Do We Know the True Burden of Tick-Borne Encephalitis? A Cross-Sectional Study.

INTRODUCTION: Tick-borne encephalitis (TBE) is an acute human arboviral infection of the central nervous system caused by a virus that is transmitted to humans mainly by tick bites. TBE is endemic in Europe and has become an increasingly important public health concern in recent years. Cases of TBE in Italy have occurred mainly in the north-east and central parts of the country. Vaccination is recommended for people who live in or visit areas at higher risk of tick bites. OBJECTIVE: The aim of our study was to ascertain the burden of TBE in the Veneto Region (north-east Italy). METHODS: Cases of TBE occurring in the region from January 1, 2007, to December 31, 2018, were extracted from the database of the mandatory notification system (MNS) and from hospital discharge records (HDRs) of admissions relating to a diagnostic code 063 according to the International Classification of Diseases, Ninth Revision, Clinical Modification. Capture-recapture methods were used to estimate the completeness of each data source (as a percentage of cases). Records including diagnostic codes 322.9 (Meningitis, unspecified) and 323.9 (Unspecified cause of encephalitis, myelitis, and encephalomyelitis) were also extracted from the HDR database. Municipalities were grouped by location, based on their elevation above sea level, as "mountains," "hills," or "lowlands". After selecting only the municipalities where cases of TBE had occurred, the proportion of cases of TBE out of the total cases of encephalitis and meningitis identified was calculated and used to estimate the number of cases of TBE potentially occurring in the municipalities that reported none. Then the observed and adjusted TBE rates per 100,000 population were calculated. RESULTS: During the 12 years considered, a total of 281 cases of TBE were identified; 155 emerged from the HDRs and the MNS, 89 only from the MNS database, and 37 only from the HDRs. The degree of completeness of the data was 93.0% for the MNS and HDRs combined, 80.8% for the MNS alone, and 63.6% for the HDRs alone. The observed annual rate of TBE in the Veneto in recent years was calculated at 0.48 per 100,000 population, with the highest standardized rate in the province of Belluno (5.95 per 100,000 population). A significant rising trend in the number of cases observed in the latest period (2015-2018) was apparent for the mountainous areas in the region (average annual percent changes: 43.7 [95% CI 19.0-73.5]). The number of cases peaked in the mountains in the month of June (0.89 per 100,000), in hilly areas in July (0.23 per 100,000) and in the lowlands in October (0.04 per 100,000). CONCLUSIONS: Our findings seem to confirm an underreporting of the cases of TBE and inadequate TBE surveillance in the Veneto, despite the clinical severity of the disease and the fact that it is mandatory to report all cases. The routine integration of different databases is crucial to the successful implementation and assessment of targeted prevention strategies and fundamental to public health decision-making on this issue.

Effectiveness of pro-active organizational models in primary care for diabetes patients.

BACKGROUND: Demographic changes and chronicity are posing new challenges to health care systems. Our study aimed to examine how effectively the three different types of proactive primary care models adopted by three different regional health care systems in Italy were improving the quality of diabetes management by general practitioners. METHODS: A coordinated Italian nationwide project to compare systematically the new proactive organizational models implemented at regional and local level (the MEDINA Project) involved several regions and their local health units (LHUs). A quasi-experimental study was conducted on a large dataset obtained by processing administrative databases. A combined indicator was developed to assess the quality of care delivered by primary care physicians, based on adherence to recommendations concerning patient monitoring and treatment. RESULT: The study concerned 602 Italian general practitioners (GPs), 174 of them female, who were caring for a total of 753,366 patients (47,575 of them diabetic). Analyzing a total score, representing global adherence to a quality management of patients with diabetes, confirmed that GPs who had adopted the new model of care for their diabetic patients obtained better results than those who had not, so the new policy was generally effective. CONCLUSION: Our study showed that introducing new, proactive primary care models could sustain efforts made around the world to guarantee good-quality chronic disease management in the primary care setting.

Developing a new clinical governance framework for chronic diseases in primary care: an umbrella review.

OBJECTIVES: Our goal is to conceptualise a clinical governance framework for the effective management of chronic diseases in the primary care setting, which will facilitate a reorganisation of healthcare services that systematically improves their performance. SETTING: Primary care. PARTICIPANTS: Chronic Care Model by Wagner et aland Clinical Governance statement by Scally et alwere taken for reference. Each was reviewed, including their various components. We then conceptualised a new framework, merging the relevant aspects of both. INTERVENTIONS: We conducted an umbrella review of all systematic reviews published by the Cochrane Effective Practice and Organisation of Care Group to identify organisational interventions in primary care with demonstrated evidence of efficacy. RESULTS: All primary healthcare systems should be patient-centred. Interventions for patients and their families should focus on their values; on clinical, professional and institutional integration and finally on accountability to patients, peers and society at large. These interventions should be shaped by an approach to their clinical management that achieves the best clinical governance, which includes quality assurance, risk management, technology assessment, management of patient satisfaction and patient empowerment and engagement. This approach demands the implementation of a system of organisational, functional and professional management based on a population health needs assessment, resource management, evidence-based and patient-oriented research, professional education, team building and information and communication technologies that support the delivery system. All primary care should be embedded in and founded on an active partnership with the society it serves. CONCLUSIONS: A framework for clinical governance will promote an integrated effort to bring together all related activities, melding environmental, administrative, support and clinical elements to ensure a coordinated and integrated approach that sustains the provision of better care for chronic conditions in primary care setting.

