Reducing cardiovascular risk in diabetes: insights from the ADVANCE study

BACKGROUND Blood pressure is an important determinant of the risks of macrovascular and microvascular complications of type 2 diabetes. That’s why guidelines recommend intensive lowering of blood pressure in those patients. The ADVANCE (Action in Diabetes and Vascular disease: preterAx and diamicroN-MR Controlled Evaluation) study has been recently introduced. It assessed the effects of such an approach on vascular disease using a fixed combination of the ACE-inhibitor perindopril, and the diuretic indapamide, in a population of patients with type 2 diabetes and a broad range of blood pressure values. METHODS After a 6-week active run-in period, 11,140 patients with type 2 diabetes were randomised to treatment with a fixed combination of perindopril and indapamide or matching placebo, in addition to current therapy. Primary end-points: major macrovascular and microvascular events, defined as death from cardiovascular disease, non-fatal stroke or non-fatal myocardial infarction, and new or worsening renal or diabetic eye disease. The macrovascular and microvascular composites were analysed jointly and separately. RESULTS To the end of the follow-up a meaningful reduction of the deaths has been obtained, both for cardiovascular causes and for macro and microvascular events, examined in together (in the total) (separately significance has not turned out). The best result has been obtained in the reduction of the renal events. DISCUSSION AND CONCLUSIONS The authors conclude that routine administration of a fixed combination of perindopril and indapamide to patients with type 2 diabetes and with a good controlled blood pressure, was well tolerated and reduced the risks of major vascular events, including death, but it remains the doubt if these results have been obtained because of the better pressure control or are specific of this preconstructed association

the erectile dysfunction as a cardiovascular risk factor

Erectile dysfunction (ED), defined as the inability of the subject of the male gender to achieve and/or maintain an erection sufficient to permit satisfactory sexual intercourse, is a source of great discomfort for patients in everyday life. This condition has a high prevalence in the general population, although frequently underestimated in clinical practice. The purpose of this article is to review the epidemiology, the pathophysiology and the clinical features of this disease, emphasizing the importance of erectile dysfunction as an indicator of silent atherosclerotic disease

La progressione della malattia renale cronica

La progressione della malattia renale cronica G. Pinna Basso peso alla nascita, numero di nefroni e malattia renale cronica D. Manfellotto, M. Cortinovis, N. Perico, G. Remuzzi Malattia renale in corso di diabete mellito: vecchi e nuovi paradigmi E. Gatti, I. Pellicelli, A. Bovino, D. Fasano, E. Gnappi, L. Zerbini, A. Magnano, S. Pioli, L. Bianchi, A. Caiazza, T.M. Attardo, M. Meschi Il ruolo dell’ipertensione arteriosa nella malattia renale cronica: vittima e colpevole A. De Pascalis, D. Vetrano, A. Tomassetti, S. Bianchi, G. Cianciolo Il ruolo dell’autoimmunità nelle malattie renali M. Giliberti, V. Di Leo, E.D. Stea, A. Mitrotti, L. Gesualdo Transizione dal danno renale acuto alla malattia renale cronica F. Di Mario, M.C. Pacchiarini, E. Fiaccadori Le frontiere del trattamento dell’iperpotassiemia A. Montagnani, M. Caselli, S. Cappell

Il dolore tra natura e cultura

Summary Pain and suffering represent unavoidable experiences that have left a deep mark on the history of mankind. In this review, pain is examined from an anthropological point of view, because there is no pain without suffering, and every biophysical event is brought to the consciousness of an individual by an emotional signal. The body is an entity that changes from culture to culture and operates within particular historical and social contexts. Each society incorporates the concept of pain into its particular worldview, assigning it a specific meaning and value. Few human experiences can be read in as many different keys: from neuroscience to linguistic research, perspective selection, and emotional and cognitive functions. Although pain is currently regarded as a destructive force that is per se pathological, it is actually a form of protection. In today's society, pain is experienced as a problem in itself, a disease within a disease, and its physiopathological aspects have been extensively characterized. But pain must also be analyzed within its anthropological, sociological, political, and economic contexts. The phenomenon of pain lies at the crossroads between nature and culture, and analysis from this perspective is essential for explaining the multiplicity of related data. The "anthropology of pain" explains, among other things, the assortment of reactions to identical pain stimuli among individuals and groups: for example, the higher opposition to pain observed among individuals living in poverty, the phenomenon of "combat analgesia", and the wide variety of analgesics used by traditional populations

Influence of dietary protein and fructooligosaccharides on fecal fermentative end-products, fecal bacterial populations and apparent total tract digestibility in dogs

