1,721,028 research outputs found
La legislazione del dolore e la sua applicazione in Italia: pregi e difetti
No full textNella storia molti sono stati gli studiosi, i filosofi, gli scienziati e i medici che hanno contribuito alla conoscenza del dolore da vari punti di vista, etico, fisiopatologico e terapeutico; tuttavia, ancora oggi la corretta terapia del dolore resta una delle più importanti controversie della società in generale e della comunità scientifica e sanitaria in particolare. Combattere la sofferenza e dare sollievo alla persona malata significa migliorare la qualità della vita per la persona assistita, ma anche la qualità dell’assistenza. La cura del dolore, oltre che un dovere etico, è infatti una buona pratica clinica, il dolore infatti è un fenomeno patologico, che condiziona pesantemente la vita delle persone, con conseguenze sulla sfera psicologica, emotiva, relazionale. In Italia l’attenzione al problema “dolore” ha cominciato a svilupparsi soprattutto nel campo delle cure palliative, volte a garantire una dignità di fine vita, trattando le sofferenze fisiche e psicologiche dei malati terminali. Palliativo deriva dal termine latino pallium, che significava mantello, per sottolineare l’avvolgente presa in carico, proprio come un mantello, del dolore del malato con terapie mediche e psicologiche. L’inutilità del dolore da cancro, considerato una sofferenza fine a se stessa perché priva del ruolo di campanello d’allarme, e la sua insopportabilità, unite all’elevata incidenza e mortalità della malattia neoplastica in quegli anni, hanno spinto tanti clinici tra cui l’oncologo Umberto Veronesi, a quel tempo direttore generale dell’Istituto Nazionale dei Tumori dal 1975, e l’anestesiologo professor Vittorio Ventafridda, responsabile del Servizio di Terapia del Dolore e di Cure Palliative e direttore scientifico della Fondazione Floriani, a intraprendere una personale battaglia contro il dolore neoplastico. Dall’impegno di questi due clinici e con l’aiuto di altri colleghi, venne istituita anche la European Association for Palliative Care volta a diffondere le cure palliative in Europa. Le cure palliative, che racchiudevano in sé il concetto di terapia del dolore, hanno cominciato a organizzarsi negli anni ’80 con il preciso scopo di diffonderle e applicarle ai pazienti in fase terminale. Dal punto di vista legislativo le cure palliative e la terapia del dolore, a causa di non poche resistenze politiche e culturali, sono state recepite dal Governo e prese in considerazione dalle istituzioni solo negli anni ’90, grazie alla volontà delle organizzazioni non profit e agli stimoli provenienti dalle realtà internazionali più all’avanguardia in materia di assistenza. Da allora, l’opinione pubblica ha cominciato a far entrare nel proprio vocabolario le parole “cure palliative” e “terapia del dolore”. L’idea di indire una vera e propria lotta al dolore è nata, dunque, circa 50 anni fa dalla consapevolezza di alcuni medici illuminati di trovarsi di fronte a una duplice realtà: da un lato essi constatavano una globale arretratezza di pensiero nel considerare il dolore e dall’altro una mancata occasione di poterlo alleviare con farmaci oppiacei idonei a combatterlo. La maggior parte dei malati e dei loro familiari aveva infatti un atteggiamento di passiva accettazione della sofferenza, interpretata il più delle volte come una punizione o un fenomeno ineluttabile contro cui non bisognava ribellarsi, mentre i medici vivevano la sua insorgenza come una sconfitta professionale oltre che umana
Biological Therapy and Risk of Malignancies: A Literature Review
No full textData from literature show that the overall risk of cancer does not as a result from treatment with these drugs. The only cancer for which various authors have reported an increased risk, in some cases, are skin cancers, different from melanoma and melanoma. Recent results of large observational studies and meta-analyzes indicate the absence of an increased risk of lymphoma related to therapy with anti-TNF-α. It has been reported, by some authors, that there is a possible increased risk of lung cancer, especially in patients with chronic obstructive pulmonary disease. There is limited information in literature about the effects of biologics in patients with a history of cancer. Most of the guidelines indicate that treatment with biologics can be considered with caution and only in patients free of cancer since at least 5 years. Some studies report a lower oncological risk with etanercept compared to monoclonal antibodies, especially in the case of lymphoma. However, this data has not been confirmed in other studies, and has been associated with a limited period of time after starting therapy. Information about the latest biological therapies is still poor. Therefore, there is not sufficient evidence for a preferential use of certain drugs rather than others
