Listening to the neurological teams for multiple sclerosis: the SMART project.

OBJECTIVE: Aim of the research was to define the quality of life of Italian neurologists and nurses' professional caring for multiple sclerosis, to understand their living the clinical practice and identify possible signals of compassion fatigue. MATERIAL AND METHODS: One hundred five neurologists and nurses from 30 Italian multiple sclerosis centres were involved in an online quali-quantitative survey on the organization of care, combined with the Satisfaction and Compassion Fatigue Test and a collection of narratives. Descriptive statistics of the quantitative data were integrated with the results obtained by the narrative medicine methods of analysis. RESULTS: Most of the practitioners were neurologists, 46 average years old, 69% women, 43% part time dedicated to multiple sclerosis. An increased number of patients in the last 3 years were referred in 29 centres. Differences were found between neurologists and nurses. Physicians showed higher risks of burnout, reporting intensive working paces, lack of medical personnel, and anxiety caused by the precarious employment conditions. Nurses appeared more satisfied, although the reference to the lack of spaces, and the cross professional roles risk of compassion fatigue. Both positive and negative relationships of care were depicted as influencing the professional quality of life. CONCLUSION: The interviewed neurological teams need to limit the risk of compassion fatigue, which appeared from the first years of the career. The prevalence of the risk among neurologists suggests more awareness among scientific societies and health care managers on the risk for this category, as first step to prevent it.

Modulation of the central memory and Tr1-like regulatory T cells in multiple sclerosis patients responsive to interferon-beta therapy.

BACKGROUND: Interferon-beta is used to reduce disease activity in multiple sclerosis, but its action is incompletely understood, individual treatment response varies among patients, and biological markers predicting clinical benefits have yet to be identified. Since it is known that multiple sclerosis patients have a deficit of the regulatory T-cell subsets, we investigated whether interferon-beta therapy induced modifications of the two main categories of regulatory T cells (Tregs), natural and IL-10-secreting inducible Tr1 subset, in patients who are biologically responsive to the therapy. METHODS: T-cell phenotype was determined by flow cytometry, while real-time PCR was used to evaluate interferon-beta bioactivity through MxA determination, and to measure the RNA for IL-10 and CD46 molecule in peripheral blood mononuclear cells stimulated with anti-CD46 and anti-CD3 monoclonal antibodies, which are known to expand a Tr1-like population. RESULTS: Interferon-beta induced a redistribution of natural Treg subsets with a shift of naive Tregs towards the 'central memory-like' Treg population that expresses the CCR7 molecule required for the in vivo suppressive activity. Furthermore, in a subgroup of treated patients, the CD46/CD3 co-stimulation, probably through the Tr1-like subset modulation, increased the production of RNA for IL-10 and CD46. The same group showed a lower median EDSS score after two years of therapy. CONCLUSIONS: The selective increase of 'central memory-like' subset and the involvement of the Tr1-like population may be two of the mechanisms by which interferon-beta achieves its beneficial effects. The quantification of RNA for IL-10 and CD46 could be used to identify patients with a different response to interferon-beta therapy.

Conocimiento sobre riesgos y profilaxis preventiva en estudiantes de odontología / Knowledges about risk and preventive prophylaxis in students of odontology

En la práctica odontológica hay exposición a riesgos biológicos. En este trabajo indagamos: qué conocimientos sobre dichos riesgos tienen los alumnos, pues representan una problemática de morbi-mortalidad a nivel mundial, nacional y local; y si saben cómo prevenirlos y cómo proceder ante un accidente. Se encuestaron 192 estudiantes del último año de la Facultad de Odontología (UNC). El 95% afirmó conocer los riesgos vinculados con enfermedades infectocontagiosas, pero en general no conocen cuáles son. Con respecto a la profilaxis de disposición, las respuestas fueron incorrectas. El 94 % afirmó conocer los procedimientos ante un accidente de trabajo, pero hubo respuestas imprecisas y desconocimiento sobre los protocolos a seguir. De este estudio inferimos que la mayoría de los alumnos no percibe la vinculación entre riesgo- enfermedad, no conoce totalmente los protocolos relacionados a exposición con material biológico e inmunización , ni la conducta a seguir ante accidentes de trabajo en la práctica clínica.

Conocimiento sobre riesgos y profilaxis preventiva en estudiantes de odontología / Knowledges about risk and preventive prophylaxis in students of odontology

En la práctica odontológica hay exposición a riesgos biológicos. En este trabajo indagamos: qué conocimientos sobre dichos riesgos tienen los alumnos, pues representan una problemática de morbi-mortalidad a nivel mundial, nacional y local; y si saben cómo prevenirlos y cómo proceder ante un accidente. Se encuestaron 192 estudiantes del último año de la Facultad de Odontología (UNC). El 95% afirmó conocer los riesgos vinculados con enfermedades infectocontagiosas, pero en general no conocen cuáles son. Con respecto a la profilaxis de disposición, las respuestas fueron incorrectas. El 94 % afirmó conocer los procedimientos ante un accidente de trabajo, pero hubo respuestas imprecisas y desconocimiento sobre los protocolos a seguir. De este estudio inferimos que la mayoría de los alumnos no percibe la vinculación entre riesgo- enfermedad, no conoce totalmente los protocolos relacionados a exposición con material biológico e inmunización , ni la conducta a seguir ante accidentes de trabajo en la práctica clínica.(AU)

