Certolizumab for the treatment of psoriasis and psoriatic arthritis: a real-world multicentre Italian study.

BACKGROUND: Certolizumab, a pegylated tumour necrosis factor-α inhibitor, reduced disease activity in randomized trials of patients with psoriasis and psoriatic arthritis. Real-life data are missing. OBJECTIVE: To confirm the effectiveness and safety of certolizumab in patients with psoriasis and psoriatic arthritis in routine clinical practice. METHODS: In this retrospective study involving 11 Italian sites, patients with psoriasis and psoriatic arthritis received subcutaneous certolizumab (400 mg loading dose at 0, 2 and 4 weeks, followed by 200 mg every 2 weeks) for up to 52 weeks. Primary outcomes included mean change from baseline in Psoriasis Area and Severity Index (PASI) and modified Nail Psoriasis Severity Index (mNAPSI) scores, and the proportion of patients achieving a 75%, 90% or 100% reduction in PASI score. Other endpoints included Disease Activity Score computed on 44 joints correlated with the erythrocyte sedimentation rate during the first hour (DAS44-ESR), Tender Joint Count (TJC), Swollen Joint Count (SJC), pain [visual analogue scale (VAS) score], inflammatory markers and quality of life (QOL). RESULTS: In the study were enrolled 153 patients (mean age: 55 years). Certolizumab reduced the mean PASI score from baseline by 4.45, 6.30 and 7.58 at weeks 12, 24 and 52, respectively (P < 0.001 for all). At weeks 24 and 52, 69.6% and 83.3% of patients had a PASI score ≤3. DAS44-ESR, TJC, SJC and mNAPSI scores, and pain VAS were also all significantly improved from baseline at each time point. C-reactive protein levels decreased during treatment, being significant at week 24. On multivariate analysis, psoriasis duration, baseline PASI, mNAPSI and pain VAS scores were found to be predictive of the improvement in PASI score at week 12. CONCLUSION: Certolizumab displayed also in the real-life encouraging results in both psoriasis and psoriatic arthritis patients.

Prevalence of Polysubstance Abuse and Dual Diagnosis in Patients Admitted to Alcohol Rehabilitation Units for Alcohol-Related Problems in Italy: Changes in 15 Years.

AIMS: Alcohol abuse has long been known as a disease with social and economic burden to society. Given the complex nature of alcohol treatment, it is worthwhile to examine the change over time of patients admitted to residential alcohol abuse rehabilitation units. METHODS: The data were collected from two Italian projects on alcoholics performed in the mid-1990s (ASSALT) and in 2009 (CORRAL), respectively. Categorical variables were considered in terms of absolute and relative frequencies. Comparisons of relative frequencies between groups were assessed by means of Fisher's exact test. Mixed logistic regression models were fitted to CORRAL data to identify the predictors of the probability of being a polysubstance abuser or having a dual diagnosis. The association estimates were reported as adjusted odds ratios and relative 95% confidence intervals. RESULTS: Compared to the mid-1990s, in 2009 patients were older (P= 0.0003), with a higher level of education (P= 0.0204), with fewer comorbidities (liver disease except cirrhosis, P < 0.0001; polyneuropathy, P= 0.0001), more frequently polysubstance abusers (P < 0.0001), affected by dual diagnosis (P < 0.0001). In 2009, the probability of being a polysubstance abuser was higher in younger and in patients with dual psychiatric diagnosis. Female gender and polysubstance abuse were positively associated to the probability of being affected by dual psychiatric diagnosis. CONCLUSIONS: The increment of patients admitted to residential programs for alcohol dependence with polysubstance abuse and/or dual psychiatric diagnoses suggests the need to pay more attention to both psychological/psychiatric interventions and internal medicine/physical rehabilitation. SHORT SUMMARY: The results of this study suggest that further research is needed to identify the best treatment strategy that is safe and effective for the new population of alcoholics.

Laparoscopic sleeve gastrectomy for morbid obesity: role of intraluminal and intraperitoneal postoperative drainage.

