social and material vulnerability. Lung cancer (in men), circulatory system diseases (in both sexes) and diabetes (in women) are the major contributors to the absolute socioeconomic inequality in Italy. The findings of this study will have important implications for planning policies to reduce the existing disparities in mortality in Italy

Derivation of linear elasticity for a general class of atomistic energies

The purpose of this paper is the derivation, in the framework of Gamma-convergence, of linear elastic continuum theories from a general class of atomistic models, in the regime of small deformations. Existing results are available only in the special case of one-well potentials accounting for very short interactions. We consider here the general case of multi-well potentials accounting for interactions of finite but arbitrarily long range. The extension to this setting requires a novel idea for the proof of the Gamma-convergence which is interesting in its own right and potentially relevant in other applications

Dietary approach to stop hypertension (DASH) diet and associated socioeconomic inequalities in the United Kingdom

The dietary approach to stop hypertension (DASH) diet is an effective measure in the prevention and treatment of CVD. We evaluated recent trends in socioeconomic differences in the DASH score in the UK population, using education, occupation and income as proxies of socioeconomic position (SEP). We analyzed data on 6416 subjects aged 18 and older collected in the National Diet and Nutrition Survey (NDNS 2008-2016). The DASH score was calculated using sex-specific quintiles of DASH items. Multiple linear regression and quantile regression models were used to evaluate the trend in DASH score according to SEP. The mean DASH score was 24 (standard deviation: 5). The estimated mean differences between people with no qualification and those having the highest level of education was -3.61 points (95% CI: -4.00; -3.22). The mean difference between subjects engaged in routine occupations and those engaged in high managerial and professional occupations was -3.41 points (95% CI: -3.89; -2.93) and for those in the first fifth and last fifth of the household income distribution was -2.71 points (95% CI: -3.15; -2.28). DASH score improved over time and no significant differences in the trend were observed across SEP. The widest socioeconomic differences emerged for consumption of fruit, vegetables, wholegrains, nuts, seeds and legumes. Despite an overall increase in the DASH score, a persisting SEP gap was observed. This is an important limiting factor in reducing the high socioeconomic inequality in CVD observed in the UK

Long working hours and cardiovascular mortality: a census-based cohort study

Objectives Long working hours have been associated with cardiovascular disease (CVD) mortality. However, results are inconsistent and large cohort studies are needed to confirm these findings. Methods We conducted a census-based cohort study including 11,903,540 Italian workers aged 20-64 years, registered in the 2011 census, with a 5-year follow-up (2012-2016). We estimated cause-specific hazard ratios (cHRs) through Cox regression models to quantify the association between long working hours and CVD mortality. Results Over 5 years of follow-up, 17,206 individuals died from CVD (15,262 men and 1944 women). Men working 55 or more hours per week had a cHR of 0.95 (95% confidence interval, CI 0.89-1.02) for all CVDs, while women showed a cHR of 1.19 (95% CI 0.95-1.49). Professional women working more than 55 h per week had a cHR of 1.98 (95% CI 0.87-4.52). Conclusions This study does not support an association between long working hours and CVD mortality among active Italian men, while it suggests a possible excess risk among women, although based on limited number of events

Random parking, Euclidean functionals, and rubber elasticity

We study subadditive functions of the random parking model previously analyzed by the second author. In particular, we consider local functions $S$ of subsets of $\mathbb{R}^d$ and of point sets that are (almost) subadditive in their first variable. Denoting by $\xi$ the random parking measure in $\mathbb{R}^d$, and by $\xi^R$ the random parking measure in the cube $Q_R=(-R,R)^d$, we show, under some natural assumptions on $S$, that there exists a constant $\bar{S}\in \mathbb{R}$ such that % $$\lim_{R\to +\infty} \frac{S(Q_R,\xi)}{|Q_R|}\,=\,\lim_{R\to +\infty}\frac{S(Q_R,\xi^R)}{|Q_R|}\,=\,\bar{S}$$ % almost surely. If $\zeta \mapsto S(Q_R,\zeta)$ is the counting measure of $\zeta$ in $Q_R$, then we retrieve the result by the second author on the existence of the jamming limit. The present work generalizes this result to a wide class of (almost) subadditive functions. In particular, classical Euclidean optimization problems as well as the discrete model for rubber previously studied by Alicandro, Cicalese, and the first author enter this class of functions. In the case of rubber elasticity, this yields an approximation result for the continuous energy density associated with the discrete model at the thermodynamic limit, as well as a generalization to stochastic networks generated on bounded sets.Comment: 28 page