Immunodeficiency and autoimmune phenomena in female hyper-IgM syndrome
No full textWe report an unusual case that highlights the clinical problemsassociated with autoimmune phenomena. A female (born 1972) was referred to our hospital with systemic lupus erythematosus (SLE) diagnosis. During the follow-up (7 years),we observed the appearance and the disappearance of a lot of autoantibodies detected. The history of recurrent bacterial sinopulmonary infections since puberty and enlargement of lymphonodes, elevated IgM, very low IgA and normal IgG levels, and the variable autoantibody profile oriented toward a “defective Ig class switch recombination” disorder: the hyper-IgM syndrome. Immunodeficiency and autoimmune phenomena may occur concomitantly in the same individual and sometimes the differential diagnosis is difficult
IS THERE A DISSOCIATION BETWEEN CLINICAL REMISSION AND ULTRASONOGRAPHIC ASSESSMENT IN RHEUMATOID ARTHRITIS?
No full textBackground: Achieving remission is the aim of treatment in RA. Modern joint imaging improves the accuracy of remission measurement in RA; In particular Power Doppler Ultrasonographic (PDUS) findings may have a predictive value in disease activity and radiologic outcome.Objectives: To Evaluate and to confirm the clinical remission and the absence of synovial inflammation by means PDUS monitoring.Rheumatology Unit of Modena was the promoter of the URAR study (Ultrasound evaluation in RA patients with clinical remission) national group that aims to this target.Methods: The patients were recruited in the Rheumatology Unit of Modena and they were chosen sequentially in the rheumatologic out-patient's department dedicated to arthritis.The study included 54 patients (10 men, 44 women) with RA in therapy with DMARDS, anti-TNF or no therapy in clinical remission according to ACR criteria and DAS 28 < 2.6. All patients had active wrist or hand inflammation in the past. US examination evaluated the presence of active Synovitis (ACD), Power Doppler (PD) signal and Sinovial Hypertrophy (SH) on the following bilateral joints: Metacarpophalangeal – Proximal Interphalangeal joints – Flexor tendons (on 2°-3° fingers) and Wrist (radiocarpal and midcarpal joints). Scores and scales have been chosen according to the literature (1)Results: 19 patients (35.2%) displayed a negative US evaluation in the meaning of an agreement between clinical and US parameters. However 35 patients (64,1%) with clinical remission showed a positive ultrasonographic assessment and at least an active parameter (ACD, PD, SH). No correlation was found between US examination and antibody assessment (anti-CCP and RF): according to the statistic function "Half-Normal Plot" parameters are completely independent. Small differences were also found between patients in therapy with anti-TNF or other therapies (DMARDS, corticosteroids): they showed similar US assessment so that there is no statistical significance in the comparison between the two groups. Among eleven patients that presented swollen and tender joints at the latest physical examination which preceded US exam just 5 patients had a correspondence at the US: positive joints at the clinical evaluation showed a US confirmation too. Otherwise the other patients had a mismatch between clinical assessment and the PDUS: it did not confirm the presence of inflammation in the corresponding swollen – tender joints or showed a positive ultrasonographic assessment in other locations.Conclusion: The remission state is a great therapy target and its attainment seems to be possible and not only through the biological therapy.Clinical remission is not always confirmed by US evaluation, therefore it is not possible to exclude a complete absence of synovial inflammation just on the base of DAS 28 value. It seems particularly interesting the mismatch between clinical assessment and PDUS: according to this finding an integration between clinical and US results seems to be useful to guide clinical procedure and disease monitoring
The discrepancy between clinical and ultrasonographic remission in rheumatoid arthritis is not related to therapy or autoantibody status.
