Journal of Diabetes & Metabolism

AMD: Associazione Medici Diabetologi (Italian Association of Clinical Diabetologists); BMI: Body Mass Index; GFR: Glomerular Filtration Rate; HDL: High Density Lipoprotein; LDL: Low Density Lipoprotein

Diabetes mellitus is one of the most widespread pathologies in the world affecting about 300 million people, a figure set to increase within the next twenty years [1]. In Italy there are about 3 million people affected with different percentages in each age group. In particular, more than 50% of all outpatients cared by diabetes clinics are aged 65 years or older. This population group has multiple problems requiring a broad range of assistance and treatment, due to the fact that they are frail and/or suffer from multiple comorbidities [2]. Over the past twenty years diabetes care has significantly improved. Broad clinical studies [3-7] evaluated, along with the glycemic control, the effects of blood pressure and lipid control on the prevention of long term diabetic complications, thus contributing to the current opinion about the complexity of diabetes care. In addition, these studies have provided the basis for setting the metabolic goals in the treatment of diabetes mellitus.

From a clinical perspective approaching elder adults with long-standing diabetes often associated with microvascular and macrovascular complications or elder subjects with newly diagnosed diabetes generally leads to a different intensity of care and to different therapeutical choices. Nevertheless, in both cases the presence of frailty, disability or comorbidities associated to a shorter life expectancy brings about the need of individualizing the clinical approach from the metabolic goals to the pharmaceutical choice and from the empowerment of the patient, or of the care-giver, to the follow-up plan [8].

Despite the effort in spreading these evidences to the medical community through guidelines, these are not yet fully applied in clinical practice. Thus it is still necessary to implement all those actions necessary to reach the goal and to constantly monitor the process by specific indicators.

Since 2006 the AMD (Associazione Medici Diabetologi) Society has promoted a continuous improvement in the quality of diabetes care in Italy through its annual AMD ANNALS campaign. The campaign involves diabetes care centers throughout the entire country. All these centers electronically collect data during routine outpatient management in order to elaborate pre-specified indicators of the care process. AMD has identified a set of indicators to be used for benchmarking activities [9,10]. Quality indicators include process measures evaluating diagnostic, preventive and therapeutic procedures performed by the participating centers, and outcomes indicators measuring favorable and unfavorable modifications in the patient health status.

To date, there is a lack of specific analyses on the quality of care provided to elderly population with type 2 diabetes; therefore, the aim of this study is to analyze some indicators linked to the quality of care provided by diabetes centers to young old (i.e. ≥ 65-74 years old) and old patients (i.e. ≥ 75 years old) as compared to younger ones in order to evaluate the attitude of Italian diabetes specialists in caring the elder population and to highlight critical areas.

Selection of samples and analysis of the data

An extensive database containing data from 251 Italian Diabetic Centers has been used.

Centers share common software for data extraction from electronic medical records. Data are collected on annual basis in a standardized format (AMD File Data) and centrally and anonymously analyzed. The entire project is conducted without allocation of extra resources or financial incentives, but simply through a physician-led effort, made possible by the commitment of the involved specialists.

We analyzed data from 414,814 subjects with type 2 diabetes that were seen in 2009.

This extensive database is the result of the continuous improvement in the quality program, called AMD Annals campaign, promoted by the AMD Society and it reflects the usual clinical practice of Italian diabetologists.

A set of indicators has been identified for benchmarking activities:

• Process indicators: evaluating diagnostic, preventive and therapeutic procedures

• Outcome indicators: estimating favorable and unfavorable modification in patient health status

• Use of drugs (diabetic, antihypertensive, lipid-lowering)

In our study, we have analyzed the following indicators:

- Process measures which were taken at least once a year for the following parameters:

• Glycated haemoglobin (Hb1Ac)

• Arterial blood pressure

• Lipid profile

• Albuminuria

• Renal function - calculation of Glomerular Filtration Rate (GFR)

• Foot examination

• Fundus examination

• Intermediate outcomes indicators

• Percentage of patients with HbA1c ≤ 7%

• Distribution of HbA1c level in population subgroups

• Percentage of patients with levels of cholesterol LDL <100 mg/ dl and >130 mg/dl.

• Percentage of patients with blood pressure ≤ 130/80 and ≥ 140/90 mmHg

• Distribution of BMI by population subgroup

• Percentage of smokers

• Percentage of patients with micro/macroalbuminuria

• Distribution of the patient for classes of GFR

In case of multiple readings collected from the same patient throughout the year, the most recent available record was taken as a benchmark.

The cholesterol LDL was estimated by the Friedwald equation. Microalbuminuria was defined as an albumin excretion rate in between 20 and 200 mcg/min alternatively both the albumin/creatinine ratio (>2.5 in men or >3.5 in women) or a microalbumin >30mg/l were used for definition. The GFR was calculated with the MDRD formula (modification of the diet in renal disease).

