Enhancing the care of women with rheumatic diseases during pregnancy: challenges and unmet needs in the Middle East.

Pregnancy in women with rheumatic disorders is known to be associated with risks for both the mother and fetus; however, these risks can be minimized with proper planning and careful management of the disease. In the Middle East, there are specific cultural challenges that may have a negative impact on the care that women with rheumatic disorders receive. There is a need for cross-collaboration between specialist physicians, improved awareness of rheumatic disorders among the general public and more open discussion with patients about the potential complications of pregnancy. Women in the region are often unwilling to discuss their disease with their partner and are even less likely to seek advice regarding family planning from their physician. The objective of this review is to highlight the specific challenges of pregnancy management and to discuss why establishing specialist pregnancy clinics for women with rheumatic disorders could be an effective solution. Such clinics can provide high quality care before, during and after pregnancy as shown in several European and US centers. Additionally, such clinics could be useful for the collection of pregnancy outcomes data from the Middle East, which may currently be lacking in the region, in order to highlight where further improvements can be made. With specialist care and analysis of pregnancy outcomes, the standard of care for women with rheumatic disorders in this area could be significantly improved.

Defective natural killer cell anti-viral capacity in paediatric HBV infection.

Natural killer (NK) cells exhibit dysregulated effector function in adult chronic hepatitis B virus (HBV) infection (CHB), which may contribute to virus persistence. The role of NK cells in children infected perinatally with HBV is less studied. Access to a unique cohort enabled the cross-sectional evaluation of NK cell frequency, phenotype and function in HBV-infected children relative to uninfected children. We observed a selective defect in NK cell interferon (IFN)-γ production, with conserved cytolytic function, mirroring the functional dichotomy observed in adult infection. Reduced expression of NKp30 on NK cells suggests a role of impaired NK-dendritic cell (DC) cellular interactions as a potential mechanism leading to reduced IFN-γ production. The finding that NK cells are already defective in paediatric CHB, albeit less extensively than in adult CHB, has potential implications for the timing of anti-viral therapy aiming to restore immune control.

Cross-cultural adaptation and preliminary test-retest reliability of the Italian version of the Complexity Rehabilitation Scale-Extended (13th version).

BACKGROUND: In Italy, the lack of appropriate use of intensive rehabilitative services is an acknowledged issue, as demonstrated by periodic epidemiological surveys. Rehabilitation activities are planned without considering the clinical complexity, known to be one of the most fundamental factors able to outline the real patients' needs on recently clinical practice rehabilitation guidelines. Alternative diagnostic systems become, therefore, necessary. For this reason, we would like to propose the Rehabilitation Complexity Scale - Extended version (RCS-E) within intensive rehabilitation units in Emilia Romagna. AIM: This study aims at submitting an Italian translation, cross-cultural adaptation and preliminary reliability evaluation of the Rehabilitation Complexity Scale Extended (13th Version) (RCS-E). DESIGN: Face validity and test-retest reliability. SETTING: The study was conducted in three different rehabilitation units of the Emilia Romagna region, Northern Italy. POPULATION: Ten expert physicians and 51 Intensive (code 56) rehabilitation in-patients were recruited. METHODS: A cross-cultural adaptation of the scale was built from English into Italian, closely complying with international guidelines. Face validity and test-retest reliability were carried out to evaluate the comprehensibility and goodness of fit of the new scale. RESULTS: An overall positive judgement was obtained with the face validity test. No significant differences were observed between the original and the adapted scale scoring. Internal consistency measured on 51 patients by Cronbach's alpha was 0.702 for the scale. The estimated SEM was 1.211. ICCconsistency was 0.702. Split-Half reliability and the Spearman-Brown prophecy were 0.633 and 0.775, respectively. Test-retest reliability of the RCS-E measured with ICCagreement was 0.903. CONCLUSION: The adapted RCS-E provides a sensitive and reliable tool that appears to be suitable for measuring clinical complexity in Italian code 56 rehabilitation units. It is the first Italian version of the scale to be devised. CLINICAL REHABILITATION IMPACT: Further statistical validation will assess the Italian RCS-E as a possible instrument for guiding the patients' assignment to the rehabilitation settings that best suit their specific needs. These preliminary data represent the first step through this purpose.