No full textTo evaluate the clinical remission by means of power Doppler ultrasonographic (PDUS) monitoring in a group of patients with rheumatoid arthritis (RA) in clinical remission (DAS28 < 2.6). The study included 54 patients with RA in therapy with DMARDS, anti-TNF, or no therapy in clinical remission according to ACR criteria and DAS 28 < 2.6 for at least 6 months. All patients had active wrist or hand inflammation in the past. US examination evaluated the presence of active synovitis, power Doppler signal, and synovial hypertrophy on the following bilateral joints: metacarpophalangeal-proximal interphalangeal joints-flexor tendons (on 2°-3° fingers) and wrist (radiocarpal and midcarpal joints). In 19 patients, there was an agreement between clinical and US parameters. However, 35 patients with clinical remission showed a positive ultrasonographic assessment and at least an active parameter. No statistic correlation was found between US examination and antibody assessment (anti-CCP and/or RF). Patients in therapy with anti-TNF or other therapies showed similar US assessment without significant statistical differences. Among eleven patients that presented swollen and tender joints at the latest physical examination, which preceded US exam, just 5 patients had an US confirmation too. In the other patients, the PDUS did not confirm the presence of inflammation in the corresponding swollen and tender joints or showed a positive ultrasonographic assessment in other locations. The remission state is a great therapy target and not only through the biological therapy. Synovial inflammation could persist independently from type of therapy or autoantibody statu
COMPLEMENT DEPLETION IN RHEUMATOID ARTHRITIS PATIENTS TREATED WITH TOCILIZUMAB: A MARKER OF CLINICAL EFFICACY?
No full textObjectives: Tocilizumab (TCZ) is a humanized monoclonal antibody against the α-chain of the IL6 receptor. In clinical trials TCZ had been shown to lower complement levels in Rheumatoid Arthritis (RA) patients independently of disease activity. We therefore evaluated complement factors in our series of patients treated with anti IL6 to show whether there was any correlation.
Methods: 16 patients with active RA (14 F/2 M; mean age 56.3±11.2SD) were treated with TCZ (13 after anti-TNF failure and 3 naives). The patients were monitored for therapy response (DAS 28), HAQ, including clinical and laboratory parameters. All patients received DMARDs treatment and prednisolone ≤ 7.5 mg/day.
Results: Prior to the treatment, therapy complement levels were normal: C3 124.65±14.52 and C4 23.88±7.23 (normal values: C3 90-180 mg/dl, C4 10-40 mg/dl).
Revaluation of these parameters revealed a decrease already after the first 3-month treatment. The complement depletion increased at the 6th month and persisted during the ongoing therapy. After the 12th month mean values were C3 89.35±10.21 and C4 11.64±6.39.
In four patients the treatment was stopped for the clinical remission with normalization of C3/C4 factors in the follow-up.
Concerning the RA disease activity, 14/16 patients showed a good EULAR response (initial DAS28: 5.79±0.86, ESR 41.94±18.81, CRP 3.62±3.14, HAQ 1.39±0.71; after 3 months DAS 28 2.23±0.52, ESR 6.13±3.10, CRP 0.27±0.24, HAQ 0.79±0.73).
After 24 weeks, for 2/16 patients (1F/1M) the therapy was stopped for inefficacy; in both patients the levels of complement factors did not decrease during TCZ treatment.
In all patients no signs for the development of autoimmunity or infection could be observed.
