A reorientation strategy for reducing delirium in the critically ill. Results of an interventional study.

BACKGROUND: A wide variability in the approach towards delirium prevention and treatment in the critically ill results from the dearth of prospective randomised studies. METHODS: We launched a two-stage prospective observational study to assess delirium epidemiology, risk factors and impact on patient outcome, by enrolling all patients admitted to our Intensive Care Unit (ICU) over a year. The first step - from January to June 2008 was the observational phase, whereas the second one from July to December 2008 was interventional. All the patients admitted to our ICU were recruited but those with pre-existing cognitive disorders, dementia, psychosis and disability after stroke were excluded from the data analysis. Delirium assessment was performed according with Confusion Assessment Method for the ICU twice per day after sedation interruption. During phase 2, patients underwent both a re-orientation strategy and environmental, acoustic and visual stimulation. RESULTS: We admitted a total of respectively 170 (I-ph) and 144 patients (II-ph). The delirium occurrence was significantly lower in (II-ph) 22% vs. 35% in (I-ph) (P=0.020). A Cox's Proportional Hazard model found the applied reorientation strategy as the strongest protective predictors of delirium: (HR 0.504, 95% C.I. 0.313-0.890, P=0.034), whereas age (HR 1.034, 95% CI: 1.013-1.056, P=0.001) and sedation with midazolam plus opiate (HR 2.145, 95% CI: 2.247-4.032, P=0.018) were negative predictors. CONCLUSION: A timely reorientation strategy seems to be correlated with significantly lower occurrence of delirium.

Fatigue strength of PMMA bone cement mixed with gentamicin and barium sulphate vs pure PMMA.

Barium sulphate is added to polymethylmethacrylate (PMMA) bone cement as a radiopacifier. Gentamicin is an antibiotic added to bone cement to treat or prevent infection in arthroplasty. This study investigated the combined effect of barium sulphate and gentamicin sulphate on the fatigue strength of PMMA bone cement. Three different formulations were studied: pure PMMA, PMMA with barium sulphate added and PMMA with barium sulphate and gentamicin sulphate added. Before testing all specimens were stored in water at 37 degrees C for at least 15 days to season the PMMA and to elute the antibiotic. Fatigue tests were performed following a previously validated procedure. The slope part of the Wöhler diagram was obtained and a rough endurance limit was estimated for all three formulations. The experimental data showed that the addition of barium sulphate to PMMA bone cement affected the fatigue strength of the material, whereas addition of gentamicin sulphate to the radiopaque PMMA had no effect on the fatigue properties of the bone cement. While PMMA with barium sulphate added was confirmed to have a reduced fatigue strength when compared with plain PMMA, no detrimental effect was found for the addition of gentamicin sulphate to radiopaque PMMA.

The effect on the fatigue strength of bone cement of adding sodium fluoride.

New bone cements that include several additives are currently being investigated and tested. One such additive is sodium fluoride (NaF), which promotes bone formation, facilitating implant integration and success. The influence of NaF on the fatigue performance of the cement as used in biomedical applications was tested in this paper. In fact fatigue failure of the cement mantle is a major factor limiting the longevity of a cemented implant. An experimental bone cement with added NaF (12 wt%) was investigated. The fatigue strength of the novel bone cement was evaluated in comparison with the cement without additives; fatigue tests were conducted according to current standards. The load levels were arranged based on a validated, statistically based optimization algorithm. The curve of stress against number of load cycles and the endurance limit were obtained and compared for both formulations. The results showed that the addition of NaF (12 wt%) to polymethylmethacrylate (PMMA) bone cement does not affect the fatigue resistance of the material. Sodium fluoride can safely be added to the bone cement without altering the fatigue performance of the PMMA bone cement.

Radiopacity and fatigue characterization of a novel acrylic bone cement with sodium fluoride.

Acrylic bone cement must provide good radiographic visibility and good long-term mechanical resistance in joint replacements. A new formulation of cement with 6% barium sulfate and 6% sodium fluoride was developed (Fluoride Bone Cement). Barium sulfate is a necessary addition to allow radiographic visibility although it reduces the mechanical strength of the material. Sodium fluoride promotes bone formation. However, its effect on the mechanical behavior is currently unknown while its influence on radiopacity can only be roughly estimated. The aim of this investigation was to establish if the new formulation would be suitable for clinical trials. In this respect, a mechanical (fatigue test) and radiographic (optical density measurements on x-ray films) characterization was performed on a typical commercially available cement with barium sulfate added and on the Fluoride Bone Cement. It was demonstrated that the fluoride cement has a (marginally) superior fatigue strength and comparable radiopacity to commercial radiopaque cements.