BACKGROUND AND AIMS: Bleeding and staple line leak are the most common postoperative complications of LSG. To prevent and/or to promptly identify such complications, conventional peri-operative protocols imply post-operative gastric decompression (NGT) and staple line drain (IAD). Our aim was to evaluate the role of naso-gastric tube (NGT) and intra-abdominal drain (IAD) in preventing and/or facilitating identification and treatment of post-operative complications after sleeve gastrectomy. PATIENTS AND METHODS: A retrospective observational study on two consecutive series has been undertaken to evaluate the real utility of routine placement of NGT and IAD at the end of a LSG to prevent (primary end-point), promptly identify (secondary end-point) and manage (tertiary end-point) bleeding and staple line leakage. Collected outcome data of all consecutive cases, which underwent primary LSG at our Department, were analyzed. The first 100 consecutive patients (group A) received the standard perioperative protocol and the other consecutive 100 (group B) received a fast track protocol (no NGT neither IAD). RESULTS: The two groups were not different in their outcome. Two bleeding occurred in Group A and were conservatively treated. One abscess developed in group B soon after surgery. It was diagnosed by an abdominal CT performed because patients presented fever, leucocitosis and tachycardia. It was successfully treated by percutaneous ultrasound-guided drainage. One fistula occurred in group B after discharge on 30th post-operative day. Fistula was suspected based on fever and tachycardia in absence of any abdominal discomfort and was confirmed by an abdominal CT. The patient was successfully treated in 40 days by endoscopic positioning of a gastric tube-prosthesis and percutaneous ultrasound-guided drainage of abdominal collection. A third patient in group B experienced bleeding suspected due to hemoglobin drop and confirmed by abdominal CT. He also was conservatively treated. CONCLUSIONS: In conclusion, placement of drains does not facilitate detection of leak, abscess, or bleeding after primary LSG.

[Alcohol-addiction inpatient: characteristics of patients and rehabilitation program]. / La residenzialità alcologica ospedaliera: caratteristiche dei pazienti e dei percorsi terapeutici/riabilitativi.

AIM: The treatment of alcohol addiction in Italy has had a progressive evolution of therapeutic structures for in-and outpatients. During the last 20 years there had been a crescent presence of short residential treatment facilities (1-6 months) characterized by a high level of medical and psychotherapeutic intervention. About two years ago 12 of them jointed together in an association called CORRAL (COordinamento of Residenzialità Riabilitive Alcologiche). The aim of this study was to describe the socio-demographic medical and other characteristics of the patients coming for this type of treatment and to describe the characteristics of the residential treatment itself including referring and aftercare. METHODS: Two thousand sixty-one hospitalized patients of the 12 rehabilitative alcohol units were examined by using a questionnaire and collecting various sociodemographic variables and clinical diagnosis of the patients. Even it was asked who had referred the patients, the characteristics of the residential treatment and of the planned aftercare. RESULTS: The present residential facilities are mainly distributed in the North of Italy. The typical patient is male, with a high school instruction and with a comorbidity regarding psychiatric and liver disorders. The majority of the patients were referred by the public ambulatory services for addictions (SerT/SerD). The characteristics of the residential treatment were medical, pharmacological and psychotherapeutic interventions with a high intensity and the presence of a general-purpose staff. CONCLUSIONS: This study outlined a model of residential rehabilitation of alcohol disorders characterized by short duration and a complex, intense therapeutic intervention mainly addressed to patients with a severe clinical condition and a low level of social problems. Further research should be useful to understand better which sort of patient characteristics obtain a better clinical result and for that even economically a major effectiveness from this type of residential treatment.

New insights into the pathogenesis of cutaneous autoimmune disorders.

T helper 17 (Th17) cells are characterized by the secretion of IL-17, a proinflammatory cytokine. They represent a newly described T helper subpopulation that is distinct from Th1 and Th2 lineages. Because of their pleiotropic activity on fibroblasts, keratinocytes, endothelial cells, neutrophils and memory T cells, Th17 cells are thought to be crucial in mediating tissue inflammation and autoimmunity. Autoimmune diseases were classically considered as Th1-mediated disorders such as rheumatoid arthritis or mixed Th1/Th2 diseases such as inflammatory bowel diseases, systemic lupus erythematosus, bullous diseases, but new evidence suggests the deep involvement of Th17 cells in their pathogenesis that, potentially, may address a selective therapeutic approach targeting the IL23/Th17 pathway. This review summarizes the current knowledge of the pathogenic contribution of Th17 cells in select cutaneous autoimmune disorders, including lupus erythematosus, scleroderma, dermatomyositis, bullous pemphigoid and pemphigus vulgaris.