Conclusions: In the Tocilizumab OPTION study, mean levels of complement proteins C3 and C4 decreased but the data were not shown. It can be hypothesized that complement factors are consumed during the elimination process of immune complexes (IL6-anti-IL6Ab); moreover, in a case report of six RA patients the authors commented that this phenomenon requires further observation with respect to the clinical relevance. In an open label, dose-escalating, Phase I study Tocilizumab in Systemic Lupus Erythematosus complement C3 and C4 showed clear dose-related decreases. The Authors of such trial provided the first evidence that the TCZ-associated hypocomplementemia represents decreased production rather than increased activation. Also Olokizumab, a novel IL6 inhibitor in trials showed in RA patients the same dose-related reductions in complement C3 and C4. Reduction in complement levels is therefore believed to be consecutive to the inhibition by TCZ of IL6 stimulation of hepatocyte acute phase protein synthesis and of significant C3 upregulation.
In our patients there is a good correlation between C3 and C4 decrease and clinical response, while we have not observed any decrease in patients unresponsive to TCZ. The levels of C3 and C4 are more related to the efficacy than PCR or ESR values, which in 1 patient decreased in absence of clear clinical improvement. The number of patients is too small to reach a conclusion but we hypothesize that the dosage of the C3 and C4 can be a rapid and sensitive marker of the response to anti-IL6 treatment. Therefore, a close follow-up of these parameters at 2-3 months from the start of the therapy can guide the therapeutic strategy
EXPERIENCE OF MULTIDISCIPLINARY TEAM FOR COMPLEX HAND FUNCTION PROBLEMS AT THE RHEUMATOLOGY OUTPATIENT CLINIC OF MODENA
No full textOrthopedic surgery (OS) is an integral part of the total management programme for patients with rheumatic disease (RD). Indication for synovectomies as well reconstructive surgery in RD should be based on a joint decision between the patient, the rheumatologist, the orthopaedic surgeon as well as other health professional. The proposed functional activities of the patients and their own personal goals should be taken into account. Consequently, the package of care should be individual and tailored to the persons identified needs.In 2006 in Academic Hospital of Modena, Italy, at the Rheumatology outpatient clinic a multidisciplinary team has been performed consisting of rheumatologists, hand surgeon, physiatrist, and hand physiotherapist, occupational therapist). Rheumatologists normally are responsible for referring the patients on to others specialists. The team works together to evaluate patients affected by chronic inflammatory diseases (rheumatoid arthritis - RA, spondyloarthropaties - Spa, microcristalline arthropathy) or connective tissue diseases with complex hand function problems.The discussion during the visit and the execution of the various tests have enabled patients to understand functional changes that the disease has caused and has made them more available to use splints or to undergo surgery.At the end of the diagnostic and functional study 19 patients were sent to the surgery (9 synovectomies, 10 reconstructive surgeries) while the others received physiotherapy/rehabilitation appropriate to their needsConclusion: These aspects support a team approach in the planning and performance procedures in patient with rheumatic diseases; ideally, orthopaedic surgeon, physiatrist, and rheumatologist as well as the multidisciplinary team should work together in a functional musculoskeletal unit with a multidisciplinary approach.Patients showed to appreciate this approach
On- and off-label use of rituximab in rheumatic diseases
Full text linkSteadily growing knowledge about pathogenetic mechanisms in autoimmune rheumatic diseases (RDs) has paved the way to different therapeutic approaches. In particular, the availability of biologics on the market has dramatically modified the natural history of rheumatic chronic inflammatory diseases with a meaningful impact on patients’ quality of life. Among the wide spectrum of available biological treatments, rituximab (RTX), initially used in the treatment of non- Hodgkin’s lymphoma, was later approved for rheumatoid arthritis and anti-neutrophil cytoplasmic antibodies-associated vasculitis. Currently, in rheumatology, RTX is also used with off-label indications in patients with systemic sclerosis, Sjögren’s syndrome and systemic lupus erythematosus. RTX