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The Management of Psoriatic Arthritis in Italy: Organizational Impact Analysis of Optimized Pathways
Full text linkBACKGROUND: The management of psoriatic arthritis requires competencies in the fields of both rheumatology and dermatology, and a multidisciplinary approach.AIM: To propose an effective pathway for the diagnosis, monitoring and treatment of psoriatic arthritis in the Italian context, and to assess its organizational impact on the Regional Health Service of Lombardy Region.METHODS: The analysis was performed through interviews conducted with two key opinion leaders in the areas of dermatology and rheumatology. The current pathway of patients who present symptoms that might be related to psoriatic arthritis was defined and an optimized pathway was then proposed on the basis of the clinical practice, considering the implementation of a dermatology and rheumatology shared outpatient service. The organizational impact of the optimized pathway was then assessed from both the hospital and that of the Regional Health Service of Lombardy Region perspectives.RESULTS: The implementation of the service would have a positive impact on patients’ experience, improving the quality of the service provided, thanks to the multidisciplinary approach adopted, limiting the patients’ resources needed for the diagnosis, reducing the number of visits and time loss. The optimized pathway, therefore, would have a limited impact on the marketing mix, while potentially improving patients satisfaction, increasing the possibility of patients’ retention. To successfully implement the dermatological and rheumatologic multidisciplinary service, a precise communication strategy is mandatory.CONCLUSIONS: The optimized pathway for the diagnosis and management of psoriatic arthritis proposed would have a limited organizational impact at both hospital and Regional Health Service levels, while leading to theoretical benefits in terms of a prompt diagnosis of the pathology
Novel Therapies in HBV Infection
Full text linkCurrent treatments for chronic hepatitis B are able to provide a sustained suppression of the viral replication (i.e., persistent undetectability of HBV DNA). This leads to improvement of liver fibrosis and reduction of clinical complications. However, hepatitis B surface antigen (HBsAg) persists in most patients, probably justifying a still increased risk of hepatocellular carcinoma. Indeed, obtaining a complete and sterilizing cure with elimination of the covalently closed circular DNA (cccDNA) or silencing its activity is still a holy grail. New molecules are under evaluation to suppress viral replication acting on multiple phases of the HBV cycle or improve specific immune response against HBV. Molecules acting on HBV cycle have already showed encouraging results, such as entry inhibitors, small interfering RNAs (siRNAs), capsid assembly modulators (CAMs), nucleic acid polymers (NAPs). Also, promising results have been observed with immune-modulators, therapeutic vaccines, and other immune-based approaches. Among these, toll-like (TLR) or anti-programmed receptor agonists antibody 1 of the cell death protein (PD1) (e.g., nivolumab) are most promising. This paper describes newer drugs appearing on the horizon, including antiviral drugs targeting different steps of the HBV life cycle and therapeutic approaches based on immune-modulation
Basilar Artery Occlusion: Clinical Management and Therapy
Full text linkBasilar artery occlusion is a potentially life-threatening subset of the larger category of posterior circulation strokes, carrying > 80% fatality rate without treatment. This condition accounts for about 1% to 4% of all ischemic strokes and is generally related to local atherothrombosis or cardioembolism.Diagnosis can be challenging because presenting symptoms are often non focal, such as headache, dizziness, and vertigo. The onset of the symptomatology can be abrupt without preceding events, abrupt with prodromal symptoms, or progressive and stuttering. Finally, the severity of clinical presentation may range from isolated cranial nerve palsies to tetraplegia, locked-in state, or coma.If basilar artery occlusion is readily recognized and confirmed with the aid of neuroimaging, intravenous thrombolysis or endovascular treatment can be undertaken immediately in order to recanalize the occluded artery and thus reduce mortality and improve outcome
A 66-year-old Man With Fever and Altered Mental Status: A Case Report
Full text linkWe describe the case of a 66-year-old man who was admitted to the Emergency Department with high fever, urinary incontinence, asthenia, and altered mental status characterized by drowsiness and lethargy from the previous night. The head CT scan was negative, while the chest X-ray showed a right basal reduced transparency and solitary pulmonary nodules already known and considered as expression of asbestosis. No acute neurological signs were observed by the consultant neurologist. A diagnosis of right basal pneumonia complicated by delirium was made and an empiric antibiotic therapy with ceftriaxone plus azithromycin was started. As patient’s conditions did not improve in the following 48 hours, a lumbar puncture was performed, with the microbiological isolation of L. monocytogenes. According to the indications of the infectious disease consultant, a new antibiotic regimen with ampicillin/sulbactam plus gentamicin was introduced. The chest CT scan performed as further examination revealed right pleural thickening highly suspicious for mesothelioma. The patient was discharged after 4 weeks with no neurological deficits
