The role of GP’s compensation schemes in diabetes care: evidence from panel data

The design of incentive schemes that improve quality of care is a central issue for the healthcare sector. Nowadays we observe many pay-for-performance programs, where payment is contingent on meeting indicators of provider effort, but also other alternative strategies have been introduced, for example programs rewarding physicians for participation in diseases management plans. Although it has been recognised that incentive-based remuneration schemes can have an impact on GP behaviour, there is still weak empirical evidence on the extent to which such programs influence health outcomes. We investigate the impact of financial incentives in Regional and Local Health Authority contracts for primary care in the Italian Region Emilia Romagna for the years 2003-05. We focus on avoidable hospitalisations (Ambulatory Care Sensitive Conditions) for patients affected by type 2 diabetes mellitus, for which the assumption of responsibility and the adoption of clinical guidelines are specifically rewarded. We estimate a panel count data model using a Negative Binomial distribution to test the hypothesis that, other things equal, patients under the responsibility of GPs receiving a higher share of their income through these programs are less likely to experience avoidable hospitalisations. Our findings support the hypothesis that financial transfers may contribute to improve quality of care, even when they are not based on the ex-post verification of performances.

Impacto de los residuos de ivermectina en los procesos tecnológicos de la leche y sus derivados

Se evaluó la estabilidad química de los residuos de ivermectina (IVM, fármaco antiparasitario) en leches bovina y ovina. La estabilidad del fármaco se midió mediante cromatografía liquida de alta performance analizando muestras de leche con residuos de IVM antes y después del tratamiento térmico. Además se evaluó, mediante la prueba del yogur y estudios microbiológicos de recuento de bacterias lácticas, el efecto de los residuos sobre la viabilidad de las bacterias ácido lácticas. Los residuos de IVM en leche demostraron ser estables a los tratamientos térmicos utilizados en la industria láctea de pasteurización: baja temperatura/largo tiempo (LTLT 65ºC, 30 min) y alta temperatura/corto tiempo (HTST 75ºC, 15 s). Los procesos de industrialización de la leche basados en la actividad de las bacterias lácticas tampoco fueron afectados por la presencia de residuos de IVM. Las concentraciones evaluadas no modificaron el incremento de la acidez en la prueba del yogur y no disminuyeron los recuentos de bacterias lácticas presentes en muestras de yogures elaborados con residuos del antiparasitario. El impacto de los residuos de fármacos antiparasitarios en los procesos tecnológicos de elaboración de alimentos y en la salud del consumidor a largo plazo debe ser cuidadosamente analizado.Chemical stability of ivermectin residues (IVM, antiparasitic drug) in cattle and sheep milk was evaluated. IVM residues were measured in milk samples before and after heat treatment by high performance liquid chromatography. Additionally, the effect of drug residues on the lactic acid fermentation was assessed by testing the viability and counts of lactic acid bacteria. IVM concentrations in milk were stable after standard procedures used in dairy industry LTLT pasteurization (65°C, 30 min) and HTST (75°C, 15 s). Industrial milk processing based on the activity of lactic acid bacteria was not affected by the presence of IVM residues. IVM concentrations did not affect the increment of acidity nor the number of lactic acid bacteria in yogurt samples. The impact of the residues of antiparasitic drugs in technological processes of food processing and consumer health must be carefully analyzed to avoid long-term consequences

Physico-Mechanical Performances of Mortars Prepared with Sorted Earthquake Rubble: The Role of CDW Type and Contained Crystalline Phases

Construction and demolition waste (CDW) from earthquake rubbles was used here as recycled aggregates (RA) in cementitious binders. The materials were sorted in six groups: concrete (CO), natural stone (NS), tile (TI), brick (BR), perforated brick (PF) and roof tile (RT). The abundance (wt.%) of crystalline phases in each RA type was determined by X-ray Powder Diffraction (XRPD). Each group of RAs was used alone (100 wt.% of RA) and mixed with quartz-rich virgin aggregates (VA) to prepare 13 types of mortars (12 specimens per type): one reference mortar (RM) with only VA, six recycled aggregate mortars (RAM) and six recycled-plus-virgin aggregate mortars (RVAM). The physical and mechanical properties of aggregates and mortars reflect the type and abundance of crystalline phases in each CDW group. Recycled mortars rich in concrete, natural stones and tiles have better mechanical performance than mortars prepared with recycled bricks, perforated bricks and roof tiles. For each RA, RVAMs have superior mechanical characteristics than the corresponding RAM. Since the type and amount of phases contained in recycled aggregates strongly control the mechanical performance of new construction materials, they should be routinely quantified as reported here, in addition to other physical features (water absorption, density, etc.). The separation of heterogeneous CDW into homogeneous RA groups is necessary for the production of new construction materials with stable and predictable performances to ensure CDW recycling, especially in areas hit by major adverse events, where large amounts of still valuable materials could be used for reconstruction processes

