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Acquired Hemophilia in a Patient With Rheumatoid Arthritis: Case Report and Literature Review
Full text linkAcquired hemophilia (AH) is a rare bleeding disorder caused by the spontaneous development of autoantibodies against coagulation factors, most commonly factor (F) VIII (acquired hemophilia A, AHA). The clinical manifestation of AHA includes mostly spontaneous hemorrhages into skin, mucous membranes, muscles, soft tissues, or joints. AHA should be suspected when a patient with no history of hemorrhages presents with bleeding and an unexplained prolonged activated partial thromboplastin time. The diagnosis is based on the clinical picture, the presence of low FVIII activity and evidence of FVIII inhibitor. In around half of patients, an underlying disorder (rheumatic diseases, malignancy, infections) or taking some drugs are associated with AHA; the remaining cases are idiopathic. Rheumatoid arthritis is a chronic inflammatory condition, marked by swelling and tenderness of small joints; it is usually treated with steroid and immunosuppressive drugs such as methotrexate, TNF-alpha inhibitors, and other biologic therapies (abatacept, tocilizumab, rituximab).We presented a patient with rheumatoid arthritis who developed acquired hemophilia A with hemarthroses; starting from this case, we focused on the literature about AHA in rheumatic diseases. We found 35 cases, 15 in systemic lupus erythematosus and 12 in rheumatoid arthritis, while the remaining cases were reported in Sjögren’s syndrome, polymyalgia rheumatica, systemic sclerosis, and psoriatic arthritis. Ecchymosis and cutaneous hematomas were the main clinical features while hemarthroses was quite a rare condition, shown in just three patients
Evaluation of patients treated for diabetic retinopathy: an analysis of the administrative databases of the Lazio Region
Full text linkBACKGROUND: In Italy there are an estimated 4 million patients suffering from diabetes mellitus (DM). The most important ocular complication of DM is diabetic retinopathy (DR), which affects about one third of diabetic patients.AIMS: To identify, within the Lazio Region, the cohort of patients starting treatment for DME in the years 2010-2016 and calculating the annual cost of therapy; and to assess the appropriateness of the drugs prescribed.METHODS: From the Health Information System of the Lazio Region were identified all subjects who, in the 2010-2016 period, had received at least one prescription for dexamethasone intravitreal implant (i.i.) or intravitreal triamcinolone or ranibizumab or aflibercept or bevacizumab. For the cohort of users selected, the appropriateness of the treatment were evaluated calculating the number of administrations performed in the first four months of the index prescription and the number of administrations performed during the 12 months of treatment.RESULTS: In 2016, 7,265 patients in the Lazio Region received at least one prescription of ranibizumab (43.0%), aflibercept (37.5%) and dexamethasone i.i. (19.5%). Among the 3,416 patients naïve at 6 months, who started treatment in the 2013-2015 period and who did not switch to different drugs, 78.7% started treatment with ranibizumab, 16.0% with dexamethasone i.i. and 5.3% with aflibercept. The mean annual cost for the treatment of a patient with DME and naïve at 6 months was equal to € 2,388; a total cost for only the naïve patients selected in the 2013-2015 period is therefore estimated at approximately € 8.2 million. The average annual cost of dexamethasone i.i. treatment was € 1,497, lower than that of ranibizumab (€ 2,562) and aflibercept (€ 2,485). The expenditure for patients receiving less than 3 administrations of ranibizumab or aflibercept in the first 10 months of treatment was estimate equal to € 1.3 million.CONCLUSIONS: The administrations of dexamethasone i.i. are in line with what is indicated in the prescribing information, while for ranibizumab and aflibercept a potential under-use has been identified. A greater appropriateness of the drugs prescribed, accompanied by an optimal adherence to therapy, would strongly reduce the current waste of resources
4Q Model: How to Apply Guidelines for COPD in Primary Care
Full text linkAccording to Italian General Practitioners (GPs), it is difficult to use guidelines and consensus, because they refer mainly to the disease and they are not close to the variability of real life.To help GPs perform clinical audits and address some management problems, we have devised a new analysis methodology: four-quadrant (4Q) diagnostic analysis.4Q model describes, in a fairly realistic way, the characteristics and clinical issues of patients with chronic obstructive pulmonary disease (COPD) during visits in the General Medicine setting. Using this model, GPs can identify and group patients in four specific areas; depending on the membership, the intervention is defined by the guidelines and the evidence-based medicine
Peritoneal Tuberculosis Presenting as Chronic Ascites With Scrofula: A Case Report
Full text linkPeritoneal tuberculosis (PTB) is a common type of extrapulmonary tuberculosis; however, due to variety of clinical presentations, diagnostic challenges do occur. The nonspecific features of this disease can lead to diagnostic delays and the development of complications. In addition, PTB can mimic a malignancy, especially in women who present with ascites and elevated cancer antigen (CA) 125 levels. A high index of suspicion is an important factor in an early diagnosis. Moreover, an early diagnosis and the initiation of antituberculous therapy are essential for preventing morbidity and mortality. Fortunately, most of these patients respond very well to standard antituberculous therapy.Here, we have reported the case of a young female patient who presented with chronic ascites, mild abdominal tenderness, and later, scrofula. Ultimately, she was diagnosed with PTB based on her test results. We expect that this case report will contribute to the existing literature on this subject
