Human tularemia in Italy. Is it a re-emerging disease?

In order to evaluate whether tularemia is re-emerging in Italy, data on mortality and morbidity (obtained by the National Institute of Statistics; ISTAT), Italian cases described in the scientific literature and data concerning hospitalizations for tularemia (obtained by the National Hospital Discharge Database) were analysed. From 1979 to 2010, ISTAT reported 474 cases and no deaths. The overall number of cases obtained from the literature review was at least 31% higher than that reported by ISTAT. Moreover, the number of cases reported by ISTAT was 3·5 times smaller than hospitalized cases. The real frequency of the disease should be carefully investigated and taken into account in order to implement specific prevention measures.Tularemia is a contagious infectious disease due to Francisiella tularensis that can cause serious clinical manifestations and significant mortality if untreated. Although the frequency and significance of the disease has diminished over the last decades in Central Europe, over the past few years, there is new evidence suggesting that tularemia has re-emerged worldwide. To know the real epidemiology of the disease is at the root of correct control measures. In order to evaluate whether tularemia is re-emerging in Italy, data on mortality and morbidity (obtained by the National Institute of Statistics; ISTAT), Italian cases described in the scientific literature and data concerning hospitalizations for tularemia (obtained by the National Hospital Discharge Database) were analysed. From 1979 to 2010, ISTAT reported 474 cases and no deaths. The overall number of cases obtained from the literature review was at least 31% higher than that reported by ISTAT. Moreover, the number of cases reported by ISTAT was 3·5 times smaller than hospitalized cases. In Italy tularemia is sporadic, rarely endemic and self-limiting; but, although the trend of reported tularemia does not support the hypothesis of a re-emerging disease, the study demonstrates a wide underreporting of the disease. The real frequency of the disease should be carefully investigated and taken into account in order to implement specific prevention measures

Indicatori di qualità microbiologica delle acque: problemi e prospettive

Gli indicatori convenzionali di contaminazione fecale forniscono un prezioso contributo alla valutazione della qualità igienica dell’acqua. Negli ultimi anni sono stati individuati alcuni limiti importanti che ne hanno messo in discussione la validità e hanno posto il problema della necessità di una rivisitazione del loro significato. Nei Paesi industrializzati, nei quali la normativa vigente che concerne la qualità delle acque è molto rigorosa, si sono verificate numerose epidemie, nonostante gli indicatori convenzionali di contaminazione fecale indicassero una qualità microbiologica adeguata. Queste epidemie sono state attribuite a microrganismi patogeni emergenti, che sono spesso caratterizzati da una resistenza ai processi di disinfezione superiore rispetto agli indicatori convenzionali.Per assicurare un’adeguata qualità microbiologica delle acque, sono stati avviati vari percorsi tra i quali i Water Safety Plans dell’Organizzazione Mondiale della Sanità, la rivisitazione del ruolo dei possibili indicatori di qualità microbiologica, la messa a punto di metodi specifici per alcuni microrganismi patogeni e di metodi per una rapida rilevazione di qualità microbiologica non adeguata

Cardiovascular Events in Patients Received Combined Fibrate/Statin Treatment versus Statin Monotherapy: Acute Coronary Syndrome Israeli Surveys Data

The effect of combination of fibrate with statin on major adverse cardiovascular events (MACE) following acute coronary syndrome (ACS) hospitalization is unclear. The main aim of this study was to investigate the 30-day rate of MACE in patients who participated in the nationwide ACS Israeli Surveys (ACSIS) and were treated on discharge with a fibrate (mainly bezafibrate) and statin combination vs. statin alone.The study population comprised 8,982 patients from the ACSIS 2000, 2002, 2004, 2006, 2008 and 2010 enrollment waves who were alive on discharge and received statin. Of these, 8,545 (95%) received statin alone and 437 (5%) received fibrate/statin combination. MACE was defined as a composite measure of death, recurrent MI, recurrent ischemia, stent thrombosis, ischemic stroke and urgent revascularization.Patients from the combination group were younger (58.1±11.9 vs. 62.9±12.6 years). However, they had significantly more co-morbidities (hypertension, diabetes), current smokers and unfavorable cardio-metabolic profiles (with respect to glucose, total cholesterol, triglyceride and HDL-cholesterol). Development of MACE was recorded in 513 (6.0%) patients from the statin monotherapy group vs. 13 (3.2%) from the combination group, p = 0.01. 30-day re-hospitalization rate was significantly lower in the combination group: 68 (15.6%) vs. 1691 (19.8%) of patients, respectively; p = 0.03. Multivariable analysis identified the fibrate/statin combination as an independent predictor of reduced risk of MACE with odds ratio of 0.54, 95% confidence interval 0.32–0.94.A significantly lower risk of 30-day MACE rate was observed in patients receiving combined fibrate/statin treatment following ACS compared with statin monotherapy. However, caution should be exercised in interpreting these findings taking into consideration baseline differences between our observational study groups

Metabolic Control in Type 1 Diabetes: Is Adjunctive Therapy the Way Forward?