Validation of an Italian version of the arthritis impact measurement scales 2 (ITALIAN-AIMS2) for patients with osteoarthritis of the knee. Gonarthrosis and Quality of Life Assessment (GOQOLA) Study Group.

OBJECTIVE: To validate a translated version of the revised and expanded Arthritis Impact Measurement Scales (AIMS2) to be used by Italian patients with osteoarthritis (OA) of the knee. METHODS: The AIMS2 was translated into Italian and administered to a cohort of 178 outpatients with symptomatic OA of the knee who attended 12 participating rheumatological institutes in northern, central and southern Italy. A random sample of 71 patients were readministered the AIMS2, 7 days after the first visit, to evaluate the instrument's test-retest reliability. After 6 months, the subjects were asked to return to the institutes for a second administration of the questionnaire. RESULTS: The internal consistency reliability of each scale score, as estimated by Cronbach's alpha coefficient, was high and indicated that the components of the scale measured the same construct. The items all correlated with each other, but there was no redundancy; this indicates that each domain addressed a somewhat different aspect of functional disability. The test-retest reliability equalled or exceeded 0.80 for eight of the 12 scales. Factor analysis provided a three-factor health status model explaining 63.5% of the variance. Arthritis pain and psychological scale were loaded on the first factor, together with physical scales for mobility level and walking and bending. The upper limb function scales formed the second factor. The third factor was determined by the social dimension. These results demonstrate that the physical health status scales of the AIMS2 are valid, as shown by the significant, moderate to high correlations between the AIMS2 subscales and the majority of the clinical measures. CONCLUSION: Our data suggest that, like the original questionnaire, the translated version of AIMS2 is a reliable, consistent and valid instrument for measuring health status and physical functioning in patients with OA of the knee.

Fasciíte necrotizante cervical: uma complicaçäo de abscesso de origem dentária / Cervical necrotizing fasciatis: a complication due to an abscess of dental origin

Relatamos um caso de Fasciíte Necrotizante da regiäo cérvico-facial após abcesso dentário, em um paciente portador de Diabetes melito descompensado. Esta infecçäo aguda resultou numa invasividade profunda com necrose da fáscia, gordura subcutânea e pele da regiäo cervical. O sucesso do tratamento baseou-se no diagnóstico precoce da doença básica, na terapia antibiótica de largo espectro e no desbridamento agressivo

[Fever of unknown origin in rheumatology]. / Febbri di origine oscura in reumatologia.

Fever occurs frequently in several rheumatic disorders, and remains a diagnostic and therapeutic challenge to the rheumatologist in spite of the great advances made in the fields of medical diagnosis and technology. It can be the initial symptom of a rheumatic disease, but it can also be the expression of a disease flare, of an infectious complication, of a secondary neoplasm or be of iatrogenic origin. The pathogenesis of fever in rheumatic diseases is still quite unclear; however, recently IL-1, IL-6 and other endogenous pyrogens, such as Tumor necrosis factor, have been shown to play a pivotal role in causing pyrexia during inflammatory conditions. In the presence of longstanding fever of unknown origin, it is mandatory to carry out a number of selected appropriate examinations with the patient's informed consent. The aim of this study was to review the frequency and the characteristics of fever at the onset and in the course of a number of rheumatic diseases, such as chronic inflammatory arthropathies, connective tissue diseases, reactive arthritis and dysmetabolic arthropathies. Finally, we have reviewed the features of fever during arthritis complicating non-rheumatic diseases and during adverse reactions related to drugs that are widely prescribed for the treatment of rheumatic disorders.

Quality of life assessment during six months of NSAID treatment [Gonarthrosis and Quality of Life (GOAL) Study].

OBJECTIVE: To identify the time point of the greatest degree of improvement in daily living activities, pain and depression in patients with osteoarthritis (OA) of the knee during 6 months of treatment with NSAIDs, in order to define compliance and drop-out rate. METHODS: 107 patients were recruited into a multicentre, prospective, randomized, controlled trial comparing two treatments, piroxicam-beta-cyclodextrin (PBCD) and slow release diclofenac (DCL). RESULTS: The greatest improvement in quality of life occurred in both groups after 3 months, with a slight further gain observed by the end of treatment. The Stanford Health Assessment Questionnaire score improved (p < 0.05 vs baseline) at 3 and 6 months with PBCD and at 6 months with DCL. The Arthritis Impact Measurement Scale score improved (p < 0.05 vs baseline) after 6 months in both groups. Significant (p < 0.05 vs baseline) improvement in other psychological and pain scores were recorded in both groups after 3 and 6 months. Compliance with treatment at 3 months was 73% for PBCD and 72% for DCL, and was 60% in both groups at 6 months. CONCLUSIONS: The results of this study indicate that the optimal length of time for an NSAID trial in OA patients is 3 months, when assessment of daily living activities is considered as the main outcome criterion.