Harnessing alveolar macrophages for sustained mucosal T-cell recall confers long-term protection to mice against lethal influenza challenge without clinical disease.

Vaccines that induce T cells, which recognize conserved viral proteins, could confer universal protection against seasonal and pandemic influenza strains. An effective vaccine should generate sufficient mucosal T cells to ensure rapid viral control before clinical disease. However, T cells may also cause lung injury in influenza, so this approach carries inherent risks. Here we describe intranasal immunization of mice with a lentiviral vector expressing influenza nucleoprotein (NP), together with an NFκB activator, which transduces over 75% of alveolar macrophages (AM). This strategy recalls and expands NP-specific CD8+ T cells in the lung and airway of mice that have been immunized subcutaneously, or previously exposed to influenza. Granzyme B-high, lung-resident T-cell populations persist for at least 4 months and can control a lethal influenza challenge without harmful cytokine responses, weight loss, or lung injury. These data demonstrate that AM can be harnessed as effective antigen-presenting cells for influenza vaccination.

Hepatitis B infection: current concepts and future challenges.

Chronic hepatitis B (CHB) is a global health problem affecting more than 350 million people worldwide. Chronic carriage of HBV is related to the age when the infection occurs; the younger the age the higher the chronicity rate. Knowledge of the natural history of CHB is important for the management of the disease. The goal of hepatitis B treatment is to prevent cirrhosis, liver decompensation and hepatocellular carcinoma. In clinical practice, treatment response is determined by the suppression of serum HBV DNA levels. However, current antiviral therapies are usually unable to achieve sustained off-treatment responses and eradicate the infection. Impairment of immune responses including defective innate non-cytolytic antiviral function together with exhausted T cells and the tolerogenic liver environment may all contribute to the poor clinical response. A more comprehensive understanding of the immunological phases of CHB, potential triggers of liver flares and molecular mechanisms underlying viral persistence and immunopathology will help to tailor future therapeutic strategies. A synergistic approach of boosting the immune response of the host by specific immunotherapeutic interventions and effective viral load suppression will be needed to promote sustained viral clearance in chronic infection.

[Application problems of the use of the Core set ICF in the rehabilitation area]. / Problematiche applicative dell'uso dei Core set ICF in ambito riabilitativo.

Many validation studies of instruments of evaluation derived from ICF (International Classification of Functioning, Disability and Health) are actually in course. In particular, a multicentric protocol with the goal of validating some ICF core sets (in the two forms comprehensive and brief) and the WHO-DAS II Scale is coordinated by the Montescano Scientific Institute of Maugeri Foundation and is currently carried out in our country. During the realization of the protocol some implementation difficulties have emerged; it is essential to point out these problems in order to contribute to their solution. These include in particular: 1) Poor inter-operator repeatability of the evaluation relative to the attribution of the qualificators describing the difficulty level of the person in exam in performing a function, an activity or in relation to an environmental factor; 2) Interrelation problems with the patient due to the complexity of defining some categories in particular in the environmental factor component; 3) Conceptual and applicative problems deriving from the categories of the activity and participation component. Overcoming such difficulties seems to be an essential requirement in order to propose a wide spread application of the ICF evaluation instruments in the practice.

[Organizational climate, trust and burnout in a rehabilitation center]. / Clima organizzativo, fiducia e burnout in un centro di riabilitazione.

Today human resources are considered of fundamental importance and necessity for the success of the organizations that provide health services. The aims of the present study were: 1) to investigate the perception that rehabilitation medical staff employees have of their hospital organization, 2) to quantify their evaluation concerning organizational trust, 3) to identify eventual burnout symptoms and their relationship with perceived organizational climate and trust. The sample consisted of 131 employees, subdivided into 6 professional categories. Three questionnaires were administered to the employees. The results evidenced significant differences between the various professional groups regarding the climate perceived and trust in the organization. Administrative personnel, nurses and medical graduates revealed a greater satisfaction, responsibility and work integration than the other employee groups (p = 0.023). All the scales which measured organizational climate correlated (inversely) with those measuring burnout (p" 0.05), indicating the existence of a close relationship between a work climate perceived as collaborative (r = -0.33) and characterized by a continuous exchange of information about the hospital organization (r = -0.50), and the psychological well-being experienced by the employees. This study confirms the importance of promoting organizational strategies aimed at mutual reinforcement and support characterized by regular and constructive feedback, wherein there is a reciprocal recognition of each employee's role through a clear, open communication.

