Sex differences in the effect of type 2 diabetes on major cardiovascular diseases: results from a population-based study in Italy.

The aim of the study is to assess sex difference in association between type 2 diabetes and incidence of major cardiovascular events, that is, myocardial infarction, stroke, and heart failure, using information retrieved by diabetes register. The inhabitants of Reggio Emilia (Italy) aged 30\u201384 were followed during 2012\u20132014. Incidence rate ratios and 95% confidence intervals were calculated using multivariate Poisson model. The age- and sex-specific event rates were graphed. Subjects with type 2 diabetes had an excess risk compared to their counterparts without diabetes for all the three major cardiovascular events. The excess risk is similar in women and men for stroke (1.8 times) and heart failure (2.7 times), while for myocardial infarction, the excess risk in women is greater than the one observed in men (IRR 2.58, 95% CI 2.22\u20133.00 and IRR 1.78, 95% CI 1.60\u20132.00, resp.; P of interaction < 0.0001). Women had always a lesser risk than men, but in case of myocardial infarction, the women with type 2 diabetes lost part of advantage gained by women free of diabetes (IRR 0.61, 95% CI 0.53\u20130.72 and IRR 0.36, 95% CI 0.33\u20130.39, resp.). In women with type 2 diabetes, the risk of major cardiovascular events is anticipated by 20\u201330 years, while in men it is by 15\u201320

Determinants of inappropriate setting allocation in the care of patients with type 2 diabetes: A population-based study in Reggio Emilia province

The study aims to describe the distribution of patients with type 2 diabetes (T2D) by care plan and to highlight determinants of underuse and overuse of integrated care (IC). This cross-sectional study included all T2D patients resident in Reggio Emilia on 31/12/2015 based on the population-based diabetes registry. Eligibility for IC requires good glycaemic control, no rapid insulin, no kidney failure and no diabetes complications. We calculated the proportion of IC underuse and overuse and adjusted prevalence estimate using multivariate logistic regression. Determinants were age, sex, citizenship, district of residence and time since diagnosis. Of 29,776 patients, 15,364 (51.6%) were in diabetes clinic plan, 9851 (33.1%) in IC plan and 4561 (15.3%) not in any care plan (i.e., in Other group). There were 10,906 (36.6%) patients eligible for IC, of whom 1000 in Other group. When we adjusted for all covariates and restricted the analysis to patients included in care plans, the proportion of those eligible for IC plan but cared for in diabetes clinic plan (i.e. underuse of IC) was 28% (n = 3028/9906; 95%CI 27–29). Similarly, the proportion of those not eligible for IC but cared for in IC plan (i.e. overuse of IC) was 11% (n = 1720/11,896; 95%CI 10–11).The main determinant of both IC underuse and overuse was the district of residence. Foreign status was associated with underuse (37%; 95%CI 33–43), while old age (≥80 years) with both underuse (36%; 95%CI 0.33–0.38) and overuse (23%; 95%CI 22–25). The criterion for suspension of IC plan most frequently found was renal failure, followed by hospitalization for diabetes-related complications. Patients are more often allocated to more specialized settings than not. Healthcare provider-related factors are the main determinants of inappropriate setting allocation

Compliance with Tuberculosis Screening in Irregular Immigrants

Tuberculosis (TB) is a serious public health problem in many regions of the world, especially in the poorest areas. For this reason, screening for active and latent forms must be considered when dealing with high-risk groups such as irregular immigrants in Western countries. We conducted a retrospective cohort study by recruiting subjects aged 6515 years who underwent a tuberculin skin test at a dedicated National Health Service Centre in a northern Italian province between 1 January 2012 and 31 December 2013. These participants were followed up until 31 December 2016. We aimed at evaluating an experimental protocol for active and latent tuberculosis screening, focusing on patient compliance, feasibility, and capability to detect clinical forms of the disease. We enrolled 368 irregular immigrants, i.e., immigrants not having a valid residence permit and who were therefore not entitled to choose a general practitioner. In total, 90.22% of these completed all the steps for the screening of active TB, while 87.33% also undertook screening for the latent form of the disease. Homelessness, self-reported prostitution, female sex, and employment status adversely affected compliance. Chronic alcohol consumption was associated with increased risk of no beginning or interruption of the procedures. All of the five patients with active TB successfully completed the treatment. Overall, adherence to the screening program was high compared to other studies in immigrants, possibly owing to organizational factors such as the availability of cultural mediators, the network between the different health services, the presence of dedicated nursing staff and a free-of-charge service. In addition, selected vulnerable subgroups should be targeted using tailored screening and follow-up programs

Effectiveness of integrated care model for type 2 diabetes: A population-based study in Reggio Emilia (Italy)