Overall, 414,814 patients with type 2 diabetes referred to 236 diabetes outpatients centers during the year 2009 were evaluated; 165,388 (39.9%) of these patients were aged less than 65 years (young group), 144,965 (34.9%) between 65 and 74 years (young old group), and 104,461 (25.2%) more than 74 years (old group). Mean age was 55.8 ± 7.8 in the first group, 70.0 ± 2.8 in the second group, and 80.3 ± 3.9 in the third group. As for the gender, in the young old group a prevalence of men (54.8%) compared to women (45.2%) was reported. Conversely, women were more prevalent in the older group (54.8% vs 45.2%).

As for the percentage of patients annually monitored for HbA1c, there was not a significant difference among the groups being respectively 92.5% in the young, 93.3% in the young old, and 91.2% in the old group.

The percentages of young, old young and old patients with a HbA1c <7% were respectively 43.4%, 45% and 42.5% respectively, while approximately 11% in both groups of elder individuals had a HbA1c >9% compared to 16.5% in the young group. Yet, it should be considered that almost one fourth of the elder subjects had values of less than 6.5%, suggesting a potential risk of hypoglycaemia (Figure 1).

Figure 1: Trend of glycated hemoglobin by aged classes (normalized to 6%).

The data concerning the measurement of the GFR were taken from 102,505 subjects between 65 and 74 years and from 73,099 subjects aged ≥ 74 years, i.e. near two thirds of the population in each group and slightly less in the young group. Analyzing the distribution of the population by class of GFR, 8.4% of young and 22.4% of young old patients have a GFR lower than 60 ml/min, while this percentage rose up to 40.3% in individuals older than 75 years (Figure 2).

Figure 2: People distribution by GFR classes (ml/min).

Microalbuminuria was recorded in only 37% of subjects aged ≥ 74 years while in those aged between 65 years and 74 years it was 42.9%, a percentage equal to that observed in young individuals (42.8%).

Annual lipid profile was lacking in 23.9% of young, 24.8% of young old and 31.9% of old group.

Total cholesterol (CT) levels tended to decrease with increasing age. In diabetic individuals over 65 years, both levels of CT and C- LDL were lower as compared to younger patients.

Less than 25% of the patients aged over 65 years showed C-LDL values exceeding 130 mg/dl compared to younger patients (29.6%).

Accordingly, the elderly population had a better lipid profile also in terms of serum triglycerides (TG) and C-HDL. With increasing age, the TG values tend to decrease, and C-HDL values both (females and males) tend to increase (Figure 3).

Figure 3: Lipid profile: mean values by age group.

Measurement of arterial blood pressure was taken in 80% of young and young old patients and in 75% of old. The percentage of patients with blood pressure readings ≥ to 140/90 mmHg increased with age being 51.1%, 60.3% and 62.1% respectively(Figure 4).

Figure 4: Trends of blood pressure values by age classes.

A foot examination was performed in only 14.5%, 13.6 and 10.4% of the young, young old and old group respectively.

When considering only those patients at risk for foot lesions (i.e. those having a neuropathy or a low-limbs arteriopathy) the percentage of those who received a foot examination at least once a year, is still unsatisfactory, especially in the older group (22.4% in 65-74 years group and 19.3% in ≥ 74 years group) but it was low even in younger people (22.5%).

The percentage of subjects who underwent an annual examination of the fundus is similar in young and young old (35% and 34.7%) and very low in the old group (26.2%).

Near 40% of patients between 65 and 74 years old, and 31% of those aged over 74 years were obese (BMI ≥ 30) and 26% in both groups were overweight (BMI in-between 27.0 and 29.9). In the young group obese and overweight patients were respectively 47.3% and 23.8%.

The percentage of smokers was 13.8% in young old group and 7.2% in old group. The percentage of smokers is approximately twice in male than in female patients. Smokers were 25.6% among young individuals.

The aim of this study was to evaluate possible differences in the quality of the care received by type 2 diabetic patients over 74 years compared to younger people. The study involved a large number of Italian diabetes centers involved in the AMD Annals campaign in 2009.

Quality of care was estimated by pre-specified indicators in the process area and intermediate outcomes were evaluated.

As for glycemic evaluation elder people receive the same attention as the younger. Diabetologists focus their attention on renal function (GFR evaluation) more in people over 65 years old than in those below this age while after 74 years microalbuminuria is estimated less frequently. This one may argue that while GFR is a concern for possible adverse event due to the therapy, it is not perceived as an important task to screening and follow-up of early stage of renal disease in elder individuals. This attitude is confirmed by the lower percentage of elder people undergoing an annual fundus examination compared to younger ones. Taken as a whole these results suggest that as for microvascular complications the Italian specialist care individuals aged 65-74 years in the same way of those younger than 65 years. The same picture can be depicted for the evaluation of cardiovascular risk factors such as lipids and blood pressure and for foot examination.

When considering the effect of care in terms of glycemic control, 45% of people aged 65-74 years and 42.5% of those aged more than 74 years have an HbA1c% lower than 7 and these percentages are similar to the ones in the younger group.