TSH Normal Alta: Su relación con bajo HDL-Colesterol en mujeres con resistencia a la insulina con independencia de otros posibles factores concurrentes / High Normal TSH: Its relationship with low HDL-Cholesterol in women with insulin resistance regardless of other possible concurrent factors

Objetivo: En el hipotiroidismo tanto clínico como subclínico se han descripto alteraciones en el metabolismo lipídico, entre ellas la disminución de colesterol de lipoproteínas de alta densidad (HDL-C). Considerando el rango normal de TSH entre 0.4-3.0 μUI/ml y valores normales altos entre 2.0 y 3.0 μUI/ml, nosotros investigamos la hipótesis de que niveles normales altos de TSH e insulinorresistencia (IR) se encuentran relacionados con HDL-C bajo en mujeres, en ausencia de otros factores concurrentes. Materiales y métodos: Estudiamos en un estudio transversal a 200 mujeres sanas, edad 18-50 años, eutiroideas, normotensas, con anticuerpos antiperoxidasa (ATPO) negativos, no diabéticas, premenopáusicas, IMC 18.0-25.0 Kg/m2, perímetro de cintura ≤ 88 cm; perímetro de cuello ≤ a 35 cm. Se las dividió en 4 grupos, cada uno compuesto por 50 mujeres: Grupo 1 (G1) TSH ≥ 2μU/ml, IR; grupo 2 (G2) TSH ≥ 2μU/ml, no IR; grupo 3 (G3): TSH 0,40 a 1,99 μU/ml, IR; Grupo 4 (G4) TSH 0,40 a 1,99 μU/ml, no IR. Se les midió lípidos, TSH, T4 total y libre (T4L), glucosa e insulina basal y posprandial, índices HOMA y QUICKI y volumen tiroideo (VT). Resultados: Observamos que en el G1 el nivel de HDL-C (46,7± 8,1 mg/dl) fue significativamente menor que en los restantes grupos. (vs G2: 56,8 ± 8,6 mg/dl; vs G3: 51,2 ± 7,6 mg/dl y vs G4: 56,5 ± 9,1 mg/dl. (p<0,01). La frecuencia de pacientes con HDL-C bajo en G1 fue significativamente mayor que en los restantes grupos (vs G2: OR 1,83, IC: 1,23-2,70; vs G3: OR 1,49, IC: 1,04-2,31; vs G4: OR 1,90, IC: 1,29-2,81) . No encontramos diferencias significativas en los niveles de HDL-C entre los restantes grupos. Conclusiones: Observamos en mujeres eutiroideas con TSH normal alta insulinorresistentes, sin otros factores concurrentes, niveles de HDL-C significativamente más bajos que en mujeres no insulinorresistentes y que en mujeres insulinorresistentes con TSH normal baja.

It has been described abnormalities in lipid metabolism in clinical and subclinical hypothyroidism, including the reduction of high-density lipoprotein cholesterol (HDL-C). Considering the normal range for TSH between 0.4-3.0 uUI / ml and high-normal values between 2.0 and 3.0 uUI / ml, we investigated the hypothesis that in euthyroid women, high-normal TSH levels and insulin resistance (IR) are associated with low HDL-C. We observed in euthyroid women with high-normal TSH and insulin resistance, without other factors, a significantly lower level of HDL-C than in non-insulin or insulin resistance women with low-normal TSH.

Management of overt and subclinical hypothyroidism. Factors influencing L-thyroxine dosage.

With the aim of establishing optimal dosage schedules, 171 women with either overt (OH, n = 80) or subclinical (SCH, n = 91) hypothyroidism were assessed before and 6 months after starting L-thyroxine (LT4) replacement therapy. Each group was further classified into four subgroups according to post-therapy serum TSH level, as follows: A) complete suppression; B) partial suppression; C) normal range and D) above normal range (insufficient response). In all subgroups, LT4 doses were higher for OH than for SCH, whether expressed as total daily dose (micrograms) or as a function of either actual or ideal body weight (micrograms/kg BW). In OH, LT4 dose was higher for subgroups A or B as compared with either C or D. In SCH, subgroup A received a larger dose than the other subgroups. Post-treatment serum thyroxine levels showed the same pattern for both OH and SCH. Mean LT4 dose was similar in patients with high and normal antithyroid antibodies and in patients with goiter and in those without it. In goitrous patients thyroid volume decreased in subgroup B, particularly in those patients that had elevated antithyroid antibodies, but not in subgroup C. In OH patients a significant negative correlation was found between daily LT4 dose per kg actual BW and actual BW, especially in subgroup C for patients with a body mass index > 27 kg/cm2 (r = -0.90, p < 0.001). In subgroup C of the SCH group, a negative correlation between LT4 dose and age was noticed. Both in OH and in SCH, LT4 dose per kg actual BW required to obtain a serum TSH within the normal range was lower in women with a body mass index (BMI) > 27 kg/m2 than in those with a BMI < or = 27 kg/m2. LT4 doses for subgroup C did not differ from those needed in hypothyroid patients with previous Graves' disease, in either OH or SCH patients.