Derivation of a linearised elasticity model from singularly perturbed multiwell energy functionals

Linear elasticity can be rigorously derived from finite elasticity under the assumption of small loadings in terms of Gamma-convergence. This was first done in the case of one-well energies with super-quadratic growth and later generalised to different settings, in particular to the case of multi-well energies where the distance between the wells is very small (comparable to the size of the load). In this paper we study the case when the distance between the wells is independent of the size of the load. In this context linear elasticity can be derived by adding to the multi-well energy a singular higher order term which penalises jumps from one well to another. The size of the singular term has to satisfy certain scaling assumptions whose optimality is shown in most of the cases. Finally, the derivation of linear elasticty from a two-well discrete model is provided, showing that the role of the singular perturbation term is played in this setting by interactions beyond nearest neighbours

Intercostal neurolysis for the treatment of postsurgical thoracic pain: A case series

Introduction: We investigated the possible role of intercostal surgical neurolysis in relieving chronic neuropathic pain refractory to other nonsurgical treatments in patients with postsurgical thoracic pain. Methods: We retrospectively collected clinical data on patients referred to the Neurosurgery Unit of Policlinic Hospital of Milan. Ten patients (age range, 20-68 years) suffering from neuropathic pain for at least 2 months after thoracic surgery underwent intercostal neurolysis. Results: Compared with preneurolysis, pain intensity decreased 1 month postneurolysis and remained stable 2 months postneurolysis (median score [interquartile range]: 8 [6-9] preneurolysis, 4 [3-5] 1 month after, and 3 [2-5] 2 months after, P < 0.001). Antiepileptic drugs for pain control decreased after neurolysis. Discussion: Surgical intercostal neurolysis may be a promising therapeutic option in patients with chronic neuropathic pain associated with neurological deficits

Low-Calorie Beverage Consumption, Diet Quality and Cardiometabolic Risk Factors in British Adults

Low-calorie beverages (LCBs) are promoted as healthy alternatives to sugar-sweetened beverages (SSBs); however, their effects on diet quality and cardiometabolic profile are debatable. This study aimed to verify the association between LCB consumption, diet quality and cardiometabolic risk factors in British adults. Data analysis from 5521 subjects aged 16 and older who participated in two waves of the National Diet and Nutrition Survey Rolling Programme (2008\u207b2012 and 2013\u207b2014) was carried out. Compared with SSB consumption, LCB consumption was associated with lower energy (mean difference: -173 kcal, 95% confidence interval, CI: -212; -133) and free sugar intake (-5.6% of energy intake, 95% CI: -6.1; -5.1), while intake of other nutrients was not significantly different across groups. The % difference in sugar intake was more pronounced among the young (16\u207b24 years) (-7.3 of energy intake, 95% CI: -8.6; -5.9). The odds of not exceeding the UK-recommended free sugar intake were remarkably higher in the LCB as compared to the SSB group (OR: 9.4, 95% CI: 6.5\u207b13.6). No significant differences were observed in plasma glucose, total cholesterol, LDL, HDL or triglycerides. Our findings suggest that LCBs are associated with lower free sugar intake without affecting the intake of other macronutrients or negatively impacting cardiometabolic risk factors

On the effect of interactions beyond nearest neighbours on non-convex lattice systems

We analyse the rigidity of non-convex discrete energies where at least nearest and next-to-nearest neighbour interactions are taken into account. Our purpose is to show that interactions beyond nearest neighbours have the role of penalising changes of orientation and, to some extent, they may replace the positive-determinant constraint that is usually required when only nearest neighbours are accounted for. In a discrete to continuum setting, we prove a compactness result for a family of surface-scaled energies and we give bounds on its possible Gamma-limit in terms of interfacial energies that penalise changes of orientation