International Classification of Functioning, Disability and Health (ICF) core sets for osteoarthritis. A useful tool in the follow-up of patients after joint arthroplasty.

AIM: The first aim of this study was to verify the applicability of the International Classification of Functioning Disability and Health (ICF) core set for osteoarthritis (OA) as an outcome tool after the total hip arthroplasty (THA) and total knee arthroplasty (TKA), in order to follow the changes of the profile of functioning after joint arthroplasty. METHODS: Seventy-two OA inpatients were consecutively enrolled during the first three days of rehabilitation after THA (34.7%) or TKA (65.3%) and were evaluated of the ICF Core Set for OA. Patients were interviewed at the beginning of the study one month prior to surgery, at the end of the rehabilitation treatment lasting on average three weeks and three and six months after their discharge. RESULTS: The ICF core set data comparison showed many significant differences among the four evaluations with a significant improvement in many categories assessed. At the six months interview activity limitations and participation restrictions were still reported, even if with a lower percentage as compared to the first evaluation. CONCLUSION: The ICF core set for OA resulted an interesting outcome tool after the THA or TKA, even if more research is needed, mainly on data reliability and category definition. Even tough problems in the administration were encountered, the ICF core set allowed to focus on issues and aspects of patient's every day life usually not taken into account or not codified in the usual care assessment.

An Italian experience in the ICF implementation in rehabilitation: preliminary theoretical and practical considerations.

PURPOSE: The International Classification of Functioning, Disability and Health (ICF) in its complete form cannot be adopted in clinical rehabilitative practice due to its complexity and size. Ongoing international research is aimed at validating and verifying the reliability of simplified instruments derived from the ICF (ICF Core Sets). An Italian multicentre study was recently conducted with these aims. The purpose of this article is to present some qualitative considerations on ICF Core Sets implementation. METHOD: A brief schedule purposely built to assess the difficulties encountered by the health professionals who administered the ICF Core Sets were sent them via e-mail. Due to the small size of the sample, a qualitative analysis was performed. RESULT: The main difficulties which emerged were: (i) To clearly translate the ICF categories' contents in a language easily understandable especially by patients with low education and concrete cognitive style, (ii) the process of assigning the qualifier to the given category, particularly with the 'Activity and Participation' and 'Environmental factors' components, and (iii) the influence of evaluators' different professional backgrounds on interview performance. CONCLUSION: Since the classification was designed to uniform language and to promote homogeneous ways of evaluation in extremely different healthcare and social contexts, more studies are necessary to improve reliability and to identify the best methods of using the ICF in daily clinical practice.

[Function recovery in patients with knee arthroplasty: role of proprioceptive rehabilitation]. / Il recupero funzionale del ginocchio artroprotesizzato: ruolo dell'allenamento propriocettivo.

This study evaluates the outcome of proprioceptive rehabilitation in 18 patients who underwent knee joint prosthetic replacement using the dynamic electronic plate Pro-kin_machine. The proprioceptive performance was determined by having the patients trace a set of three outlines (horizontal, vertical and circular) using the foot of the operated limb. The measures of outcome parameters were: 1) time taken to do the test; 2) score of accuracy of the test measured in percentage. Tests were performed on admission, half way through rehabilitation and on discharge. Each patient had 15 sittings of physiotherapy. Our results demonstrate a significant improvement of both parameters at the end of the treatment. After prosthetic knee joint replacement, not only is it important to re-establish mechanical stability but also dynamic stability. The latter can be achieved through active virtual taping by the stabilizer muscles. Prompt management of instability of the joint in the rehabilitation phase is extremely important in the re-activating of the control mechanisms that are compromised by the surgical operation.

Efficacy of etoricoxib 60 mg/day and diclofenac 150 mg/day in reduction of pain and disability in patients with chronic low back pain: results of a 4-week, multinational, randomized, double-blind study.