Data should be interpreted taking into account the medical treatment used to achieve the target. For instance, HbA1c values below 7% might be inappropriate in elderly frail patients, due to the high risk of hypoglycemia; such values may be acceptable only if reached using molecules such as insulin-sensitizer or incretins. Geriatric guidelines for the type 2 diabetes management in the elderly population (over 70 years) stress this concept also in case of individuals who are not frial, indicating the 7% value of HbA1c as the minimum level to be reached in elder people [2]. The AMD Annals provide evidence about one of the most common long-term complication of diabetes, the kidney function impairment. Results in term of HbA1c in the elderly population should be evaluated in relation to this variable, as it determines the risk of adverse events linked to the therapy. Conversely, more than one in ten individuals observed has a significantly high level of HbA1c. These levels might be primarily associated with the development or the worsening of geriatric syndromes [11], cognitive decline and incontinence, and therefore, like excessively low levels, they should be avoided.

GFR declines with age. The levels of GFR and the levels of albuminuria are useful for an adequate evaluation of the stage of renal disease [12] and their values give complementary information.

In 24 % of type I diabetic patients, a reduction of GFR in the absence of albuminuria has been reported [13], this percentage is even higher in type 2 individuals ranging from between 39 to 62% [14]. Even more significant results were found in the Italian Study RIACE [15], where three-quarters of the population studied were aged over 60 years and a prevalence of 56.6% in the non-albuminuric form in diabetic patients with CKD stage 3 or more was observed, whereas only 30.8% and 12.6% were respectively micro and macroalbuminuric. Several studies have confirmed the relationship between GFR, albuminuria and increased incidence of cardiovascular events [16,17]. In the RIACE study [15], a strong association between coronary events and reduction of the GFR was observed, while for cerebrovascular and peripheral vascular disease a close association with the albuminuric phenotypes, indicating a different clinical pathogenesis, was reported. Thus specialists must pay the same attention in evaluating both the variables.

It has been clearly demonstrated how the reduction in lipid levels, particularly LDL-C, induce a significant reduction in terms of disease status and death from cardiovascular disease [18] and that this effect can be appreciated, after only three years of treatment, much earlier than the effect of a good glycemic control [19].

Guidelines shared by the principal scientific societies have not indicated a specific target in the management of hypercholesterolemia in the elderly, especially in the diabetic population [20].

Resting on the effectiveness of lipid lowering therapy in individuals below 80 years old, the same objectives for younger people are recommended for very old people in both primary and secondary prevention [21].

Our elder population showed a better lipid profile than the younger. These results can be interpreted in different ways but a survival effect is likely. It is remarkable that HDL-C and triglycerides values are respectively higher and lower in the young old and old subgroups were obese patients were less represented.

Yet, it is necessary to consider that the treatment of the elderly with hypercholesterolemia must be individualized, taking into consideration both age and cardiovascular risk, as well as the general function and grade of independence and disability, as recently proposedand carefullyweighing the risks and benefits of statin therapy [22,23].

With increasing age a large part of patients show pressure readings higher than 140/90. In particular, there is an increase in systolic value and the relative cardiovascular risk.

The treatment of hypertension in the elderly is associated with a significant reduction in the mortality from cardiovascular and microvascular complications [24]. It has been widely demonstrated that the reduction of circulatory complications occurs after at least 8 years of good glucose control. Yet, in case of regular control of blood pressure, the benefits are already evident after 2-3 years [25].

Antihypertensive treatment in the elderly is highly effective in reducing cardiovascular events when blood pressure is reduced below 140 mm Hg, but it loses its effectiveness with further reduction.

The guidelines from the American Society of Geriatrics [25] state that the acceptable blood pressure to achieve, for whatever therapy undertaken, is equal to or less than 140/90, where tolerated. However, it is potentially harmful to reach values under 120 mmHg because of the risk of hypotension and falls [16,26,27].

However, given the considerable heterogeneity of the elderly, the American Diabetes Association guidelines advice target blood pressure <140/80 mmHg, recommending aims that are less constricting for elderly patients that have low life expectancy [28].

Feet were examined only in one fifth of the patients and even less in the age group over 75 years. The data collected indicate an important critical area, considering that the patients at risk are diabetic individuals with neuropathy, a history of diabetic foot, progressive amputations or arterial obstructive disease in the lower limbs. All diabetic individuals should undergo at least once a year a complete check up of their feet. Particular attention must be given to patients over 70 years, and the following aspects must be considered: social, assistance, comorbidity, fragility and other circumstances increasing the risk of developing the “diabetic foot”. This critical finding on foot examination is an issue for the diabetes teams in Italy and claim for a different organization.

In this regard, it is necessary to identify and assign specific tasks to the support systems in primary and secondary care that are interdependent on similar programs, involving also general practitioners who can play a key role in preventive care [29].

Diabetic retinopathy is the most threatening among the chronic microvascular complications of diabetes for elderly patients; the incidence of blindness is 6-12 case/100,000 inhabitants/year over 70 years of age and the strongest predictor of retinopathy is the duration of diabetes [30]. Considering the effects of visual loss in type 2 diabetes, patients should be screened for diabetic retinopathy at the time of diagnosis. The following examinations should be programmed at least every two years, and even more frequently in cases of diabetic retinopathy [21].