Despite advances in insulin therapies, patients with type 1 diabetes (T1DM) have a shorter life span due to hyperglycaemia-induced vascular disease and hypoglycaemic complications secondary to insulin therapy. Restricting therapy for T1DM to insulin replacement is perhaps an over-simplistic approach, and we focus in this work on reviewing the role of adjuvant therapy in this population. Current data suggest that adding metformin to insulin therapy in T1DM temporarily lowers HbA1c and reduces weight and insulin requirements, but this treatment fails to show a longer-term glycaemic benefit. Agents in the sodium glucose co-transporter-2 inhibitor (SGLT-2) class demonstrate the greatest promise in correcting hyperglycaemia, but there are safety concerns in relation to the risk of diabetic ketoacidosis. Glucagon-like peptide-1 agonists (GLP-1) show a modest effect on glycaemia, if any, but significantly reduce weight, which may make them suitable for use in overweight T1DM patients. Treatment with pramlintide is not widely available worldwide, although there is evidence to indicate that this agent reduces both HbA1c and weight in T1DM. A criticism of adjuvant studies is the heavy reliance on HbA1c as the primary endpoint while generally ignoring other glycaemic parameters. Moreover, vascular risk markers and measures of insulin resistance—important considerations in individuals with a longer T1DM duration—are yet to be fully investigated following adjuvant therapies. Finally, studies to date have made the assumption that T1DM patients are a homogeneous group of individuals who respond similarly to adjuvant therapies, which is unlikely to be the case. Future longer-term adjuvant studies investigating different glycaemic parameters, surrogate vascular markers and harder clinical outcomes will refine our understanding of the roles of such therapies in various subgroups of T1DM patients

Influence of Platelet Reactivity on Outcome of Patients With Acute Myocardial Infarction Undergoing Primary Angioplasty

n/

Antithrombotic therapy in patients with acute coronary syndromes: a balance between protection from ischemic events and risk of bleeding

Platelet activation plays a primary role in the pathogenesis of acute coronary syndromes (ACS); thus, anti-thrombotic therapy with aspirin and clopidogrel represents the mainstay of treatment in those patients. However, low clopidogrel response has become a contemporary issue in interventional cardiology, increasing the risk of ischemic events and significantly worsening short- and long-term prognosis after coronary stenting. Alternative approaches to overcome this phenomenon have been investigated as well as increase in the loading and maintenance clopidogrel doses, reloading patients already on chronic therapy, use of newer and more effective antiplatelet agents. Otherwise a more aggressive antiplatelet treatment may lead to possible increase in bleeding complications. A strategy of an individualized antiplatelet therapy according to point-of-care platelet function tests may represent the optimal approach to balance both ischemic and hemorrhagic risk

Platelet function and inhibition in ischemic heart disease

Platelets play an important role in the pathogenesis of thrombosis, the most common cause for the development of acute coronary syndromes such as complications occurring during percutaneous coronary intervention. Platelets act with a multiple step mechanism, in which different surface molecules are involved representing important therapeutic targets of antiplatelet agents. Despite clopidogrel efficacy which has been demonstrated in several studies, recurrent ischemic events remain considerably high in patients on treatment due to low clopidogrel responsiveness, a phenomenon influenced by environmental, clinical, and genetic factors. New P2Y12 blockers such as prasugrel and ticagrelor have been successfully introduced in clinical practice, whereas cangrelor, with a rapid offset and reversible platelet inhibition, may represent a useful bridging therapy in patients undergoing surgery. Moreover, the simultaneous inhibition of thrombin platelet aggregation by protease-activated receptor inhibitors may be an adjunctive approach in patients with coronary artery disease

Antithrombotic therapy in patients with acute coronary syndromes: a balance between protection from ischemic events and risk of bleeding

Platelet activation plays a primary role in the pathogenesis of acute coronary syndromes (ACS); thus, anti-thrombotic therapy with aspirin and clopidogrel represents the mainstay of treatment in those patients. However, low clopidogrel response has become a contemporary issue in interventional cardiology, increasing the risk of ischemic events and significantly worsening short- and long-term prognosis after coronary stenting. Alternative approaches to overcome this phenomenon have been investigated as well as increase in the loading and maintenance clopidogrel doses, reloading patients already on chronic therapy, use of newer and more effective antiplatelet agents. Otherwise a more aggressive antiplatelet treatment may lead to possible increase in bleeding complications. A strategy of an individualized antiplatelet therapy according to point-of-care platelet function tests may represent the optimal approach to balance both ischemic and hemorrhagic risk