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Objective: The purpose of this study was to assess incidence of and risk factors for recurrent cardiovascular disease (CVD) in type 2 diabetes.Research Design and Methods: We estimated the incidence of recurrent cardiovascular events in type 2 diabetic patients, aged 40-97 years, followed by a network of diabetes clinics. The analysis was conducted separately for 2,788 patients with CVD at enrollment (cohort A) and for 844 patients developing the first episode during the observation period (cohort B).Results: During 4 years of follow-up, in cohort A the age-adjusted incidence of a recurrent event (per 1,000 person-years) was 72.7 (95% CI 58.3-87.1) in men and 32.5 (21.2-43.7) in women, whereas in cohort B it was 40.1 (17.4-62.9) in men and 22.4 (12.9-32.0) in women. After controls were included for potential predictors (familial CVD, obesity, smoking, diabetes duration, glycemic control, microvascular complications, geographic area, and antihypertensive and lipid-lowering treatment), male sex, older age, and insulin use were significant independent risk predictors (cohort A) and serum triglyceride levels >/=1.69 mmol/l emerged as the only metabolic (negative) prognostic factor (cohort B). In both cohorts, a prior CVD episode, especially myocardial infarction, was by far the strongest predictor of recurrent CVD.Conclusions: Approximately 6% of unselected diabetic patients in secondary prevention develop recurrent major CVD every year. Those with long-standing previous CVD show a higher incidence of recurrence. Male sex, age, high triglyceride levels, and insulin use are additional predictors of recurrence. [ABSTRACT FROM AUTHOR]

Purpose: The use of surgical antibiotic prophylaxis (SAP) in children is poorly characterized. Our aim was to evaluate the effectiveness of a quality improvement (QI) intervention targeting SAP in children, by means of a multicenter prospective intervention study, with a before and after design., Methods: We prospectively investigated elective surgical procedures performed in children <18 years, prior to the QI intervention, after the intervention and at 9-month follow-up. The primary outcomes were adherence to SAP indications and SAP appropriateness, defined considering antibiotic choice, timing of first dose and duration of administration. We compared SAP adherence and appropriateness prior the QI intervention, to the post-intervention and the follow-up. We considered patient and procedure characteristics as covariates in two logistic regression models to assess the effect of the QI intervention on SAP adherence and appropriateness., Results: We collected information on 2383 procedures (pre-intervention: 784; post-intervention: 790; follow-up: 809). The QI intervention had a significant impact on the adherence to SAP indications (86.6% in the post-intervention, compared to 82.0% prior to the intervention; p < 0.05), and on its appropriateness (35.7% compared to 19.9%; p < 0.01). The impact of the intervention on SAP appropriateness was maintained at follow-up (38.3%; p < 0.01 compared to pre-intervention). All components of SAP appropriateness significantly improved after the intervention and at follow-up. The logistic regression analyses confirmed the effect of intervention in improving adherence to SAP indications and appropriateness., Conclusions: Following the QI intervention, there was a significant improvement in quality of SAP in pediatric surgery, though more efforts are needed to increase SAP appropriateness.

Objective: To assess the relationship of waist circumference and weight/height ratio with height, and their association with components of the metabolic syndrome, in Type 2 diabetic patients., Design: multicenter cross-sectional survey on a cohort enrolled in a prospective observational study., Subjects: 13,232 patients (6816 women and 6416 men) with Type 2 diabetes, not currently affected by macrovascular complications., Measurements: height, weight, waist and hip circumference, waist/hip and waist/height ratios., Results: waist circumference was significantly correlated with height after adjustment for potential confounders (adjusted r=0.19 and 0.23 in women and men, respectively), while waist/height ratio showed an inverse correlation with height (r=-0.14 and -0.15, respectively). Elevated waist/height ratio was more predictive of hypertension and hypertriglyceridemia, than waist circumference or waist/hip ratio., Conclusions: Waist circumference is correlated with height; thresholds for waist circumference could need adjustment for height. Waist/height ratio, although inversely correlated with height, could be a better predictor of abnormalities associated with abdominal adiposity than waist circumference alone.

Objectives: A temporal relationship between the increasing use of antibiotics and the increasing levels of antibiotic resistance has been established for Streptococcus pneumoniae. There are also data that support the presence of a geographic correlation between the level of resistance and the pattern of use among different countries and even within the same country. The aim of this study was to evaluate the potential geographic correlation between the use of beta-lactams and erythromycin in different Italian regions and the resistance of these antibiotics to invasive strains of S. pneumoniae during the period 1999-2000., Methods: Ecological study., Results: In Italy the mean level of resistance for penicillin and erythromycin was 11.4% and 28.9%, respectively. The highest level of resistance for both antibiotics was observed in central and southern regions (i.e. Campania, Lazio and the combined regions of Calabria, Puglia and Sicilia). These regions were also those with the highest consumption of antibiotics. A strong correlation was found between the prevalence of resistance to erythromycin and the regional use of macrolides (r=0.93, P=0.001) and beta-lactams (r=0.84, P=0.002). With regard to penicillin resistance, the greatest correlation was observed for oral penicillin (r=0.85, P=0.002)., Conclusion: Our study provides further evidence of the association between regional level of antibiotic use and prevalence of antibiotic resistance.