Diabetes centers must be supplied with devices and/or facilities necessary to follow up examinations. It is recommended to cooperate with thenearesteye clinics and to involve patients in educational courses about the prevention and early diagnosis of diabetic retinopathy, in order to improve self-education [21].

In addition to check ups, good metabolic balance, adequate control of blood pressure, and reduction in the cardiovascular risk factors reduce the risk and progression of diabetic retinopathy [31,32].

Obesity tends to be less prevalent in very old patients. This could be related to the fact that the most overweight patients died prematurely; however, it should be noted that with increasing age, the BMI loses its value as an index for obesity, mainly due to the progressive reduction in height, and its predictive powers on mortality [33].

The percentage of smokers was lower in both sexes with increasing age. This phenomenon could depend on a higher number of discontinuations, related to the increase in comorbidity, in particular those due to cardiovascular problems predisposed by smoking.

Nonetheless, the number of smokers over seventy-five years of age (1 out of 10 men and almost 1 out of 20 women) is still very impressive, and it suggests that there is need for a greater commitment by doctors in this field.

Despite the high level of diabetes care in Italy compared to other Western Countries some areas are still critical and a gap between guidelines recommendations and clinical practice is evident. This gap is more evident in elder people over 74 years of age. In this subgroup, that is by definition the one in need of higher attention, the Italian specialists underestimate the risk for both acute and long-term complications.

Finally, our results can be partially biased by the fact that physicians may omit to record the result of a carried out procedure but the large number of centers and of subjects included in the study make the results reliable.

Thus, any effort should be made by the cultural and organizational perspective to overcome the existing gap.

The authors of this paper gratefully acknowledge the support given by the researchers participating in the AMD Annals Initiative.

Editorial Board (in alphabetical order): Adolfo Arcangeli - Prato, Antonino Cimino - Brescia, Paolo Di Bartolo - Ravenna, Danila Fava - Roma, Augusto Lovagnini-Scher – Cusano Milanino (MI), Alberto Marangoni – Bassano Del Grappa (VI), Illidio Meloncelli - S. Benedetto del Tronto (AP), Maria Franca Mulas – Oristano, Antonio Nicolucci, Santa Maria Imbaro (CH), Andrea Nogara – Chioggia, Fabio Pellegrini, Santa Maria Imbaro (CH), Maria ChiaraRossi - Santa Maria Imbaro (CH), Salvatore Turco – Napoli, Giacomo Vespasiani -S. Benedetto del Tronto (AP)

Statistical analysis: Antonio Nicolucci, Maria Chiara Rossi, Fabio Pellegrini, Giuseppe Lucisano, Basilio Pintaudi, Marco Scardapane, Riccarda Memmo, Elena Pellicciotta, Fondazione Mario Negri Sud, Santa Maria Imbaro (CH).

Regional Tutors (in alphabetical order by region): La Penna G, Paciotti V,– Abruzzo; Venezia A – Basilicata; Armentano G, Giovannini C – Calabria; Armentano V, Laudato M, Turco S – Campania; Laffi G, Monesi M - Emilia Romagna; Felace G, Tortul C - Friuli Venezia Giulia; Santantonio G, Suraci C – Lazio; Ghisoni G, Raffa M – Liguria; Genovese S, Lovagnini-Scher CA, Mangone I, Richini D, Rocca A – Lombardia; Garrapa G, Tortato E – Marche; Vitale C – Molise; Comoglio M, Fornengo R – Piemonte; De Cosmo S, Gentile FM - Puglia; Gigante A, Mastinu F – Sardegna; Di Benedetto A, Saitta G – Sicilia; Calabrese M, Orsini P – Toscana; De Blasi G, Romanelli T - Trentino Alto Adige; Cicioni G, Pocciati S – Umbria; Marangoni A, Nogara A – Veneto.