BACKGROUND AND METHODS: The efficacy and safety of etoricoxib 60 mg/day in patients with established chronic low back pain (CLBP) were compared with those of diclofenac 150 mg/day in a 4-week, multicentre, randomized, double-blind, parallel-group trial. Four hundred and forty-six adult patients with CLBP (Quebec Task Force on Spinal Disorders Class 1 or 2) and with worsening pain upon discontinuation of pre-study analgesic medication were enrolled in the study. The study primary efficacy endpoint was change from baseline in Low Back Pain Intensity Scale (LBP-IS) score over the 4-week treatment period. Secondary and other efficacy endpoints included: changes in Roland and Morris Disability Questionnaire (RMDQ), Patient Global Assessment of Response to Therapy (PGART) and Low Back Pain Bothersomeness Scale (LBP-BS) scores. Early efficacy was assessed using PGART and LBP-IS scores 4 h after the first dose on the mornings of Days 1, 2 and 3. The overall safety and tolerability of etoricoxib 60 mg/day during 4 weeks of treatment were also assessed. RESULTS: The least-squares mean time-weighted change from baseline LBP-IS score over 4 weeks was -32.94 mm (95% CI -36.25, -29.63) for etoricoxib, indicating substantial efficacy in relief of pain. The treatment difference for the primary outcome was 2.51 mm (95% CI -1.50, 6.51), fulfilling the prespecified equivalence criterion of 95% confidence interval wholly within +/- 10 mm. Etoricoxib improved all secondary and other efficacy outcomes. There were no statistically significant between-group differences in the proportion of patients with one or more clinical adverse events (AEs) (etoricoxib 35%, diclofenac 39%), or the proportion of patients who discontinued due to AEs (etoricoxib 7%, diclofenac 5%). CONCLUSIONS: The results of this study confirm that, for adult patients with CLBP, etoricoxib 60 mg once daily over 4 weeks is effective for relief of pain and improvement of physical function and comparable to high-dose diclofenac 150 mg daily.

[Assessment of function recovery in patients with total knee prosthesis]. / Valutazione della ripresa funzionale nei pazienti sottoposti ad intervento di protesi totale di ginocchio.

The aim of this study was to analyse the evolution of motor performance in a group of patients who underwent surgical knee replacement. We also assessed patient satisfaction at 3 and 9 months after the operation. Sixty-two patients (40 women, 22 men, mean age 72.4 years) underwent isokinetic evaluation associated with surface EMG. All the patients had undergone a total prosthetic knee joint replacement for arthrosis, and had followed a standardised 30-day rehabilitation program at our centre for recovery of knee joint function, strengthening of the flexor-extensor muscles and restoration of ambulation as best as possible. Each of these patients underwent isokinetic evaluations 3 months and 9-10 months after their operation. The isokinetic test consisted of carrying out 5 flexion-extensions of the knee at an angular velocity of 60 degrees/second, followed by an endurance test of 30 repetitions of flexion-extension of the knee at 120 degrees/second. This isokinetic test provided data on extensor strength and flexor strength; furthermore, specifically designed software allowed simultaneous visualisation of the surface EMG tracing, torque and joint excursion. The first analysis showed a macroscopic decrease in the strength of the flexor-extensor muscles of the knee. This muscle weakness was clearly evident 3 months after the operation and was particularly pronounced for the extensor muscles of the operated limb compared with the muscles of contralateral, unoperated limb. Muscle weakness was still present 9 months after the operation although there had been a considerable improvement compared with 6 months previously; the imbalance in the flexor/extensor ratio, which differed from that in the contralateral, unoperated limb, was noted to be still present. The surface EMG demonstrated persistent myoelectrical activity in the flexors even when the extensor activity was predominant: this is an expression of imbalance between agonists-antagonists. A questionnaire administered to the patients about their satisfaction with the operation revealed that 9 months after the surgery 23 patients still complained of continuous joint pain with increased loads, 27 complained of frequent pain with load-bearing and only 12 no longer complained of any disturbance, manifesting full satisfaction with the operation. Total knee replacement is thus a valid treatment in those cases in which degenerative joint disease necessitates a radical solution. Nevertheless, dissatisfaction with the operation is common, and may be due to persistence of joint pain and incomplete joint recovery of joint function or muscle strength. In our series of patients, we found that although there was progressive recovery of strength of both the flexor and extensor muscles, a considerable imbalance remained between the operated and unoperated limbs; this finding was also confirmed by the surface EMG investigation.

