Three essays on the role of federalism in the Swiss healthcare system

Switzerland is a country with a strongly decentralized political system, based on federalism and institutions of direct democracy, on a liberal economic culture, and on a well-developed tradition of mutualism and social security (generous social expenditure and welfare system). Switzerland is unique for its high level of decentralization and for the particular distribution of competences and roles between the central State (the Confederation) and the cantonal authorities. This particular setting allows cantons to have significant leeway in the organization of health care and the implementation of specific public policies. This thesis aims to give a contribution to the health economics literature, assessing some of the internal implications of the Swiss federal setting in the health care sector (chapters 1 and 2) and drawing some more general public policy results, exploiting the Swiss context (chapter 3). The first two chapters explore two different sides of the equity of the Swiss health care system. In the first chapter, I assess to what extent the political autonomy allocated to cantons leads to differences in the level of regressivity in the financing of the health care system and over time. The second chapter investigates the role of managed care contracts and higher deductible on the equity in health care utilization. Finally, in the third chapter I carry out a policy evaluation analysis to assess the causal effects of smoking bans on acute myocardial infarction. Different from the other two chapters, this work draws conclusions that abstract from the Swiss context. Switzerland is the perfect setting where to employ our empirical strategy, due to the different times of implementation of the policy if interest. However, the results have external validity. Each work is based on a different database: the first and the third are based on administrative data, while the second one relies on survey data

Aspetti radiomici del tumore mammario: studio di associazione tra <i>signature</i> radiomica ed istotipo

Aim of this study is to assess the role of radiomics in breast cancer, focusing on its ability to predict histological phenotypes. Methods: It was carried out a retrospective study including all breast cancer patients who referred to the Diagnostic Imaging 2 Institute to perform a breast MRI prior to surgery. Histologic confirmation on surgical specimen was obtained in all patients. Results: All patients underwent a high-field (1,5 T) breast MRI (T2-weight sequences with fat suppression, T1-weight sequences and T1 after IV contrast administration). MRI enhanced sequences were contoured and first-order radiomics features were extracted through dedicated software, called 3DSlicer. Taking into account the current literature, three features were selected: entropy, 90° percentile and skewness. The association between the selected features and the histological patterns were explored. Conclusion: A possible integration of quantitative data, provided by a radiomics analysis, with clinical and histological data could enable clinicians to provide an early and accurate diagnosis as well as personalized treatments for breast cancer patients. Current limitations of a routinely application of radiomics seem both the limited knowledge among physicians of this quantitative radiological tool and the lack of standardized systems of feature extraction and data sharing

A case-report of a pulmonary tuberculosis with lymphadenopathy mimicking a lymphoma.

Abstract Clinical and radiological manifestations of tuberculosis (TB) are heterogeneous, and differential diagnosis can include both benign and malignant diseases (e.g., sarcoidosis, metastatic diseases, and lymphoma). Diagnostic dilemmas can delay appropriate therapy, favoring Mycobacterium tuberculosis transmission. We report on a case of TB in an immunocompetent, Somalian 22-year-old boy admitted in the respiratory unit of an Italian university hospital. His symptoms and clinical signs were thoracic pain, weight loss, latero-cervical, mediastinal, and abdominal lymphadenopathy. Smear microscopy and PCR were negative for Mycobacterium tuberculosis . The unclear histological pattern, the unusual clinical presentation, the CT scan signs, the BAL lymphocytes suggested the suspicion a lymphoma. Culture conversion proved Mycobacterium tuberculosis infection. This case report highlights the risk of misdiagnosis in patients with generalized lympho-adenopathy and pulmonary infiltrates, particularly in Africans young patients

Current and emerging imaging techniques to evaluate bowel dysfunctions in patients with Multiple Sclerosis: a review