HLA-B27 positive ankylosing spondylitis and polyarteritis nodosa: a case report.

A 35-year-old man, with positive HBV and HCV markers, showed clinical and histopathological features of polyarteritis nodosa (PAN), in the course of HLA-B27 positive ankylosing spondylitis (AS). The possible occurrence of both diseases in genetically susceptible subjects is discussed. Although the role of HBV surface antigen in the pathogenesis of PAN is well established, there is still a large proportion of PAN patients with no evidence of HBV infection. In the present case, the coexistence of HCV infection led us to speculate about a possible role of this virus in the pathogenesis of PAN. In our case we were able to verify the sensitivity of single photon emission computed tomography (SPECT) in the diagnosis and the clinical evaluation of the ischaemic cerebral lesions.

Involvement of atlanto-axial joint in rheumatoid arthritis: rare or frequent?

The authors studied the incidence of atlanto-axial joint involvement by conventional radiography and CT in 183 patients with classical or definite rheumatoid arthritis (RA). In determining lesions the significance of factors such as age, sex, duration and severity of the disease was evaluated. Atlanto-axial subluxations turned out to be quite frequent (30%) in the series of patients examined and were directly correlated with age, duration and stage of the disease, and extraarticular manifestations. Clinical symptoms were evident in only 70.9% of cases, confirming the correlation reported by other authors between clinical manifestations and radiologically observed lesions. Traditional radiography performed in the dynamic position revealed a prevalence of anterior subluxation, whereas CT gave a precise indication of the entity and type of atlanto-axial lesion. In conclusion, the authors confirm the importance of such investigations in all patients with RA, even those without evident clinical manifestations. They also emphasize the necessity of periodic monitoring in view of the possible risk of mortality in these patients.

Lymphoedema of the limbs in rheumatoid arthritis.

The lymphoedema of the extremities is a rare complication of rheumatoid arthritis (RA); it does not appear to be correlated with positivity for rheumatoid factor nor with the clinical activity of the disease. The authors describe 6 cases of lymphoedema in patients affected by RA; in 3 of them the lymphoedema was localized in the upper and in the remaining cases in the lower limbs. Four patients, (one of whom has been subjected to a lymphoangiography which demonstrates an obstruction of the deep lymphatics), presented an increase of the plasma fibrinogen degradation products (FDP). This could confirm the hypothesis according to which the lymphoedema could be attributable to an obstruction of the lymphatics caused by fibrin and other degradation products of the coagulation system. In one case the authors underscore the therapeutic effectiveness of lymphodrainage associated with administration of diuretics.

[Evaluation of the efficacy of intra-articular administration of somatostatin in rheumatoid arthritis]. / Valutazione dell'efficacia della somatostatina per via intrarticolare in pazienti con artrite reumatoide.

The above study was undertaken in order to evaluate the efficacy of intra-articular somatostatin in rheumatoid arthritis. Twelve patients were enrolled and all of them concluded the experiment of three consecutive intra-articular somatostatin injections of 750 mcg at two-weekly intervals. All patients reported a statistically significant reduction in painful symptomatology, particularly of pain during active movement, pain at climbing stairs, and morning stiffness. In one patient, telethermography revealed complete subsidence of articular inflammation. There were neither local nor systemic side effects.

[The utility of a classification scale of lumbar pain for the diagnosis of the fibromyalgia syndrome]. / Utilità della scala di classificazione del dolore lombare per la diagnosi di sindrome fibromialgica.

To help fibromyalgia syndrome's diagnosis, the authors propose the use of Back Pain Classification Scale (BPCS), verbal test for pain analysis, able to distinguish between organic and functional disease. Two-hundred patients suspected for fibromyalgia and forty controls completed the questionnaire and so it was possible correctly to distinguish patients with organic disease from those affected by fibromyalgia. The authors conclude that BPCS can represent a useful tool for fibromyalgia diagnosis.