Aims To compare the effectiveness of integrated care with that of the diabetes clinic care model in terms of mortality and hospitalisation of type 2 diabetes patients with low risk of complications. Methods Out of 27234 people with type 2 diabetes residing in the province of Reggio Emilia on 31/12/2011, 3071 were included in this cohort study as eligible for integrated care (i.e., low risk of complications) and cared for with the same care model for at least two years. These patients were followed up from 2012 to 2016, for all-cause and diabetes-related mortality and hospital admissions. We performed a Poisson regression model, using the proportion of eligible patients included in the integrated care model for each general practitioner as an instrumental variable. Results 1700 patients were cared for by integrated care and 1371 by diabetes clinics. Mortality rate ratios were 0.83 (95%CI 0.60-1.13) and 0.95 (95%CI 0.54-1.70) for all-cause and cardiovascular mortality, respectively, and incidence rate ratios were 0.90 (95%CI 0.76-1.06) and 0.91 (95%CI 0.69-1.20) for all-cause and cardiovascular disease hospitalisation, respectively. Conclusion For low risk patients with type 2 diabetes, the integrated care model involving both general practitioner and diabetes clinic professionals showed similar mortality and hospitalisation as a model with higher use of specialized care in an exclusively diabetes clinic setting

Impact of Insulin Therapies on Cancer Incidence in Type 1 and Type 2 Diabetes: A Population-Based Cohort Study in Reggio Emilia, Italy

Simple Summary The aim of this population-based study was to assess the impact of insulin treatment on cancer incidence in subjects with type 1 or type 2 diabetes in Italy. We found that insulin use was associated with a 20% excess for all sites cancer incidence among people with type 2 diabetes, while people with type 1 diabetes did not show any excess. Liver, pancreatic, bladder, and neuroendocrine cancers seem to be the sites with strongest association. Objective: To assess the effect of insulin on cancer incidence in type 1 (T1DM) and type 2 diabetes (T2DM). Methods: The cohort included all 401,172 resident population aged 20-84 in December 2009 and still alive on December 2011, classified for DM status. Drug exposure was assessed for 2009-2011 and follow up was conducted from 2012 to 2016 through the cancer registry. Incidence rate ratios (IRRs) were computed for all sites and for the most frequent cancer sites. Results: among residents, 21,190 people had diabetes, 2282 of whom were taking insulin; 1689 cancers occurred, 180 among insulin users. The risk for all site was slightly higher in people with T2DM compared to people without DM (IRR 1.21, 95% CI 1.14-1.27), with no excess for T1DM (IRR 0.73, 95% CI 0.45-1.19). The excess in T2DM remained when comparing with diet-only treatment. In T2DM, excess incidence was observed for liver and pancreas and for NETs: 1.76 (95% CI 1.44-2.17) and 1.37 (95% CI 0.99-1.73), respectively. For bladder, there was an excess both in T1DM (IRR 3.00, 95% CI 1.12, 8.02) and in T2DM (IRR1.27, 95% CI 1.07-1.50). Conclusions: Insulin was associated with a 20% increase in cancer incidence. The risk was higher for liver, pancreatic, bladder and neuroendocrine tumours

Modification of permeability transition pore arginine(s) by phenylglyoxal derivatives in isolated mitochondria and mammalian cells. Structure-function relationship of arginine ligands.

Methylglyoxal and synthetic glyoxal derivatives react covalently with arginine residue(s) on the mitochondrial permeability transition pore (PTP). In this study, we have investigated how the binding of a panel of synthetic phenylglyoxal derivatives influences the opening and closing of the PTP. Using both isolated mitochondria and mammalian cells, we demonstrate that the resulting arginine-phenylglyoxal adduct can lead to either suppression or induction of permeability transition, depending on the net charge and hydrogen bonding capacity of the adduct. We report that phenylglyoxal derivatives that possess a net negative charge and/or are capable of forming hydrogen bonds induced permeability transition. Derivatives that were overall electroneutral and cannot form hydrogen bonds suppressed permeability transition. When mammalian cells were incubated with low concentrations of negatively charged phenylglyoxal derivatives, the addition of oligomycin caused a depolarization of the mitochondrial membrane potential. This depolarization was completely blocked by cyclosporin A, a PTP opening inhibitor, indicating that the depolarization was due to PTP opening. Collectively, these findings highlight that the target arginine(s) is functionally linked with the opening/closing mechanism of the PTP and that the electric charge and hydrogen bonding of the resulting arginine adduct influences the conformation of the PTP. These results are consistent with a model where the target arginine plays a role as a voltage sensor

Sex Differences in Cardiovascular Mortality in Diabetics and Nondiabetic Subjects: A Population-Based Study (Italy)