Multiple Sclerosis (MS) is the most common chronic disease of central nervous system (CNS). MS patients may present with a wide variety of neurologic symptoms, including fatigue, sensory and motor disturbances, depression, cognitive disorders, bladder, bowel and sexual dysfunctions (1). Pelvic floor disorders are often overlooked symptoms in patients with MS (2). With respect to the general population, constipation and/or faecal incontinence are more frequent in MS, with an estimated prevalence ranging from 52% to 68% (3). The neuro-pathophysiological mechanism of bowel dysfunction in MS remains unclear. Several factors act in concert to maintain fecal continence; among the anatomical factors the anal sphincter is crucial, interplaying with rectum and pelvic floor muscles to controll defecation. In recent decades, technological advances in diagnostic imaging have dramatically improved our knowledge favouring the assessment of anatomical and functional deficits in patients with bowel dysfunctions. We conducted a review to provide an overview on the relevance of current and emerging imaging techniques to study morphologic and functional abnormalities of anorectal region and pelvic floor of MS patients. Multimodal imaging techniques are frequently used: both static and dynamic imaging provide new insights into the complexity of global pelvic floor dysfunctions. The defecography seems to be the gold standard examination for the identification of morphological and functional disorders of the recto-anal region and pelvic floor (4). Although MRI defecography provide more accuracy in morphologic and functional assessment and allows to avoid radiation exposure, defecography is a cost-effective procedure, simple to perform, and widely available in every hospital equipped with a fluoroscopy room

Brain perivascular spaces and autism: clinical and pathogenic implications from an innovative volumetric MRI study

IntroductionOur single-center case–control study aimed to evaluate the unclear glymphatic system alteration in autism spectrum disorder (ASD) through an innovative neuroimaging tool which allows to segment and quantify perivascular spaces in the white matter (WM-PVS) with filtering of non-structured noise and increase of the contrast-ratio between perivascular spaces and the surrounding parenchyma.MethodsBriefly, files of 65 ASD and 71 control patients were studied. We considered: ASD type, diagnosis and severity level and comorbidities (i.e., intellectual disability, attention-deficit hyperactivity disorder, epilepsy, sleep disturbances). We also examined diagnoses other than ASD and their associated comorbidities in the control group.ResultsWhen males and females with ASD are included together, WM-PVS grade and WM-PVS volume do not significantly differ between the ASD group and the control group overall. We found, instead, that WM-PVS volume is significantly associated with male sex: males had higher WM-PVS volume compared to females (p = 0.01). WM-PVS dilation is also non-significantly associated with ASD severity and younger age (&lt; 4 years). In ASD patients, higher WM-PVS volume was related with insomnia whereas no relation was found with epilepsy or IQ.DiscussionWe concluded that WM-PVS dilation can be a neuroimaging feature of male ASD patients, particularly the youngest and most severe ones, which may rely on male-specific risk factors acting early during neurodevelopment, such as a transient excess of extra-axial CSF volume. Our findings can corroborate the well-known strong male epidemiological preponderance of autism worldwide

Management of the corpse with suspect, probable or confirmed COVID-19 respiratory infection \u2013 Italian interim recommendations for personnel potentially exposed to material from corpses, including body fluids, in morgue structures and during autopsy practice.

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Interplay of Digital Proximity App Use and SARS-CoV-2 Vaccine Uptake in Switzerland: Analysis of Two Population-Based Cohort Studies

Objectives: Our study aims to evaluate developments in vaccine uptake and digital proximity tracing app use in a localized context of the SARS-CoV-2 pandemic.Methods: We report findings from two population-based longitudinal cohorts in Switzerland from January to December 2021. Failure time analyses and Cox proportional hazards regression models were conducted to assess vaccine uptake and digital proximity tracing app (SwissCovid) uninstalling outcomes.Results: We observed a dichotomy of individuals who did not use the SwissCovid app and did not get vaccinated, and who used the SwissCovid app and got vaccinated during the study period. Increased vaccine uptake was observed with SwissCovid app use (aHR, 1.51; 95% CI: 1.40–1.62 [CI-DFU]; aHR, 1.79; 95% CI: 1.62–1.99 [CSM]) compared to SwissCovid app non-use. Decreased SwissCovid uninstallation risk was observed for participants who got vaccinated (aHR, 0.55; 95% CI: 0.38–0.81 [CI-DFU]; aHR, 0.45; 95% CI: 0.27–0.78 [CSM]) compared to participants who did not get vaccinated.Conclusion: In evolving epidemic contexts, these findings underscore the need for communication strategies as well as flexible digital proximity tracing app adjustments that accommodate different preventive measures and their anticipated interactions