Morire di contenzione: riflessioni di deontologia e di infermieristica legale sulla vicenda di Francesco Mastrogiovanni
No full textTalking about physical containment, in a nursing framework, means exploring a particular world, with many “I would like, but I can not”, that often speaks us about the moral and professional distress of the team involved in the “containment process”, because this, in fact, limits the freedom of the assisted person. And this limit of rights, jarring with nursing values, often represents a perceived “necessary pain” in different nursing settings.Organizational asphyxia, lack of motivation about change, ineffective leadership, knowledge deficits, lack of role identities and awareness are often promoters of incessant dangerous conditions, which turn procedures from “necessary pain” into real crimes.Francesco Mastrogiovanni’s story is, unfortunately, the proven evidence that the malign and uncritical customs have dramatic consequence
Cost Minimization Analysis of Radiofrequency Compared to Laser Thermal Ablation in Patients with Hepatocellular Carcinoma
Full text linkBACKGROUND: Over the last decade of years, minimally invasive techniques have been developed for the treatment of hepatocellular carcinoma and liver metastases. We sought to investigate the health costs associated with the management of patients with hepatocellular carcinoma treated with radiofrequency vs laser thermal ablation and their clinical outcomes.METHODS: We performed a retrospective analysis of the ablations performed in two referral centers in southern Italy, from 2009 to 2013. Resource use was valued by year 2017 official prices, in €. Direct healthcare costs (drugs, visits, tests and hospitalizations) of different ablation techniques were compared. Total costs were analyzed from Italian NHS perspective.RESULTS: A total of 140 patients were identified. Baseline demographics and clinical outcomes of interest did not differ between the two groups. Patients treated with laser thermal ablation resulted in an expected annually cost savings of 258.9 € per patient, in one-year follow-up healthcare costs compared with radiofrequency. The largest components of annual medical expenditures were attributable to drugs, regardless of the type of ablative technique.CONCLUSIONS: The ablation using either laser thermal ablation or radiofrequency is equally effective. Laser thermal ablation would carry disposable cost savings as compared to radiofrequency. The costs associated with management of patients with hepatocellular carcinoma, treated with laser thermal ablation were lower than those treated with radiofrequency ablation
Developing a Model for the Establishment of Pre-Hospital Emergency Medicine Bases in the Northern Provinces of Iran
Full text linkBACKGROUND: The faster and more accurately Pre-Hospital Emergency Medicine as the first line of care and treatment is done, the less the mortality and disability rates are.AIM: The present study is an attempt to design a model for the establishment of pre-hospital emergency bases in the northern provinces of Iran.METHODS: This quantitative-qualitative (mixed-method) research was conducted in two parts: First, using the literature review, interviews with experts in the field, and a comparative study, the most important factors affecting the establishment were extracted. Second, the obtained data were employed to formulate the development model and to design the questionnaire. The required data for factor analysis were collected through a questionnaire distributed among 200 operational personnel in January 2018. The results were analyzed using confirmatory factor analysis and multiple regression.RESULTS: Five components were identified after the exploratory factor analysis and Varimax with an eigenvalue larger than 1. The effect coefficients calculated for human resources components, service speed, and information and communication system were 0.935, 0.765 and 0.752, respectively. The obtained goodness of fit was very close to one, indicating the one-dimensional strength of the model. The highest parameter estimation in this model was allocated to the human component as 0.935, which has a significant correlation with other components.CONCLUSIONS: In order to reduce the response time, more attention should be paid to the allocation of budget and organizational roles, education, participation from government departments, establishment of an independent medical emergency organization, and appropriate accessibility to reduce the rates of mortality and morbidity
Measles Outbreak Among Healthcare Professionals: Operational Response and Remedial Measures
Full text linkGiven the numerous cases recorded in 2017, a descriptive epidemiological study was conducted in the Viterbo Local Health Unit (LHU) area, Italy. Hospital Discharge Sheets (HDSs) and the notifications of infectious diseases (NOIDs) were used.We were able to trace the distribution of the disease both in the general population and, in particular, among the staff of Belcolle Hospital in Viterbo. In 2017, 50 cases of measles were detected among the population in the area of Viterbo. Of these, 10 concerned healthcare professionals and 3 employees of the Viterbo LHU.Due to the education and information campaign on the measles, mumps, and rubella (MMR) vaccine and the close monitoring of the vaccination coverage among the employees of the hospital (performed for the first time), only 4 cases were registered from January 1, 2018 to December 31, 2018 in the same area, and no healthcare workers were involved