is a monoclonal antibody targeted to CD20 molecules expressed on the surface of pre-B and mature B lymphocytes. It acts by causing apoptosis of these cells with antibody- and complement-dependent cytotoxicity. As inflammatory responses to cell-associated immune complexes are key elements in the pathogenesis of several autoimmune RDs, such an approach might be effective in these patients. In fact, RTX promotes a rapid and long-term depletion of circulating and lymphoid tissue-associated B cells, thus leading to a lower recruitment of these effector cells at sites of immune complex deposition, therefore reducing inflammation and tissue damage. RTX is extremely interesting for rheumatologists, as it represents an important additional therapeutic approach. Therefore, the advent in clinical practice of approved RTX biosimilars, such as CT-P10, may help in improving treatment access as well as reducing cost
EXPERIMENTAL USE OF 3D PRINTING TECHNOLOGY FOR THE CONSTRUCTION OF DEVICES AS INTEGRATION OF OCCUPATIONAL THERAPY INTERVENTION WITH RHEUMATOID ARTHRITIS PATIENTS (RA)
No full textBackground: RA is a chronic inflammatory disease that can interfere with the ability to perform activities of daily living. The adoption of aid devices allows to maintain and/or improve employment performance, reducing the pain preventing further joint damage. However, it is known that the abandonment rate of such devices is quite high, resulting in failure of the rehabilitation project, and waste of resources. The reasons people give for abandoning support technology are that they have not been involved in the process of provision, and that the devices do not have the intended effect (1).
Objectives: technology may allow customization of 3D printing devices agreed together with patients, utilizing materials which are cheap, fast and easily adjustable.
Methods: The study was organized into the following phases: recruitment of RA patients for the “joint protection laboratories”; sessions of the “joint protection laboratories”; recruitment of patients for the identification of needs for customized aid devices; co-design of customized aid devices; printing of customized aid devices; delivery of customized aid devices; detection using customized aid devices.
We have collected a list of needs to be able to develop such customized aid devices at the end of a course to educate on joint protection covering: ergonomic gestures, management of fatigue and pain, environmental adaptations and aid devices.
18 patients (17 women and 1 man), age between 30 and 75 years old, were organized into small groups for the “joint protection laboratories”. 9 patients expressed their specific needs regarding the aid devices and therefore subsequent meetings were organized that have allowed us to produce and deliver customized objects.
Autodesk® Fusion360 for object modeling; Ultimaker Care for slicing; 3D printing DeltaWASP 20 40. For the collection of the design features we used the PA board (product analysis) of the USERfit tool. For the psycho-social impact assessment of the assistance, the PIADS (Psychosocial Impact of Assistive Devices Scale – scale -3+3) was used, and for the evaluation of the patient's satisfaction with respect to the aid device, QUEST (Quebec User Evaluation of Satisfaction with Technical Aids, scale 1–5) was used.
Results: 6 aid devices were customized: hand grip holder for chalk, toothbrush, ignition key, tablespoon, iron, as well as a handle to open the moka coffee machine.
The psychosocial assessment of 6 delivered aid devices, collected through PIADS, showed an overall positive outcome (mean competence +1.488; adaptability: +1.690; self-esteem: +1.375). The assessment of patient satisfaction through QUEST, was good overall (scale 1–5: satisfaction aid: 4.75; service satisfaction: 4.68).
Conclusions: This work also demonstrated, over a range of small numbers, that the path of co-design and production of customized aid devices via rapid manufacturing with 3D printing technology is feasible and fulfillin
Epstein-Barr Virus Reactivation after Infliximab in Rheumatoid Arthritis: A Case Report
Full text linkTNF-alpha blockers represent one of the most important therapeutic strategies for rheumatoid arthritis, but their use has raised the question about their safety profile, particularly in respect to viral infections/reactivations. We describe the case of a patient who developed a symptomatic EBV reactivation 11 days after the first infusion of infliximab
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