Participating centres (in alphabetical order by town):Marilena Lanero, Carla Bergonzini, Maria Grazia Bertero, Alba Rapetti, Gabriella Martini, Monica Tornaghi - Acqui Terme (AL); Antonino Pipitone, Lucio Bellinetti, Gemma Frigato, Daniela Santipolo - Adria (RO); Massimo Boaretto, Luisa Parmesan, Barbara Conte, Iva Manfroi, Fanny Soccol, Nadia Cumina - Agordo (BL); Annamaria Nuzzi, Elisabetta Benedusi Pagliano, Emanuele Fraticelli, Paola Viberti, Antonietta Pasquero - Alba (CN); Adalberto Pagano, Enrico Papini, Marco Chianelli, Filomena Graziano, Irene Misischi, Lucilla Petrucci, Roberta Rinaldi, Stefania Silvagni - Albano Laziale (RM); Maura Rosco - Alberobello (BA); Egle Ansaldi, Francesco Malvicino, Maurizia Battezzati, Paolo Maresca, Marcella Balbo, Clara Palenzona - Alessandria; Giovanni Cicioni, Stefania Venturi - Amelia (TR); Valentino Cherubini, Antonio Iannilli, Martina Biagioni, Chiara Giorgetti, Maria Cristina Alessandrelli, Alessandra Cesaretti, Anna Maria Paparusso - Ancona; Massimo Boemi, Rosa Anna Rabini, Gabriele Brandoni, Federica D’Angelo - Ancona; Maria Luigia De Cicco, Federica Giampetruzzi, Filomena Loconte, Simona Maldera, Stefania Annese, Palma Di Corato, Daniela Strippoli, Tiziana Rizzi - Andria (BAT); Giulio Doveri, Emma Lillaz, Antonio Ciccarelli, Salvatore Giardina, Roberta Courthoud, Paola Mararia, Elisa Pascale, Silvana Flou - Aosta; Grazia Pia Ricciardi, Paola Di Masa - Aprilia (LT); Guido Vitalone, Donatella Setti, Giuseppe Piticchio, Patrizia Contrini, Camilla Mazzola - Arco (TN); Paola Ponzani, Valeria Ghigliotti, Andrea Corsi - Arenzano (GE); Vincenzo Mazzini, Marina Orlandi, Maria Cristina Pollace - Argenta (FE); Stefano Fazion, Maria Luisa Spina, Cinzia Francesconi - Asola (MN); Vincenzo Trosini, Roberto Berardinucci, Katia Dolcetti, Paola Colleluori, Emanuela Cannarsa, Valeria Montanari, Paolo Di Berardino - Atri (TE); Mario Velussi - Aurisina (TS); Vincenzo Paciotti, Pasquale Alfidi, Bruno Verdecchia, Luigina Baliva, Alessia Di Pietro, Giovanna Franchi, Patrizia Luce - Avezzano (AQ); Simona Flora Maldera, Mariangela Manicone, Daniela Strippoli, Ida Console, Rossella Caringella, Anna Leonardini, Michele Giardino, Giuseppe Stornelli, Cristina Palmiotto,Gianluca Besozzi, Daniela Di Marzo, Adriana Lategola,Alessandra Marcotrigiano, Paolo Sciascia - Bari; Alberto Marangoni, Alessandro Pianta, Maria Ferrari, Sara Balzano, Gianpietro Beltranello - Bassano Del Grappa (VI); Massimo Boaretto, Concetta Nadia Aricò, Corradina Alagona, Laura Cervo, Silvia Rossa, Rosella Zanon - Belluno; Franco Travaglino, Rita Graziella Guarnieri - Biella; Maura Rosco, Maria Concetta Di Pace - Bisceglie (BAT); Gilberto Laffi, Silvio Giangiulio, Michele Grimaldi, Giovanna Santacroce, Fernanda Cerrelli, Rita Manini, Adolfo Ciavarella - Bologna; Stefano Zucchini, Claudia Balsamo, Mirella Scipione, Giulio Maltoni, Alessandra Rollo - Bologna; Bruno Fattor, Tiziano Monauni, Florian Amor, Dalia Crazzolara, Gerhard Orion, Michela Cristini, Sylvia Lintner,Johanna Eisath - Bolzano; Laura Chiappini, Sandra Alberti - Bondeno (FE); Stefano Garavelli, Teresa Calari, Paola Marini - Borgo Valsugana (TN); Marco Buschini, Daniela Bonfiglioli, Damiano Mones - Borgomanero (NO); Aldo Giuseppe Morea, Lucia Bondesan, Sandro Perbellini - Bovolone (VR); Emanuele Fraticelli, Mauro Ravera - Bra (CN); Antonino Cimino, Umberto Valentini, Angela Girelli, Liliana Rocca, Barbara Agosti, Emanuela Zarra - Brescia; Gianfranco De Blasi, Michael Bergmann, Franz Plaickner, Alessandra Ferro Ingaglio, Irmgard Pradi, Marianne Piok, Rosmarie Unterkircher, Marion Pichler - Bressanone (BZ); Giuseppina Palamà, Patrizia Palma, Claudia Pisanello, Antonio Trinchera - Brindisi; Brigitte Viehweider - Brunico (BZ); Mauro Giovanni Schiesaro, Giovanni Vita, Beatrice Cenci, Laura Pizzamiglio - Bussolengo (VR); Francesca Spanu, Sandro Cocco, Rasangela