Cost-Effectiveness Analysis of Dimethyl Fumarate in the Treatment of Relapsing Remitting Multiple Sclerosis: An Italian Societal Perspective
Full text linkBACKGROUND: Delayed-release dimethyl fumarate (also known as gastro-resistant dimethyl fumarate, hereafter dimethyl fumarate) is an oral disease-modifying therapy used for the treatment of Relapsing-Remitting Multiple Sclerosis (RRMS), an autoimmune chronic inflammatory condition of the central nervous system.OBJECTIVE: The objective of this economic analysis was to compare cost-effectiveness of dimethyl fumarate with the alternatives used as first-line treatment of RRMS in Italy.METHODS: The analysis was conducted from the Italian societal perspective. Health outcomes and costs were evaluated over a 50-year time horizon (equivalent to a lifetime horizon). Both health outcomes and costs were discounted at 3.5%. The cost-effectiveness analysis was conducted by adapting a Markov model, already used in previous similar economic analyses conducted in RRMS, to the Italian context. The Markov model estimated the clinical and economic consequences of treating RRMS patients with the following therapeutic options: dimethyl fumarate; interferon (IFN) beta-1a subcutaneous (SC) at two different doses, 22 mcg and 44 mcg; IFN beta-1b SC; glatiramer acetate (GA) SC 20 mg; oral teriflunomide. Clinical efficacy data were retrieved from an elaboration of an already published mixed treatment comparison (MTC). Both direct and indirect costs (disability, treatment acquisition, administration, monitoring, relapses, adverse events) were included in the analysis. One-way and probabilistic sensitivity analyses were carried out and cost-effectiveness acceptability curves generated.RESULTS: In the base-case analysis, dimethyl fumarate was more efficacious than alternatives, in terms of both survival (19.634 vs. 19.440-19.600 life years for alternatives), and quality-of-life-adjusted survival (6.526 vs. 5.143- 6.189 QALYs for alternatives). The total lifetime cost per patient treated with dimethyl fumarate (€ 954,286) was lower than that of the other DMTs included in the analysis. Therefore, dimethyl fumarate was dominant compared with all analyzed alternatives. Dimethyl fumarate was also the therapeutic option with the highest benefit on disease burden. In fact, costs of disability management were lower than those of all the other first-line drugs included in the analysis. The results of one-way deterministic sensitivity analysis and probabilistic sensitivity analysis confirmed the reliability of base-case results.CONCLUSIONS: The results of the cost-effectiveness analysis confirm that dimethyl fumarate is an optimal first-line treatment for RRMS in Italy, compared with the other first-line alternatives included in the economic analysis, when evaluated from the societal perspective
Optimizing Pain Control in a Patient with Lumbar Spinal Stenosis: A Report of Clinical Management
Full text linkLumbar spinal stenosis is a leading cause of low back pain and one of the most common causes of work absences. Treatment is initialized with narcotic and non-narcotic medications, which have been shown to work in the majority of patients. For those who do not find relief with medications and seek pain/symptom relief, invasive spinal surgery is the last resort.This case describes the escalation and dose titration of narcotic and non-narcotic medications in a patient with worsening lumbar spinal stenosis that was unable to proceed with surgical intervention for the next several months and had failed his prior outpatient pain regimen. Proper titration of a basal narcotic dose in addition to optimizing non-narcotic medications, including muscle relaxants, proved to better control pain in the interim until surgical intervention. Our case shows how several different teams of physicians and non-physician providers collaborated to optimize pain control using several different treatment regimens with different doses and routes until a safe and effective plan was created for long-term use
La valutazione medico-legale delle ipoacusie in ambito assistenziale (invalidità civile e sordità civile) e previdenziale INPS
No full textThe authors address the issue of hearing loss assessment for civil incapacity and INPS social security disability benefits.The purpose of this work is to compile an easy-to-use handbook for the public and for doctors unfamiliar with legal medicine who need to address the complex issue of performing a medical-legal assessment of hearing loss for INPS social security disability and civil incapacity.General practitioners often incorrectly fill out INPS online application forms to obtain subsidies from Local Health Authorities (ASL / ASP) for the purchase of hearing aids for entitled citizens recognised as legally disabled due to loss of hearing.Frequently, instead of «civil incapacity», doctors select the term «legal deafness», introduced in 2006 as the legislative definition for deaf-mute individuals, i.e. persons with congenital deafness or hearing impairments acquired during childhood that have affected the normal learning of speech