Maxillary sinus augmentation with three different biomaterials: Histological, histomorphometric, clinical, and patient-reported outcomes from a randomized controlled trial

Background: Lateral maxillary sinus augmentation (MSA) is a predictable bone regeneration technique in case of atrophy of the posterior-upper maxilla. Aimed at obtaining quantity and quality of bone suitable for receiving osseointegrated implants, its success is largely due to the skill of the surgeon, but also to the characteristics of the biomaterial used. Methods: Twenty-four patients needing MSA were included in the study. The patients were randomly allocated to three different groups: anorganic bovine bone mineral as control, tricalcium phosphate with or without hyaluronic acid (HA) as test groups. Nine months after MSA, bone biopsies were harvested for the histomorphometric analysis. Secondary outcomes were mean bone gain, intraoperative and postoperative complications, implant insertion torque, implant failure, and patient-reported outcome measures. Results: Although the percentage of new bone was not statistically different between the three groups (P =.191), the percentages of residual biomaterial was significantly higher (P <.000) and nonmineralized tissue significantly lower (P <.000) in the control than in the test groups. Test groups did not differ significantly from each other for all histomorphometric parameters. The implant insertion torque was significantly higher in the control group (P <.0005). The rest of the secondary outcomes were not significantly different between the groups. Conclusion: MSA is a safe and predictable procedure in terms of histological, clinical, and PROAMs, regardless of the biomaterial used. The addition of HA did not influence the outcomes

EPMA maps unveil the actual chemical variations and crystallisation sequence of pyroxene and plagioclase solidified from a basaltic liquid at variable cooling rates

Crystal-chemical variations of pyroxene (px) and plagioclase (plg) have been analysed by X-ray electron-microprobe (EPMA) mapping to quantify their actual chemical dispersions. These phases were experimentally crystallised from a basaltic liquid (B100, MORB from Iceland) at cooling rates of 1, 7, 60 and 180 °C/h from 1300 °C down to 800 °C. Experiments were run at ambient conditions applying defined temperature paths mirroring characteristic cooling rates from innermost to outermost portions of metre- to centimetre-thick lavas, dikes and bombs emplaced under submarine to subaerial conditions. As the cooling rate increases from 1 to 180 °C/h, the run-products become progressively enriched in pyroxene and depleted in plagioclase, while spinel is invariably low (few area%) and glass is significant only at 180 °C/h. An increase of cooling rate generally leads to enrichment of Al2O3 and depletion of MgO in px, while the opposite behaviour is observed for plg; these trends are mirrored by calculated cations (apfu: atom per formula unit) and components. Average variations as a function of cooling rate are similar to those already observed through classical analysis performed by single point EPMA. However, the actual chemical distributions of CaO versus MgO, Al2O3 and FeOtot oxides unveil the presence of a wider range in pyroxene chemistry. In particular, one px (px-1, CaO-rich, diopsidic type) is present at all the applied cooling rates; a very low CaO-px (px-2, pigeonite or orthopyroxene type) is detected at 1 °C/h; and, finally, once more population of px (px-3, CaO-poor diopsidic type) appears at 60 and 180 °C/h. By contrast, plg analyses yield invariably identical compositions. Textural variations as a function of cooling rate and geothermometric estimations indicate that px-1 crystallised at high-T (or low ΔT), while plg mainly grew in the residual melt produced by the saturation of px. If only textures were evaluated, this order of segregation would like remain unrecognised since px at low cooling rates is smaller than plg. The abundance of phases, their crystal-chemical features, and their order of segregation can be regarded through a theoretical framework of a time-temperature-transformation (TTT) diagram. The most significant chemical variations are displayed by MgO and Al2O3 for both px and plg, which faithfully capture the evolution of cooling conditions. The chemical compositions of px-1 is close to the thermodynamic equilibrium only at 1 °C/h. As the cooling rates increase, the px chemistry indicates disequilibrium conditions. Finally, this study shows that as ΔT/Δt increases, the most abundant px (px-1) and plg are forced towards compositions that become progressively closer to those of the parental liquid

Timely DNA Vaccine Combined with Systemic IL-12 Prevents Parotid Carcinomas before a Dominant-Negative p53 Makes Their Growth Independent of HER-2/neu Expression

Double transgenic mice overespressing the transforming rat HER-2/neu oncogene and the mutated p53, with both deminant-negative and a gain-of-function properties, display early aggressive and metastasizing parotid tumors. Multiple acinar and ductal hyperplasia foci overexpressing the HER-2/neu gene product are evident at wk 5 and progress to poorly differentiated carcinoma by wk 7. Mice die before wk 18 with invasive carcinomas and multiple metastases that no longer express HER-2/neu. A combination of repeated electroporations of plasmids coding for the extracellular and transmembrane domains of the rat HER-2/neu receptor with systemic IL-12 administrations started when the parotids that present diffuse hyperplasia protected all female and 50% of the male mice until the close of the experiment at wk 40. This combined treatment began when multifocal in situ - carcinomas that were already present cured 33% of the females and 25 % of the males. The most prominent immunologic features associated with the antitumor protection were the production of high titers of anti-HER-2/neu Abs and the nonappearance of cell-mediated cytotoxic reactivity. In conclusion, anti-HER-2/neu vaccination combined with systemic IL-12 control parotid carcinomas as far as p53 mutation makes their growth independent of HER-2/neu expression