The objective of this study is to assess the impact of diabetes on cardiovascular mortality, focusing on sex differences. The inhabitants of Reggio Emilia province on December 31, 2009, aged 20–84 were followed up for three years for mortality. The exposure was determined using Reggio Emilia diabetes register. The age-adjusted death rates were estimated as well as the incidence rate ratios using Poisson regression model. Interaction terms for diabetes and sex were tested by the Wald test. People with diabetes had an excess of mortality, compared with nondiabetic subjects (all cause: IRR = 1.68; 95%CI 1.60–1.78; CVD: IRR = 1.61; 95%CI 1.47–1.76; AMI: IRR = 1.59; 95%CI 1.27–1.99; renal causes: IRR = 1.71; 95%CI 1.22–2.38). The impact of diabetes is greater in females than males for all causes (P=0.0321) and for CVD, IMA, and renal causes. Further studies are needed to investigate whether the difference in cardiovascular risk profile or in the quality of care delivered justifies the higher excess of mortality in females with diabetes compared to males

Reengineering of a suburban post-acute ward into a community hospital

Background: Chronic patients present highly complex conditions in which biomedical, psychosocial, and environmental factors are intricately intertwined. The population admitted to acute hospital wards is increasingly elderly and comorbid and often requires intermediate care. Objective: A decommissioned post-acute care ward within a district hospital will be rearranged into a 20bed community hospital. Integrated care through the biopsychosocial model will facilitate hospital discharges and prevent relapses: a reduction in admissions and length of stay in general hospitals for chronic patients is expected, along with improvements in patientrelated outcomes. Methods: A multi-professional board consisting of key stakeholders was convened to frame the organizational model and develop a digitally integrated chart. The International Classification of Functioning, Disability and Health (ICF) was chosen as the leading framework for patient assessment. The Individualized Care Plan (ICP) will be digitally implemented to tailor interventions to individual conditions. Families, caregivers, and general practitioners (GPs) will be actively involved, and periodic follow-ups will assess the progress of the plan

EPR AND ENDOR STUDY ON MIXED-CRYSTALS OF AN INDOLINONE NITROXIDE RADICAL AND THE ISOELECTRONIC KETONE .2. EPR AND ENDOR INVESTIGATION ON RADICAL PAIRS IN MIXED-CRYSTALS

The EPR spectrum due to radical pairs was studied in mixed crystals containing 5% of a nitroxide indolinone radical and 95% of the isoelectronic ketone. Each radical pair gives rise to a pair of lines in the wings of the main spectrum. The first order analysis of the angular dependence of the fine splittings gave the electron-electron dipolar tensors due to three different pairs. The comparison of the experimental tensors with the calculated ones allowed us to identify the radical pairs in the crystal structure. The temperature dependencies of the EPR intensities of two types of radical pairs were analysed and the singlet-triplet energy separations were obtained. The magnetic susceptibility of the pure radical crystal has been determined and compared with the results of the EPR of the mixed crystals. An ENDOR investigation was performed on the radical pairs at T = 5 K. The spectra can be explained by taking into account the inter radical electron-nuclear dipolar interaction

Diagnostic values of glycated haemoglobin and diagnosis of diabetes: Results of a cross-sectional survey among general practitioners in the province of Reggio Emilia, Italy

AbstractAimsThe aim of this study was to investigate whether subjects included in the diabetes register solely because their HbA1c was over the diagnostic threshold received a diagnosis of diabetes from their general practitioner (GP).MethodsThe study included all registered cases in 2009–2010 aged 18 or over that were identified only by the laboratory database because they had one or more HbA1c over the 6.5% threshold and for whom we did not find any information in the search of full electronic clinical records. Multilevel logistic regression was used to examine the influence of GP and patient characteristics.ResultsThere were 228 participating GPs (76.3% of those invited) and 832 assessed subjects (68.8% of study population). There was a strong clustering among the GPs (residual intraclass correlation = 0.52, 95% CI 0.40–0.64). About one in two (55.5%) subjects with two or more HbA1c > =6.5% has been diagnosed as diabetic and the percentage declined – unless zeroing – in case the abnormal value was only one (28.3%). The likelihood of being labelled ‘no diabetes’ was greater in subjects aged less than 65 or over 74 with respect to the reference age group (OR 1.89, 95% CI 1.13–3.15; OR 1.55 95% CI 0.94–2.53). The same likelihood consistently decreased when HbA1c test was accompanied by abnormal fasting plasma glucose (FPG) assay (OR 0.20, 95% CI 0.12–0.32).ConclusionsA permanent exchange of information between the diabetes register and GPs should be maintained to improve the care of patients and the awareness of criteria for diabetes diagnosis among GPs