Role of Th17 in the pathogenesis of cutaneous inflammatory diseases.

Th17 cells are a new T-cell subtype characterized by the capability of producing IL-17. They are reported to be involved in a wide range of cutaneous immune-mediated conditions and, particularly in this review, we sought to elucidate the Th17 role in the pathogenesis of some common inflammatory diseases including psoriasis, allergic contact dermatitis and atopic dermatitis.

Dermoscopic Analysis of 72 "Atypical" Seborrheic Keratoses. / Análisis dermatoscópico de 72 queratosis seborreicas «atípicas¼.

BACKGROUND: Seborrheic keratoses (SK) are easily recognizable by clinical and dermoscopic approach, nevertheless, some lesions act as a simulator of different skin conditions lacking typical clinical and dermoscopic criteria. OBJECTIVE: The aim of our study was to find specific dermoscopic features or a global pattern to improve diagnostic skills for challenging SK. MATERIALS AND METHODS: We examined 72 atypical SK excised from September 2014 up to September 2017 by using the 2-step algorithm modified by Malvehy (2002) and Argenziano (2003). RESULTS: In our study population, an average of 4.04 out of 15 dermoscopic specific criteria for SK was found (for example, multiple milia-like cysts). Additional criteria not included in 2-step algorithm were blue-whitish veil (found in 3 SK; 4.2%), polymorphous vessels (18 SK; 25%), blotch/globules (6 SK; 8.3%), shiny white streaks (3 lesions; 4.2%). The most represented global patterns were reticular (27 SK; 37.5%) and not specific (15 SK; 20.8%). All lesions exhibited peculiar findings of SK, furthermore elements suggestive for melanocytic lesion were found in 79.2% of all lesions. Comparing the literature and our results, we found 3 significant differences: a) the less prevalence of SK specific criteria in our study population; b) the description of findings usually not related to SK, among which blue-whitish veil, polymorphous vessels, blotch/globules and shiny white streaks, and c) 2 patterns not previously defined represented by "not specific pattern" (20.9% of all lesions examined) and "vascular pattern" (12.5% of all lesions examined) were also described. No specific feature or global pattern, statistically significant for dermoscopic diagnosis of difficult-to-diagnose SK have been found. CONCLUSION: Nevertheless the useful findings, no specific feature or global pattern statistically significant for dermoscopic diagnosis of challenging SK have been found. According to the 2-step algorithm and the dermatoscopic scoring system for melanocytic and not melanocytic lesion, SK with one or more dermatoscopic findings typical of melanocytic lesion should be removed surgically to exclude classic melanoma or melanoma mimicking SK.

Safety evaluation of apremilast for the treatment of psoriasis.

INTRODUCTION: Psoriasis (PSo) is a chronic inflammatory skin disease associated with co-morbidities such as hypertension, diabetes, dyslipidemia and metabolic syndrome. It is a typothypical Th1/Th17 disease that affects from 2 to 3% of the world population. Numerous are the drugs that can be used in our clinical practice; the choice of these drugs depends on the characteristics of the patient. Areas covered: Apremilast is the first oral small molecules to receive FDA approval for the treatment of adults with active psoriasis and psoriatic arthritis. It is a small-molecule that specifically inhibits the activity of cyclic AMP phosphodiesterase-4 (PDE4). Several analyses have been performed on data from phase III studies to assess apremilast safety and efficacy on psoriasis and psoriatic arthritis (PsA). Apremilast could also represent a treatment opportunity for those patients unresponsive to both systemic and biological agents or whose treatment was contraindicated. Expert opinion: For its safety profile and easy route of administration, apremilast may offer an oral treatment option for those patients that discontinue treatments because of ineffectiveness, intolerability or ineligibility to the currently available drugs.