Maria Pilosu, Pier Paolo Contini - Cagliari; Giampiero Piras, Roberto Seguro, Marco Songini - Cagliari; Marco Stabilini, Fabrizio Lombardini, Salvatorina Mura, Paola Sulis, Aldo Caddori - Cagliari; Maria Giulia Cartechini, Natalia Busciantella Ricci, Giacoma Agostinelli - Camerino (MC); Antimo Aiello, Maria Rosaria Cristofaro, Lorenzo Cocco, Simonetta Di Vincenzo, Fiorentina D’Amico, Vittoria Di Iorio, Franca Di Ponte, Graziella Giancola, Emanuela Mazzola, Vittoria Niro, Lina Notartomaso, Carmela Sabetta - Campobasso; Annamaria Nuzzi, Claudia Ballauri - Canale (CN); Sergio Casati, Daniela Tettamanzi, Margherita Casartelli, Cosimo Prete, Emanuela Gatti, Luisa Marzorati, Tiziana Cairoli - Cantù (CO); Annelisa Lesina, Francesco Romeo, Carlo Bruno Giorda, - Carmagnola (TO); Anna Vittoria Ciardullo, Daniela Piani, Angela Deroma, Ewa Grazyna Maciejewska, Veronica Baccini - Carpi (MO); Elisabetta Straface - Casalbordino (CH); Giuseppe Pozzuoli, Mario Laudato, Maria Barone - Caserta; Sergio Tondini, Flavia Borgoni - Castel del Piano (GR); Juliette Grosso, Loredana Rossi, Carla Scarsellato, Antonietta Sciulli, Federica De Marco - Castel di Sangro (AQ); Stefano Fazion, Maria Luisa Spina, Cinzia Francesconi - Castel Goffredo (MN); Loris Confortin, Narciso Marin, Mario Lamonica, Elisa Rossi, Anna Pisacane, Vanessa Cavasin - Castelfranco Veneto (TV); Stefano Genovese, Fabiana Locatelli, Valeria Valdes, Flavia Moratti, Valentina Fuso - Castellanza (VA); Giordano Filippi, Monica Camporesi, Mirca Gherardi - Castelnovo Ne’ Monti (RE); Sergio Gallana, Gloria Buganza, Adriana Valentini, Ilaria Cera - Castiglione delle Stiviere (MN); Salvatore Gialdino, Rossella Franchino - Castrovillari (CS); Vito Borzì, Concetta Gatta, Riccardo Rapisardi, Salvatore Strano, Maria Calabrò - Catania; Luigi Puccio, Raffaella Vero - Catanzaro; Giuseppe Cheluci, Susy Martucci, Anna Simoncelli, Maria Pia Giammoema, Bruna Seber, Mauro Lozzer, Sonia Andolfatto - Cavalese (TN); Gemma Frigato - Cavarzere (VE); Vincenzo Starnone, Andrea Del Buono, Anna Maria Terracciano, Egidio Gamba - Cellole (CE); Vincenzo Maria Monda, Paola Ramponi, Sandra Alberti, Elisabetta Maccaferri, Flavia Busi - Cento (FE); Francesco Castro, Antonello Guaglianone, Concezione Maccari - Cetraro (CS); Laura Corsi, Giorgio Versari, Maria Rosaria Falivene, Nicoletta Boletto, Simona Corsi, Marisa Delucchi, Simonetta Gasperi, Bruna Ferrari - Chiavari (GE); Carla Origlia, Lisa Marafetti, Carlo Bruno Giorda - Chieri (TO); Ester Vitacolonna, Livia Lina Cavuto, Federica Fraticelli, Matteo D’Angelo - Chieti; Loredana di Nisio, Filomena Simonetti - Chieti; Andrea Nogara, Gianni Ballarin, Angelo Boscolo Bariga, Silvia Di Benedetto - Chioggia (VE); Anna Maria Chiambretti, Riccardo Fornengo, Lidia Di Vito, Maria Divina Pascuzzo, Paola Urli, Monica Albertone, Primo Bassani, Carla Bellaluna, Maria Bonacci, Iolanda Bosso, Daniela Cortale, Vanda De Michelis, Margherita Di Gennaro, Vilma Magliano, Silvia Nieddu, Antonia Stranisci - Chivasso (TO); Alberto Rocca, Paola Galli, Annunziata De Blasi, Monica Castellan, Cristina Cavenaghi, Maria Iagulli - Cinisello Balsamo (MI); Virginia Trinelli, Francesco Caraffa, Daniela Gallo - Ciriè (TO); Roberto Norgiolini, Roberta Celleno, Corrado Campanelli, Daniela Biccheri, Cinzia Bondi, Giuseppa Dadi - Città di Castello (PG); Graziano Santantonio, Luciano Massa, Alessandra Zappaterreno, Lina Lottatori, Elisa Costanzo, Nicoletta Pistola - Civitavecchia (RM); Paolo Ziller, Federica Portolan, Giuseppe Pasolini - Cles (TN); Valerio Di Chiara, Maria Luisa Grata, Elisabetta Bergami, Soccorsa Ciannillo, Navia Curzola - Codigoro (FE); Luigi Capretti, Guglielmina Speroni, Luciano Fugazza - Codogno (LO); Cinzia Massafra - Cologno Monzese (MI); Maria Cristina Cimicchi, Carlo Percudani, Tiziana Risolo, Paola Saccò, Manuela Mori - Colorno (PR); Valerio Di Chiara, Maria