Multimorbidity patterns in high-need, high-cost elderly patients.

INTRODUCTION: Patients with complex health care needs (PCHCN) are individuals who require numerous, costly care services and have been shown to place a heavy burden on health care resources. It has been argued that an important issue in providing value-based primary care concerns how to identify groups of patients with similar needs (who pose similar challenges) so that care teams and care delivery processes can be tailored to each patient subgroup. Our study aims to describe the most common chronic conditions and their combinations in a cohort of elderly PCHCN. METHODS: We focused on a cohort of PCHCN residing in an area served by a local public health unit (the "Azienda ULSS4-Veneto") and belonging to Resource Utilization Bands 4 and 5 according to the ACG System. For each patient we extracted Expanded Diagnosis Clusters, and combined them with information available from Rx-MGs diagnoses. For the present work we focused on 15 diseases/disorders, analyzing their combinations as dyads and triads. Latent class analysis was used to elucidate the patterns of the morbidities considered in the PCHCN. RESULTS: Five disease clusters were identified: one concerned metabolic-ischemic heart diseases; one was labelled as neurological and mental disorders; one mainly comprised cardiac diseases such as congestive heart failure and atrial fibrillation; one was largely associated with respiratory conditions; and one involved neoplasms. CONCLUSIONS: Our study showed specific common associations between certain chronic diseases, shedding light on the patterns of multimorbidity often seen in PCHCN. Studying these patterns in more depth may help to better organize the intervention needed to deal with these patients.

Diabetes management in the primary care setting: a comparison of physicians' performance by gender.

BACKGROUND: A major shift in the gender of the medical-doctor workforce is now underway, and all over the world it is expected that an average 65% of the medical workforce will be women by 2030. In addition, an aging population means that chronic diseases, such as diabetes, are becoming more prevalent and the demand for care is rising. There is growing evidence of female physicians performing better than male physicians.AimOur study aimed to investigate whether any differences in diabetes process indicators are associated with gender, and/or the interaction between gender and different organizational models.Design and settingA population-based cross-sectional analysis was conducted on a large data set obtained by processing the public health administration databases of seven Italian local health units (LHUs). The seven LHUs, distributed all over the Italian peninsula in seven different regions, took part in a national project called MEDINA, with the focus on chronic disease management in primary care (PC). METHODS: A total score was calculated for the average performance in the previously listed five indicators, representing global adherence to a quality management of patients with diabetes. A multilevel analysis was applied to see how LHUs affected the outcome. A quantile regression model was also fitted. RESULTS: Our study included 2287 Italian general practitioners (586 of them female) caring for a total of 2 646 059 patients. Analyzing the performance scores confirmed that female general practitioners obtained better results than males. The differences between males and females were stronger on the 25th and 75th percentiles of the score than on the median values. The interaction between gender and LHU was not significant. CONCLUSION: Our study evidenced that female physicians perform better than males in providing PC for diabetes independently by the different organizational models. Further research to understand the reasons for these gender differences is needed.

Serotonin and noradrenaline reuptake inhibitors improve micturition control in mice.

Poor micturition control may cause profound distress, because proper voiding is mandatory for an active social life. Micturition results from the subtle interplay of central and peripheral components. It involves the coordination of autonomic and neuromuscular activity at the brainstem level, under the executive control of the prefrontal cortex. We tested the hypothesis that administration of molecules acting as reuptake inhibitors of serotonin, noradrenaline or both may exert a strong effect on the control of urine release, in a mouse model of overactive bladder. Mice were injected with cyclophosphamide (40 mg/kg), to increase micturition acts. Mice were then given one of four molecules: the serotonin reuptake inhibitor imipramine, its metabolite desipramine that acts on noradrenaline reuptake, the serotonin and noradrenaline reuptake inhibitor duloxetine or its active metabolite 4-hydroxy-duloxetine. Cyclophosphamide increased urine release without inducing overt toxicity or inflammation, except for increase in urothelium thickness. All the antidepressants were able to decrease the cyclophosphamide effects, as apparent from longer latency to the first micturition act, decreased number of urine spots and volume of released urine. These results suggest that serotonin and noradrenaline reuptake inhibitors exert a strong and effective modulatory effect on the control of urine release and prompt to additional studies on their central effects on brain areas involved in the social and behavioral control of micturition.