Role of hepatitis B virus specific cytotoxic T cells in liver damage and viral control.

To understand the role of cytotoxic T cells in liver damage and viral control, we used human histocompatibility leukocyte antigen (HLA)-peptide tetramers that allow direct ex vivo quantification of circulating and liver-infiltrating HBV-specific CD8 cells. Studies were carried out in two groups of patients, one without liver inflammation and minimal HBV replication and the other with liver damage and inflammation along with a high level of viral replication. Contrary to expectation, a high frequency of intrahepatic HBV-specific CD8 cells was found in the former group, i.e., the absence of hepatic immunopathology. In the replicating viraemic group, the virus specific T cells were diluted among the liver infiltrates; although with the massive cellular infiltration that was present, the absolute number was similar. It was also shown that in the low viraemia group the reservoir of CD8+ cells present in the circulation was able to expand after specific virus recognition and that this was not detectable in highly viraemic patients with liver inflammation. These results show that inhibition of virus replication can be independent of liver damage and when the HBV-specific CD8 response is unable to control virus replication it may contribute to liver pathology not only directly but by causing recruitment of non-virus specific T cells.

Demographic, autoimmune, and clinical profiles of patients with systemic lupus erythematosus in Oman.

Seventy female and three male Omani systemic lupus erythematosus (SLE) patients are described. At disease onset, 45 (62%) were under 20 years of age, and the remainder were between 20 and 44. Of all cases, 48% were familial. Over 5 years, the cumulative frequencies of autoantibodies was: antinuclear antibodies (ANA) 97%, anti-double-stranded DNA (anti-dsDNA) antibodies 92%, extractable nuclear antigen (ENA) antibodies 64%, antineutrophil cytoplasmic antibodies (ANCA) 58%, antiphospholipid (APL) antibodies 80%, and rheumatoid factor (Rf) 22%. Ribonucleoprotein (RNP) antibodies were found in 15/45 younger-onset and 2/28 older-onset patients (chi(2)=6.63, P<0.02). The mean SLE disease activity score (SLEDAI) was 13.5+11.4, and the cumulative frequencies of systemic involvement were: neurological 33.8%, vascular 10.4%, musculoskeletal 53.9%, renal 50.7%, dermal 80.5%, serosal 23.9%, immunological 95%, constitutional 31.3%, and haematological 26.0%. Linear regression analysis showed that high-titre ANA were predictors for pyuria (odds ratio [OR] 9.06, P=0.01). Antiextractable nuclear antigen antibodies were predictors for disease of the neurological (OR 26.3, P=0.008) and serosal (OR 27.7, P=0.005) systems, and anti-Sm antibodies for alopecia (OR 5.93, P=0.088) and hypocomplementaemia (OR 14.6, P= 0.016). Antibodies of known diagnostic utility may also give insights into the pathogenesis of SLE.

[Peripheral neuropathy rehabilitation. Indications for a diagnostic-rehabilitation approach]. / La riabilitazione delle neuropatie periferiche. Indicazioni per un percorso diagnostico-riabilitativo.

The increased incidence of occupational neurological disorders has led, in recent years, to the development of new specialties in neurorehabilitation for the recovery of deficits of central nervous system (CNS) lesions. This same development has not occurred for damage to the peripheral nervous system (PNS), the treatment of which is still based on empirically applied rehabilitation techniques. This is due to the fact that the peripheral neuropathies comprise a vast groups of disorders caused by a huge variety of etiological agents; in order to identify their exact cause and thus be able to differentiate rehabilitation techniques it is necessary to classify them. The aim of this study is to summarize the main rehabilitation strategies, pharmacological treatments and surgical techniques used most effectively in the management of peripheral neuropathies in order to develop a therapeutic rehabilitation strategy for each of the different forms and lay the bases for the development of specific guidelines.

Clinical features of Behçet's disease in patients in the Sultanate of Oman; the significance of antiphospholipid antibodies?