Interplay of digital proximity app use and SARS-CoV-2 vaccine uptake in Switzerland : analysis of two population-based cohort studies

Objectives: Our study aims to evaluate developments in vaccine uptake and digital proximity tracing app use in a localized context of the SARS-CoV-2 pandemic. Methods: We report findings from two population-based longitudinal cohorts in Switzerland from January to December 2021. Failure time analyses and Cox proportional hazards regression models were conducted to assess vaccine uptake and digital proximity tracing app (SwissCovid) uninstalling outcomes. Results: We observed a dichotomy of individuals who did not use the SwissCovid app and did not get vaccinated, and who used the SwissCovid app and got vaccinated during the study period. Increased vaccine uptake was observed with SwissCovid app use (aHR, 1.51; 95% CI: 1.40–1.62 [CI-DFU]; aHR, 1.79; 95% CI: 1.62–1.99 [CSM]) compared to SwissCovid app non-use. Decreased SwissCovid uninstallation risk was observed for participants who got vaccinated (aHR, 0.55; 95% CI: 0.38–0.81 [CI-DFU]; aHR, 0.45; 95% CI: 0.27–0.78 [CSM]) compared to participants who did not get vaccinated. Conclusion: In evolving epidemic contexts, these findings underscore the need for communication strategies as well as flexible digital proximity tracing app adjustments that accommodate different preventive measures and their anticipated interactions

Dissecting the Shared Genetic Architecture of Suicide Attempt, Psychiatric Disorders, and Known Risk Factors

Background Suicide is a leading cause of death worldwide, and nonfatal suicide attempts, which occur far more frequently, are a major source of disability and social and economic burden. Both have substantial genetic etiology, which is partially shared and partially distinct from that of related psychiatric disorders. Methods We conducted a genome-wide association study (GWAS) of 29,782 suicide attempt (SA) cases and 519,961 controls in the International Suicide Genetics Consortium (ISGC). The GWAS of SA was conditioned on psychiatric disorders using GWAS summary statistics via multitrait-based conditional and joint analysis, to remove genetic effects on SA mediated by psychiatric disorders. We investigated the shared and divergent genetic architectures of SA, psychiatric disorders, and other known risk factors. Results Two loci reached genome-wide significance for SA: the major histocompatibility complex and an intergenic locus on chromosome 7, the latter of which remained associated with SA after conditioning on psychiatric disorders and replicated in an independent cohort from the Million Veteran Program. This locus has been implicated in risk-taking behavior, smoking, and insomnia. SA showed strong genetic correlation with psychiatric disorders, particularly major depression, and also with smoking, pain, risk-taking behavior, sleep disturbances, lower educational attainment, reproductive traits, lower socioeconomic status, and poorer general health. After conditioning on psychiatric disorders, the genetic correlations between SA and psychiatric disorders decreased, whereas those with nonpsychiatric traits remained largely unchanged. Conclusions Our results identify a risk locus that contributes more strongly to SA than other phenotypes and suggest a shared underlying biology between SA and known risk factors that is not mediated by psychiatric disorders.Peer reviewe

Fiscal federalism and income redistribution through healthcare financing: an empirical analysis for the Swiss cantons.

Previous studies have viewed Swiss health-care financing as particularly regressive. However, as the OECD Review of the Swiss Health System (2011) stated, the income-related inequities and the inter cantonal variations are still unexplored due to a lack of available information. The present paper aims to fill this information gap concerning the Swiss health system by exploring the differences in the level of regressivity of health-care system financing across cantons and over time using household data. The empirical evidence confirms that the Swiss health-care system financing has remained quite regressive since the major reform of 1996 and that the variations in equity across cantons are quite significant. The results are an interesting contribution towards re- thinking a new possible reform of the Swiss health-care system, as well as for other federal states (such as the U.S.) that use regulation and subsidies to ensure universal coverage