[Preoperative diagnosis using color Doppler flowmetry in focal and diffuse thyroid pathology]. / Diagnostica preoperatoria mediante flussimetria color-Doppler delle patologie focali e diffuse della tiroide.

Color-doppler was first used in the study and classification of specific pathologies in 1992. One hundred and eighteen patients with focal and diffuse thyroid pathologies underwent color-doppler, flowmetry analysis and peak systolic velocity measurement (CD-FM-PSV). The PSV results allowed us to identify two subclasses a and b in class three and four (a: = < or = 30 cm/sec., b: = > 30 cm/sec.). Class 3a and 3b lesions are the most likely to represent neoplastic nodules. Based on our results, we assigned 58 patients to type 2 (follicular hyperplasia), 20 patients to type 3a (follicular adenoma and carcinomas), 16 patients to type 3b (carcinomas and Plummer's adenoma), 15 patients to type 4a (autoimmune thyroiditis and hypothyroidism) and 12 patients to type 4b (Graves' disease). Preliminary results were compared with FNAB, intra-operative and post-operative histological data. The specificity of CD-FM-PSV in diagnosis is 86%. We have concluded that CD-FM-PSV is an effective imaging technique for pre-operative diagnosis of thyroid pathologies and along with FNAB, a adequate predictive tool for thyroid nodules.

[Palliative treatment of neoplasms of the bilio-pancreatic area. Surgical diversion treatment versus endoscopic-percutaneous approach]. / Trattamento palliativo delle neoplasie del distretto bilio-pancreatico. Terapia derivativa chirurgica versus approccio endoscopico-percutaneo.

Bilio-pancreatic (BPD) tumours are pathologies with an overall resectability rate of 20-25%, with a high percentage of patients directed towards palliative treatment (70-90%). One hundred and twenty-eight patients underwent palliative treatment for BPD tumours. The M:F ratio was 1:1.5 and the mean age 61 years. The tumours were topographically divided into: 84 (63%) localised in the pancreatic head region; 34 (25%) biliary duct tumours and 6 arising in the ampulla of Vater. 42 patients (30%) underwent palliative surgical treatment (group 1) and 86 (70%) received non-surgical treatment (endoscopic percutaneous) (group 2). We also performed 6 gastrointestinal by-passes (GEA). The early morbidity rate was 36% in the first group and 12.8% in the second. The incidence of late morbidity in the first group was nil, with a mean survival of 10 months. Mortality was nil in both groups. Surgical by-pass is advisable in the presence of patients with a longer life expectancy and in good clinical condition but presents a high rate of early morbidity and a low percentage of late complications. The authors conclude that validity of the methods is similar. They believe that, in selected cases, surgical treatment remains the therapy of choice for BPD tumours.

[A case of primary intestinal lymphoma]. / Considerazioni su un caso di linfoma primitivo intestinale.

The authors examine primary small bowel tumours, dealing at some length with problems of a diagnostic and clinical nature. The difficulties often encountered in reaching an early diagnosis and the feasibility of radical surgery frequently prove to be factors conditioning prognosis. The importance is then stressed of thorough evaluation of those vague symptoms which may be the only manifestation of this disease.

[Sensitivity and specificity of transrectal ultrasonography in the preoperative staging and postoperative follow-up in rectal neoplasms. Experience with 100 clinical cases]. / Sensibilità e specificità dell'ultrasonografia trans-rettale nello staging preoperatorio e nel follow-up post-chirurgico delle neoplasie del retto. Esperienza su 100 casi clinici.