Luisa Grata, Elisabetta Bergami, Soccorsa Ciannillo, Navia Curzola - Comacchio (FE); Gian Luigi Gidoni Guarnieri, Diana Piccolo, Franca Giacon, Mariolina Scarpel, Clementina Bravin, Elena De Noni, Vanda Daniotti - Conegliano (TV); Giuseppe Panebianco, Federica Tadiotto, Virgilio Da Tos, Michele D’Ambrosio, Monica Faoncella, Marj Zogno, Cristina Lunardi, Patrizia Crivellaro, Loretta Trivellato - Conselve (PD); Dario Pellizzola, Maria Antonella Zampini, Emanuela Frezzati, Maria Elvira Raminelli, Elena Mari - Copparo (FE); Dario Gaiti, Giuseppina Chierici, Silvia Pilla, Bruna Milli, Monica Camporesi, Paola Caretta, Valeria Vezzani, Melita Copelli - Correggio (RE); Alfonso Longobucco - Cosenza; Patrizia Ruggeri, Sergio Di Lembo, Elisa Carrai, Amalia Degli Innocenti, Lucia Manini, Romano Persico, Cristiana Rossi - Cremona; Enrico Gabellieri, Daniela Sansone, Maria Stella Sbriglia, Giuseppina Comba, Giovanni Valesano, Stefania Bertello, Luisella Ballatore, Salvatore Oleandri - Cuneo; Giampaolo Magro, Francesco Tassone, Donatella Gaviglio - Cuneo; Giuseppe Marelli, Veronica Vilei, Paolo Rumi, Laura Bellato, Mara Fedeli, Antonella Merlini, Giuseppina Pinelli - Desio (MB); Giuseppe Marin, Maria Luisa Contin, Angela De Cata, Anna Patalano, Paola Parlato, Jessica Jacovacci - Dolo (VE); Giuseppe Placentino, Vittoria Zizzari, Sofia Pellanda, Luisa Folchi, Anna Lorenzini - Domodossola (VB); Donata Richini, Stefano Molinari, Chiara Inversini, Roberto Strazzieri, Paolo Stofler, Marco Andreoli, Simona Fornaro - Esine (BS); Giuseppe Panebianco, Federica Tadiotto, Virgilio Da Tos, Michele D’Ambrosio, Monica Faoncella, Marj Zogno, Cristina Lunardi, Patrizia Crivellaro, Loretta Trivellato - Este (PD); 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Benedetto del Tronto (AP); Paolo Bordin, Maurizio Sacandi, Laura Perale, Luciana Dotto, Roberto Da Ros, Nella Pupin, Elena Rosso, Fabiola Zamparo - S. Daniele del Friuli (UD); Silvestre Cervone, Matteo Pontonio, Lucia De Angelis - S. Marco in Lamis (FG); Manola Nicoletti, Nazzareno Trojan, Tiziano Croatto, Rita Centis - S. Vito al Tagliamento (PN); Patrizia Li Volsi, Elisa Levis, Giorgio Zanette - Sacile (PN); Carmela Vinci, Milena Zanon, Loredana Geretto, Cristina Toffolo, Maria Grazia Furlan - San Donà di Piave (VE); Vincenzo Sica, Raffaella Derai, Marina Armeni, Anna Bruna Urraci, Letizia Carreras, Elisabetta Cossu, Simonetta Mamusa, Maria Antonietta Pisano - San Gavino Monreale (VS); Salvatore De Cosmo, Anna Rauseo - San Giovanni Rotondo (FG); Marco Strazzabosco, Elisabetta Brun, Maria Simoncini, Chiara Alberta Mesturino, Francesco Zen - Sandrigo (VI); Roberto Sturaro, Maurizio Raffa, Federico Quattrocchi - Sanremo (IM); Anna Carbone, Cristina Gnocchi, Maria Rosa Anelli, Ester Fontana, Giuliana Alfoli - Sant’ Angelo Lodigiano (LO); Maura Rosco, Giovanni Labarile - Santeramo (BA); Fabrizia Caucci - Sassari; Luca Lione, Dino Dessì - Savona; Mario Monachesi, Giovanni Carta, Mara Boschetti, Enrica Ceresola, Emanuela Venier - Savona; Stefano De Riu, Umberto Amelia - Scafati (SA); Francesco Calcaterra, Fedele Cataldi, Marina Miola - Schio (VI); Silvana Manfrini, Silvia Rilli, Gessica Tinti - Senigallia (AN); Alessio Lai, Barbara Locci, Donatella Putzu - Senorbi (CA); Stefano Genovese, Loredana Bucciarelli, Maurizio Rondinelli, Monica Bulgheroni - Sesto S. Giovanni (MI); Stefano Gonnelli, Alice Cadirni, Italo Tanganelli - Siena; Karl Egger, Kerstin hofmann, Margareth Tanner, Heidrun Hohenegger - Silandro (BZ); Cristina Porru, Angela Canneddu, Mercedes Porcu - Siniscola (NU); Vittoria Sesta, Franca Daidone - Siracusa; Luigi Vincis, Viviana Orlandi, Cinzia Pilloni, Rossana Farci, Ilaria Pelligra, Giuseppina Renier - Sirai - Carbonia (CI); Marco Mameli, Elvira Devigus, Anna Pala - Sorgono (NU); Giuseppe Felace, Ida Fumagalli, Paola Tosoni, Daniela Ovan, Silvia Giacomello, Nada