The prevalence of symptoms in 34 Omani patients with Behcet's disease (BD) was: recurrent oral ulceration 100%, arthritis/arthralgia and genital ulceration 74% each, folliculitis 64%, neurological lesions 62%, retinal vasculitis 30%, iritis and hypopyon 26%, gastrointestinal lesions 12%, venous thrombosis and cardiovascular lesions 9% each, and pleuropulmonary lesions and epididymitis 6% each. Antiphospholipid (APL) antibodies (both anticardiolipin [ACAs] and anti-beta2 glycoprotein I [abeta2GPIs]) were present in 11/34 (32%) of the BD patients and in 54/73 (74%) of Omani patients with systemic lupus erythematosus (SLE) (chi2 = 21.2, P<0.001). In patients possessing APL antibodies, there was no significant difference in mean antibody levels between BD and SLE patients. IgM isotype antibodies, in the absence of IgG, were more prevalent in BD (5/11) than in SLE (10/54) patients (chi2 =3.8, P = 0.05). The frequency of organ involvement was similar in patients with and without APL antibodies (chi2 = 1.226, P > 0.05). This study fails to demonstrate a pathognomonic role for APL antibodies in BD.

Tribal and geographical variations of lupus in the Sultanate of Oman: a hospital-based study.

Tribal differences are demonstrated in the presentation of lupus in Omani Gulf Arabs (OGA) and Omani Arabs of Persian descent (OAP), both groups resident in and indigenous to the Sultanate of Oman. The OAP have a lower risk of joint complications, skin rash, and dsDNA antibodies than OGA (beta coefficient and 95% confidence interval [CI], -35.6, -16.4, and -2.31 and -38.05 to -33.06, -19.49 to -13.3, and -4.1 to -0.6, respectively). The OGA have higher levels of IgG isotype APL antibodies than OAP, both anticardiolipin (ACA) (t= 1.75, P= 1.04) and anti-beta2glycoprotein I (infinitybeta2GPI) (t=3.64, P=0.004) antibodies, while OAP have higher levels of ACAs, IgM isotype (t=2.86, P=0.0024), than OGA. Antiphospholipid (APL) antibodies associate differently with clinical symptoms, both within OAP and between OAP and OGA. Patients from Dakiliyah have a higher risk of joint disease than those from Muscat (relative risk ratio 5.0, 95% CI 1.3-18.3). Differences in symptomatology suggest variations in genetic linkages to human systemic lupus erythematosus.

[Correlation between computed tomography and isokinesis in patients with reconstructive surgery of anterior cruciate ligament of the knee]. / Correlazione fra tomografia computerizzata e isocinesi in pazienti operati diricostruzione di ricostruzione di legamento crociato anteriore di ginocchio.

AIM: The aim of this study was to correlate the length (measured by computed tomography) of the anterior cruciate neoligament following knee surgery with the time required by the flexors-extensors of the knee to reach isokinesis (measured using an isokinetic method). MATERIAL AND METHODS: Twenty-five patients (all males, median age 25.4 years), who had undergone surgical repair of the anterior cruciate ligament (ACL), were assessed by computed axial tomography (CT) and isokinetic tests a mean of 6.3 months after their operation. The following isokinetic parameters were calculated: time to reach isokinesis in flexion, time to reach isokinesis in extension, flexion strength, and extension strength. Mean values were calculated from all the values recorded during the test cycles performed. The CT examinations, after lateral scanograms, were carried out with 1 mm contiguous axial scans parallel to the tibial plate. It was possible to assess the integrity of the neoligament which was measured from a section of the tibial plate above the tibial cartilage to its insertion in the intercondylar furrow. RESULTS: As expected, all the values recorded from the healthy knee were significantly different from those recorded on the operated side. As far as concerns analysis of any correlations, there were good correlations between the time to reach isokinesis in extension and the length of the ACL both on the operated side (r=.62) and the healthy side (r=.69), whereas the correlations between the length of the ACL and all other measurements were moderate or very weak (from 0.44 to 0.03). DISCUSSION AND CONCLUSIONS: That the isokinetic measurements show an increased time for the extensor muscles of the operated knee to reach isokinesis is related to altered biomechanics of the passage of the tibia from a posterior translaction position to one of an anterior translaction that is, to anterior displacement of the tibia during extension of the knee, which leads to the prolonged time. The correlation between this time and the length of the ACL, as measured by CT, offers the possibility of being able to monitor the outcome of cruciate ligament repair periodically during various phases of rehabilitation treatment and of only using control CT examinations if there are any complications and/or problems.