Background: Feeding dogs with diets rich in protein may favor putrefactive fermentations in the hindgut, negatively affecting the animal\u2019s intestinal environment. Conversely, prebiotics may improve the activity of healthpromoting bacteria and prevent bacterial proteolysis in the colon. The aim of this study was to evaluate the effects of dietary supplementation with fructooligosaccharides (FOS) on fecal microbiota and apparent total tract digestibility (ATTD) in dogs fed kibbles differing in protein content. Twelve healthy adult dogs were used in a 4 74 replicated Latin Square design to determine the effects of four diets: 1) Low protein diet (LP, crude protein (CP) 229 g/kg dry matter (DM)); 2) High protein diet (HP, CP 304 g/kg DM); 3) Diet 1+1.5 g of FOS/kg; 4) Diet 2+1.5 g of FOS/kg. The diets contained silica at 5 g/kg as a digestion marker. Differences in protein content were obtained using different amounts of a highly digestible swine greaves meal. Each feeding period lasted 28 d, with a 12 d wash-out in between periods. Fecal samples were collected from dogs at 0, 21 and 28 d of each feeding period. Feces excreted during the last five days of each feeding period were collected and pooled in order to evaluate ATTD. Results: Higher fecal ammonia concentrations were observed both when dogs received the HP diets (p<0. 001) and the supplementation with FOS (p<0.05). The diets containing FOS resulted in greater ATTD of DM, Ca, Mg, Na, Zn, and Fe (p<0.05) while HP diets were characterized by lower crude ash ATTD (p<0.05). Significant interactions were observed between FOS and protein concentration in regards to fecal pH (p<0. 05), propionic acid (p<0.05), acetic to propionic acid and acetic + n-butyric to propionic acid ratios (p<0.01), bifidobacteria (p<0.05)andATTDofCP(p<0.05)andMn(p<0.001). Conclusions: A relatively moderate increase of dietary protein resulted in higher concentrations of ammonia in canine feces. Fructooligosaccharides displayed beneficial counteracting effects (such as increased bifidobacteria) when supplemented in HP diets, compared to those observed in LP diets and, in general, improved the ATTD of several minerals

Occurrence of Mycotoxins in Extruded Commercial Cat Food

The occurrence of the most important mycotoxins (deoxynivalenol, fumonisin B1 and B2, aflatoxins B1, B2, G1, and G2, ochratoxin A, zearalenone, T-2, and HT-2 toxins) was determined in 64 extruded cat foods purchased in Italy through ultra-performance liquid chromatography coupled with tandem mass spectrometry. Deoxynivalenol and fumonisins were the most common contaminants (quantified in 80 and 95% of the samples, respectively). Conversely, aflatoxins B2, G1, and G2 were not identified in any sample. Some cat foods exceeded the regulatory limit for aflatoxin B1 (n = 3) or the guidance values for zearalenone (n = 3), fumonisins (n = 2), ochratoxin A (n = 1), and T-2 (n = 1) recently established for pets in the European Union. A widespread co-occurrence of mycotoxins was observed (28, 42, and 8% of the samples contained quantifiable amounts of two, three, and four mycotoxins, respectively). This study describes criticisms regarding the mycotoxin issue in pet food and suggests an improvement of the monitoring of the pet food chain

Are multiple-choice questions a good tool for the assessment of clinical competence in Internal Medicine?

There are many feasible tools for the assessment of clinical practice, but there is a wide consensus on the fact that the simultaneous use of several different methods could be strategic for a comprehensive overall judgment of clinical competence. Multiple-choice questions (MCQs) are a well-established reliable method of assessing knowledge. Constructing effective MCQ tests and items requires scrupulous care in the design, review and validation stages. Creating high-quality multiple-choice questions requires a very deep experience, knowledge and large amount of time. Hereby, after reviewing their construction, strengths and limitations, we debate their completeness for the assessment of professional competence

Could clustering of comorbidities be useful for better defining the internal medicine patients’ complexity?

Internal medicine patients are mostly elderly with multiple comorbidities, usually chronic. The high prevalence of comorbidity and multimorbidity has a significant impact on both positive responses to treatment and the occurrence of adverse events. Clustering is the process of nosography grouping into meaningful associations with some index disease, so that the objects within a cluster have high similarity in comparison with one another. In the decision-making process it is imperative that, in addition to understanding the immediate clinical problems, we are able to explicit all the contextual factors that have to be taken into account for the best outcome of care. Cluster analysis could be leveraged in developing better interventions targeted to improve health outcomes in subgroups of patients

Cure indicators and prevalence by stage at diagnosis for breast and colorectal cancer patients: A population‐based study in Italy

People alive many years after breast (BC) or colorectal cancer (CRC) diagnoses are increasing. This paper aimed to estimate the indicators of cancer cure and complete prevalence for Italian patients with BC and CRC by stage and age. A total of 31 Italian Cancer Registries (47% of the population) data until 2017 were included. Mixture cure models allowed estimation of net survival (NS); cure fraction (CF); time to cure (TTC, 5-year conditional NS &gt;95%); cure prevalence (who will not die of cancer); and already cured (prevalent patients living longer than TTC). 2.6% of all Italian women (806,410) were alive in 2018 after BC and 88% will not die of BC. For those diagnosed in 2010, CF was 73%, 99% when diagnosed at stage I, 81% at stage II, and 36% at stages III-IV. For all stages combined, TTC was &gt;10 years under 45 and over 65 years and for women with advanced stages, but &lt;= 1 year for all BC patients at stage I. The proportion of already cured prevalent BC women was 75% (94% at stage I). Prevalent CRC cases were 422,407 (0.7% of the Italian population), 90% will not die of CRC. For CRC patients, CF was 56%, 92% at stage I, 71% at stage II, and 35% at stages III-IV. TTC was &lt;= 10 years for all age groups and stages. Already cured were 59% of all prevalent CRC patients (93% at stage I). Cancer cure indicators by stage may contribute to appropriate follow-up in the years after diagnosis, thus avoiding patients' discrimination