LAG-3 enables DNA vaccination to persistently prevent mammary carcinogenesis in HER-2/neu transgenic BALB/c mice

Within 33 weeks of life, all 10 mammary glands of virgin BALB/c mice transgenic for the transforming rat HER-2/neu oncogene under the mammary tumor virus promoter (BALB-neuT mice) progress from atypical hyperplasia to invasive palpable carcinoma. Repeated DNA vaccination with plasmids coding for the extracellular and transmembrane domain of the protein product of rat HER-2/neu (r-p185neu) delayed tumor onset and reduced tumor multiplicity, but this protection eventually declined, and few mice were tumor free at 1 year of age. Association of plasmid vaccination with administration of soluble mouse LAG-3 (lymphocyte activation gene-3/CD223) generated by fusing the extracellular domain of murine LAG-3 to a murine IgG2a Fc portion (mLAG-3Ig) elicited a stronger and sustained protection that kept 70% of 1-year-old mice tumor free. Moreover, this combined vaccination, which was performed when multiple in situ carcinomas were already evident, extended disease-free survival and reduced carcinoma multiplicity. Inhibition of carcinogenesis was associated with markedly reduced epithelial cell proliferation and r-p185neu expression, whereas the few remaining hyperplastic foci were heavily infiltrated by reactive leukocytes. A stronger and enduring r-p185neu-specific cytotoxicity, a sustained release of IFN-γ and interleukin 4, and a marked expansion of both CD8+/CD11b+/CD28+ effector and CD8+/CD11b+/CD28- memory effector T-cell populations were induced in immunized mice. This combined vaccination also elicited a quicker and higher antibody response to r-p185neu, as well as an early antibody isotype switch. These data suggest that the appropriate costimulation provided by mLAG-3Ig enables DNA vaccination to establish an effective protection, probably by enhancing cross-presentation of the DNA coded antigen

Cure of mammary carcinomas in Her-2 transgenic mice through sequential stimulation of innate (neoadjuvant interleukin-12) and adaptive (DNA vaccine electroporation) immunity.

Purpose: Whereas neoadjuvant therapy is emerging as a treatment option in early primary breast cancer, no data are available on the use of antiangiogenic and immunomodulatory agents in a neoadjuvant setting. In a model of Her-2 spontaneous mammary cancer, we investigated the efficacy of neoadjuvant interleukin 12 (IL-12) followed by ‘‘immune-surgery’’ of the residual tumor. Experimental Design: Female BALB/c mice transgenic for the rat Her-2 oncogene inexorably develop invasive carcinomas in all their mammary glands by the 23rd week of age. Mice with multifocal in situ carcinomas received four weekly i.p. injections of 100 ng IL-12 followed by a 3-week rest. This course was given four times. A few mice additionally received DNA plasmids encoding portions of the Her-2 receptor electroporated through transcutaneous electric pulses. Results: The protection elicited by IL-12 in combination with two DNA vaccine electroporations kept 63% of mice tumor-free. Complete protection of all 1-year-old mice was achieved when IL-12-treated mice received four vaccine electroporations. Pathologic findings, in vitro tests, and the results from immunization of both IFN-; andimmunoglobulin gene knockout transgenic mice and of adoptive transfer experiments all show that IL-12 augments the B- and T-cell response elicited by vaccination and slightly decreases the number of regulatory T cells. In addition, IL-12 strongly inhibits tumor angiogenesis. Conclusions: In Her-2 transgenic mice, IL-12 impairs tumor progression and triggers innate immunity so markedly that DNA vaccination becomes effective at late points in time when it is ineffective on its own

Teacher confidence in professional training: The predictive roles of engagement and burnout

Teachers' work engagement positively impacts teachers' attitudes towards their job. Nevertheless, teachers may experience burnout during their career, which negatively impacts their professional learning opportunities. In this study we investigated the relationship between teachers' levels of burnout, work engagement, and their confidence in in-service training in a sample of Italian teachers. We expected that burnout mediated the relationship between work engagement and teachers' confidence in training. A total of 481 teachers completed self-report questionnaires about engagement and burnout, with an ad hoc Confidence in Training Index developed to assess their attitudes towards professional development courses. The mediation analysis confirmed that the teachers' levels of burnout mediated the relationship between their work engagement and their confidence in in-service training. Findings suggest that teacher confidence in policies about professional training should be evaluated by taking into account their level of engagement and burnout