UNLABELLED: Preoperative staging plays an important role in the surgical treatment of rectal cancer. The most sensitive imaging techniques currently available are CT, MRI and transanal ultrasound (TAUS). The aim of the study was to evaluate the sensitivity and specificity of TAUS in the preoperative staging and postoperative follow-up of rectal cancer. METHODS: From January 1992 to May 1999, TAUS was used to study 100 patients with rectal cancer. RESULTS: Patients were staged according to the Astler-Coller classification: 1) A: 8 patients; 2) B1: 16 patients; 3) B2: 22 patients; C1: 30 patients; C2: 24 patients. The sensitivity and specificity of TAUS in the preoperative staging of these tumors were 96% for the T parameter, and 100% for the N parameter. The N but not the T parameter results are in line with the values reported in the international literature. CONCLUSION: Transanal ultrasound, in our personal experience, has proved to be a very accurate imaging technique in the preoperative staging and postoperative follow-up of rectal cancer.

[Abdominal compartment syndrome in video laparoscopic surgery. Etiopathogenetic aspects, physiopathology and personal experience]. / La sindrome addominale compartimentale in chirurgia videolaparoscopica. Considerazioni etiopatogenetiche, fisiopatologia ed esperienza personale.

The abdominal compartment syndrome (ACS) is a very seven pathology, consequence oh abdominal injuries and traumatism, acute pancreatitis, aortic aneurism rupture, acute peritonitis. The etiopatogenesis is the increase of intra-abdominal pressure with systemic consequences for cardiorespiratory and renal failure. The authors after careful physiopathologic consideration, describe, a case report of ACS in the laparoscopic cholecystectomy for acute cholecystitis. To conclusion, we report very important the accurate intraoperative monitoring of vital parameters (PCO2, PO2, Pa, Fc, PVC, Ph, Diuresis) and immediate decision at laparotomic conversion for abdominal decompression.

[Minimally invasive percutaneous ultrasonography-guided treatment of postoperative splenic abscess. Personal experience with 5 clinical cases]. / Terapia mininvasiva percutanea ultrasonoguidata degli ascessi post-chirurgici della milza. Esperienza personale su cinque casi clinici.

INTRODUCTION: Splenic abscesses are very rare pathologies encountered in daily clinical practice. The treatment, after failure of other medical treatments, has basically been surgical, in spite of large diffusion of percutaneous echo and CT techniques. The initial hesitation in applying this sort of method was caused by an unfounded fear of difficult management of haemorrhagic complications. METHODS: In our Clinic we treated 6 postoperative abscesses, observed in 5 patients. One of these (16%) was double and 3 concomitant with other intraperitoneal abscessual septic collections, which received priority in percutaneous treatment. In four cases (67%), Van-Sonnemberg drainage catheters were placed which caliber varied from 12 to 14 F. In the remaining two cases, we evacuated the abscess using an echo-guided needle puncture. In two cases we applied fibrinic glue; in one case as a haemostatic agent and in the other, to protect the wide abscessual cavity. RESULTS: We recorded the resolution of the symptomatology and instrumental findings in all patients. One patient died two weeks later due to unrelated causes. We recorded one minor complication which involved an intra-abscessual haemorrhage, which was then treated by fibrinic glue (Tissucol). CONCLUSION: Echo-guided percutaneous treatment, at present, is the treatment of choice for both multiple or single splenic abscesses. This treatment is not used for the miliaric form because we believe that in this case, the most appropriate choice is intensive medical treatment, which if fails, may require splenectomy.

[Echo-guided percutaneous drainage of abscesses and abdominal fluid collections]. / Drenaggio percutaneo ecoguidato degli ascessi e delle raccolte fluide addominali.

Abdominal abscesses are pathologies characterized by an high decree of mortality and morbidity. The pathology was once dealt with surgery evacuation the percentage of success reaches 60% while mortality runned around 24%. Today this technic has been substituted by the echo-guided treatment. The minimal invasive approach reduced dramatically the cases of complications (4-6%) and mortality (4%); it is highly suggested in the majority of the cases of visceral or endoperitoneal abscesses. Our study case counts 57 echo-guided drainages due to multiply surgery pathologies. The number of successful ends runs on 93%, this perfect agrees with the data given by literature that states a decree of success around 90%. We did no test an higher or lower decree of complications nor mortality. According to our opinion the echo-guided drainage is a primary technic in abdominal septic collections. Surgery drainage has to be aside for patients with general good health or for collections accompanied with divertcular disease of the large intestine, crohn disease, rectocolitis ulcerosis and periappendix abscess.