Peressini, Fiorella Rossi - Spilimbergo (PN); Carlo Lalli, Mafalda Agliani, Maria Luisa Picchio, Maura Scarponi, Ludovico De Pascalis, Erika Bonucci - Spoleto (PG); Francesco Malci, Anita De Ciocchis, Chiara Moscatelli - Subiaco (RM); Barbara Macerola, Angelina Mandarino, Sandra Incani - Sulmona (AQ); Silvano Davì, Maria Ausilia Caccavale, Simona Borla, Marina Pognant Gros - Susa (TO); Ennio Lattanzi, Concettina Piersanti, Anna Piersanti, Irene Spinelli, Gabriella Quaranta, Silvia D’Ascanio - Teramo; Lorenzo De Candia - Terlizzi (BA); Antimo Aiello, Pietro Di Caro, Fabrizia Flocco, Agnese Franco, Maria Antonietta Lezzi, Anna Meo, Antonella Meo, Alfredo Puntillo, Giovanna Scarpina, Marco Tagliaferri, Celeste Vitale - Termoli (CB); Giovanni Cicioni, Maria Grazia Massarelli, Stefania Venturi - Terni; Augusto Travaglini, Patrizia Draghi - Terni; Elisa Forte, Lucilla Tamburro, Catia Palmacci, Maria Palma Abbate - Terracina (LT); Stefania Deiana, Francesca Scanu - Thiesi (SS); Paolo Pomante - Tocco da Casauria (PE); Alberto Bruno, Paolo Cavallo Perin, Ezio Ghigo, Massimo Porta, Paola Scuntero, Rosanna Arcari, Silvana Bertaina, Simona Bo, Fabio Broglio, Graziella Bruno, Mariella Degiovanni, Paolo Fornengo, Giorgio Grassi, Valeria Inglese, Mauro Maccario, Giorgio Maghenzani, Saverio Marena, Valentino Martina, Pietro Passera, Gianluca Ruiu, Milena Tagliabue, Maria Zanone - Torino; Aurora Grassi, Alberto Mormile, Anna Maria Ingaramo, Pietro Demurtas - Torino; Luca Monge, Gian Mario Boffano, Katia Macrì, Paola Maio - Torino; Luca Richiardi, Alessandra Clerico - Torino; Cesare Dossena, Simona Bosoni - Tortona (AL); Francesca Novara, Daniela Mancuso, Francesca Cipro - Trapani; Paolo Acler, Tiziana Romanelli, Sandro Inchiostro, Massimo Orrasch, Cristina Faes, Silvia Clementi, Franca Endrizzi, Ilaria Nicolao - Trento; Carlo Antonio Bossi, Giancarla Meregalli, Annalisa Balini, Denise Berzi, Anna Pulcina - Treviglio (BG); Agostino Paccagnella, Maria Sambataro, Edward Kiwanuka, Tiziana Citro, Barbara Almoto, Eros Bagolin, Daniela Pizzolato, Alessandra Mauri - Treviso; Riccardo Candido, Elena Manca, Alessandra Petrucco, Elisabetta Caroli, Elisabetta Tommasi, Giuseppe Jagodnik, Nevia Daris, Rossella Alberti, Katja Tercelj, Elisabetta Presti, Sarah Perini, Elisa Del Forno - Trieste; Maria Antonietta Pellegrini, Laura Tonutti, Giorgio Venturini,Sandra Agus, Franco Grimaldi - Udine; Mauro Andreani, Federica Turchi, Maurizio Sudano, Gigliola Martinelli, Stefania Lani - Urbino (PU); Francesca Innelli, Piera Grammaldo, Angelo Vistocco - Vallo della Lucania (SA); Silvio Sposito, Renzo Rongioletti, Maria Candidi - Velletri (RM); Anna Rosa Bogazzi, Giovanna Bendinelli, Massimo Rivelli, Cristina Vietti - Venaria Reale (TO); Ermanno Moro, Antonella Senesi - Venezia; Giuseppe Saglietti, Giuseppe Placentino, Antonella Schellino - Verbania Pallanza (VB); Roberto Mingardi, Luciano Lora, Cristina Stocchiero, Rachele Reitano, Mee Jung Mattarello, Giovanni Ronzani, Silvia Pegoraro, Matteo Rolandi, Veronica Baggio, Elisa Rancan - Vicenza; Marco Strazzabosco, Elisabetta Brun, Maria Simoncini, Chiara Alberta Mesturino, Francesco Zen - Vicenza; Mauro Giovanni Schiesaro, Giovanni Vita, Beatrice Cenci, Vania ampostrini, Ilaria Basso, Augusta Turrini - Villafranca Veronese (VR); Paola Pisanu - Villasimius (CA); Ida Mangone, Enrico Cazzaniga, Giovanni Sifarelli - Vimercate (MB); Claudio Grande, Claudia Arnaldi, Paolo Fiorentini, Enrico Capotorti, Angela Del Prete - Viterbo; Umberto Iannaccone, Mauro Ragonese, Caterina Scoponi, Laura Tilaro, Silvia Pelliccioni, Rossana Slongo, Emanuela Vita - Viterbo; Arcangela Garofalo, Filippo Vitale, Giuseppina Saggio, Biagia Campanella - Vittoria (RG); Andrea Del Buono, Tommasina Sorrentino, Teresa Borrelli, Mariarosaria Matrecano - Volla (NA); Aldo Giuseppe Morea, Lucia Bondesan, Sandro Perbellini - Zevio (VR).