Management of overt and subclinical hypothyroidism. Factors influencing L-thyroxine dosage.

With the aim of establishing optimal dosage schedules, 171 women with either overt (OH, n = 80) or subclinical (SCH, n = 91) hypothyroidism were assessed before and 6 months after starting L-thyroxine (LT4) replacement therapy. Each group was further classified into four subgroups according to post-therapy serum TSH level, as follows: A) complete suppression; B) partial suppression; C) normal range and D) above normal range (insufficient response). In all subgroups, LT4 doses were higher for OH than for SCH, whether expressed as total daily dose (micrograms) or as a function of either actual or ideal body weight (micrograms/kg BW). In OH, LT4 dose was higher for subgroups A or B as compared with either C or D. In SCH, subgroup A received a larger dose than the other subgroups. Post-treatment serum thyroxine levels showed the same pattern for both OH and SCH. Mean LT4 dose was similar in patients with high and normal antithyroid antibodies and in patients with goiter and in those without it. In goitrous patients thyroid volume decreased in subgroup B, particularly in those patients that had elevated antithyroid antibodies, but not in subgroup C. In OH patients a significant negative correlation was found between daily LT4 dose per kg actual BW and actual BW, especially in subgroup C for patients with a body mass index > 27 kg/cm2 (r = -0.90, p < 0.001). In subgroup C of the SCH group, a negative correlation between LT4 dose and age was noticed. Both in OH and in SCH, LT4 dose per kg actual BW required to obtain a serum TSH within the normal range was lower in women with a body mass index (BMI) > 27 kg/m2 than in those with a BMI < or = 27 kg/m2. LT4 doses for subgroup C did not differ from those needed in hypothyroid patients with previous Graves disease, in either OH or SCH patients.

Methylbromide intoxication: a case report.

This work focuses on the neurophysiological features in a patient with action myoclonus and mental deterioration following methylbromide intoxication. The patient is a 28-year-old man, without respiratory distress or exposure to other toxics. Myoclonus improved with polytherapy (clonazepam, 5-HT, carbidopa, GABA). The neurophysiological and neuropsychological evidence in this patient suggests a possible double site of action of methylbromide at cortical and subcortical levels.

[Acute segmental hemorrhagic penicillin-associated colitis]. / Akute segmentale hämorrhagische Penicillin-assoziierte Kolitis.

Four days after beginning a perioperative antibiotic prophylaxis with amoxicillin and clavulanic acid a 33-year-old patient developed an acute haemorrhagic diarrhoea with cramp-like lower abdominal pain. Coloscopy revealed diffuse mucosal oedema with map-like ulcerations, increased susceptibility to trauma and submucous haemorrhages extending from the middle of the ascending to the middle of the descending colon. Granulocytic inflammation with cryptal atrophy was seen histologically. Stool cultures, including tests for Clostridium difficile toxin, were normal. All symptoms disappeared within three days of discontinuing the medication. Coloscopy after one week revealed marked improvement, after three months nothing abnormal. Acute segmental haemorrhagic penicillin-associated colitis is rare and must be distinguished from antibiotic-associated pseudomembranous colitis.

[Systemic thrombolysis using streptokinase. Experiences at the Civic Hospital of Lugano in the framework of the ISIS-2 study]. / Systemische Thrombolyse mit Streptokinase. Erfahrungen am Ospedale Civico Lugano im Rahmen der ISIS-2-Studie.

With a small group of Swiss hospitals we had an opportunity of participating in ISIS-2, the major study on thrombolysis in acute myocardial infarction. Experience with our microcosm (Ospedale Civico Lugano) was compared with the macrocosm of the results of ISIS-2 in 17,187 randomized patients (in brackets). Mortality was 5.1% (7.8%) in our streptokinase group and 15.8% (12.8%) in our placebo group. In the ISIS-2 study the combination of thrombolytic therapy with streptokinase, and of antiplatelet therapy with aspirin, showed a reduction of approximately one third in acute mortality of myocardial infarction, stroke and reinfarction. Our experience confirms the reduced incidence of allergic side effects (3.5%), major bleeding (0.3%) and minor bleeding (2.9%) during or after thrombolytic therapy.

Brain-stem auditory evoked potentials (BAEPs) and magnetic resonance imaging (MRI) in a case of facial myokymia.

The case of a 37-year-old woman with facial myokymia is reported. Magnetic resonance imaging (MRI), electromyography (EMG) and brain-stem auditory evoked potentials (BAEPs) supported the clinical diagnosis of suspected multiple sclerosis (MS). MRI showed a single area of abnormal signal in the pontine region. The authors discuss the possible relationship between the brain-stem lesion and the electrophysiological abnormalities demonstrated by BAEPs and the EMG of facial muscles.