Background and Aim: To compare guideline implementation and the actual delivery of secondary prevention for coronary artery disease in the cohort of Italian diabetic patients enrolled in the DAI study., Methods and Results: The DAI study is a multicentre cohort study of the prevalence and incidence of macroangiopathic events among 19,570 type 2 diabetic patients attending 201 Diabetic Care Units. For this study, we selected 1,475 subjects with a history of myocardial infarction, coronary artery bypass graft or percutaneous transluminal coronary angioplasty at enrollment. Only 25% of the coronary patients in secondary prevention were receiving lipid-lowering drugs, and 20% were receiving beta-blockers. None of the patients in 54/185 Diabetic Care Units were on statins, and none in 82/185 Units were on beta-blockers. Multivariate analysis showed a positive correlation between the number of treatments and the taking of statins, and a negative correlation with age., Conclusion: Our data highlight a gap between the therapeutic guidelines and actual treatment, with wide variability in the delivery of secondary prevention across Units. The out-of-pocket cost of medication, daily treatment burden and geographic area can be ruled out as possible explanatory factors. Physicians' prescription attitudes may be a possible reason.

Although the etiologic relation between nonsteroidal antiinflammatory drug (NSAID) use and gastrointestinal lesions is well documented, newly introduced NSAIDs deserve a fresh examination for their risk/benefit ratio. To estimate the association between consumption of ketorolac and the occurrence of gastroduodenal lesions, we conducted a case-control study. The study population comprised 600 outpatients with a confirmed endoscopic diagnosis of ulcer and erosion in 1991 and 1992 and 6,000 community controls matched by age and sex. We retrieved the prescription history through a computerized prescription monitoring system. We defined exposure to each study drug as "current" (month of endoscopy and preceding month), "recent" (second or third month preceding endoscopy). and "past" (fourth to sixth month preceding endoscopy). Current users of NSAIDs showed a 30% increase in the incidence of gastroduodenal lesions [odds ratio (OR) = 1.3; 95% confidence interval (CI) = 0.98 - 1.8] after adjustment for recent or past use of any NSAID, recent or past gastrotoxic therapy, recent or past use of gastroprotective drugs, and recent or past use of any other drug. Among NSAIDs, ketorolac was the only one showing a distinctly elevated risk of gastroduodenal lesions (OR = 4.2; 95% CI = 1.9-9.4). Current use of any NSAID was associated with almost a doubling of risk for ulcer alone (OR = 1.9; 95% CI = 1.3-3.0); no elevation in risk was found for erosions. The adjusted relative risk for ulcer associated with current use of ketorolac was 9.8 (95% CI = 3.4-28.10. Recent and past use of NSAIDs does not increase the risk of ulcer.(ABSTRACT TRUNCATED AT 250 WORDS)

A cohort of 1971 chemical workers licensed to handle ethylene oxide was followed up retrospectively from 1940 to 1984 and the vital status of each subject was ascertained. No quantitative information on exposure was available and therefore cohort members were considered as presumably exposed to ethylene oxide. The cohort comprised 637 subjects allowed to handle only ethylene oxide and 1334 subjects who obtained a licence valid for ethylene oxide as well as other toxic gases. Potential confounding arising from the exposure to these other chemical agents was taken into consideration. Causes of death were found from death certificates and comparisons of mortality were made with the general population of the region where cohort members were resident. Seventy six deaths were reported whereas 98.8 were expected; the difference was statistically significant. The number of malignancies for any site exceeded the expected number (standardised mortality ratio (SMR) = 130; 43 observed deaths; 95% confidence interval (95% CI) 94-175) and approached statistical significance. For all considered cancer sites the SMRs were higher than 100 but the excess was only significant (p < 0.05, two sided test) for lymphosarcoma and reticulosarcoma (International Classification of Diseases--9th revision (ICD-9) = 200; SMR = 682; four observed deaths; 95% CI 186-1745). The excess of cases for all cancers of haematopoietic tissue (ICD-9 = 200-208) also approached statistical significance (SMR = 250; six observed deaths; 95% CI 91-544). Focusing the analysis on the subcohort of the ethylene oxide only licensed workers, who are likely to have experienced a more severe exposure to this gas, it became evident that all but one of the observed cases of haematopoietic tissue cancers in the cohort were confined to this subgroup, enhancing the relevant SMR to 700 (95% CI 237-1637) and the SMR of lymphosarcoma and reticulosarcoma to 1693 (95% CI 349-4953).

All Italian citizens are covered by the National Health Service (NHS) and medical records of individual drug prescriptions are routinely collected and processed. A procedure entitled EPIFAR has been developed which, on the basis of a computer routine, makes it possible to trace back the prescription history of each individual included in the NHS. The validity of information gathered through the EPIFAR procedure to provide estimates of tuberculosis (TB) prevalence has been evaluated. A comparison with routine surveillance data has been made. The EPIFAR procedure identified a total figure of TB patients seven times higher than that from official notifications. A sample survey was conducted among the prescribing physicians in order to quantify the proportion of TB cases among subjects receiving prescriptions of anti-TB drugs. According to general practitioner recall 66.4% of the patients were treated because of TB diagnosis, TB prophylaxis and TB relapse.