Erasmus syndrome in a marble worker.

Erasmus syndrome is defined as the association of silica exposure and subsequent development of systemic sclerosis. The limited number of cases reported in the literature mainly involves miners and only sporadically other professionals. We describe a case of Erasmus syndrome in a marble worker. A 68 year old man came to our observation complaining pelvic and scapular girdle pain, evening fever, intense weakness and emaciation for about 1 month. He also reported to have had Raynaud's phenomenon in his hands for the last 13 years. Also, his occupational history revealed a chronic exposure to silica dust. The patient presented pain in his shoulders and hips, moderate skin thickening and sclerosis in his hands and fingers extending proximally to his wrists. The diagnosis of systemic sclerosis was determined according to his clinical and medical history, the positivity of anti-Scl 70 antibodies, the nailfold capillaroscopy suggestive of an active scleroderma pattern and the detection of a mild restrictive pulmonary syndrome. The evaluation of the organbased complications excluded a gastroenterological and cardiovascular involvement, while the chest computed tomography (CT) detected multiple small nodules with a mantle distribution and enlarged lymph nodes with no signs of interstitial lung disease and fibrosis. Additional tests (positron emission tomography-CT, flexible bronchoscopy and broncho-alveolar lavage) excluded infectious diseases and cancer. However, given the pulmonary involvement, we performed a histological examination of the parenchyma and lymph nodes, which revealed a picture of pneumoconiosis. In the end, the occupational history and the findings from the diagnostic procedures led to the diagnosis of pulmonary silicosis. The precise definition of the pulmonary involvement was essential to the therapeutic approach to this patient.

Intra-articular therapy with tumor necrosis factor-α antagonists: an update.

The aim of the study was to review from the present literature the intra-articular (IA) use of the TNF-blocking drugs. A total of 28 papers about this topic were found through a search in PubMed; the first publication's date was July 2003. These studies include a total of 214 patients affected by 12 different joint diseases that reported a total of 1046 intra-articular therapies carried out in 10 different joint sites. Infliximab and etanercept were the most widely used medications. The safety of this treatment clearly emerges from our analysis, while more difficult was the evaluation of its efficacy. Nevertheless we deduced an ideal patient profile that may better respond to the IA anti-TNF treatment.

Papular-purpuric gloves and socks syndrome due to parvovirus B19: a report of two simultaneous cases in cohabitant families.

The so-called papular-purpuric gloves and socks syndrome (PPGSS) is a condition characterized by acute onset of intense erythema, edema and petechiae with a typical localization on the hands and feet, besides mucosal lesions of the oral cavity. The syndrome has a favorable and self-limited course, requiring only a symptomatic therapy. In the 50% of the cases described in literature (ninety cases in 22 years), is documented an acute infection caused by parvovirus B19 and in only two cases the onset of PPGSS is reported among different members of the same family. The aim of the work is to describe two cases of PPGSS arisen during a short time period in two family members affected by an acute parvovirus B19 infection found by serum sampling. The peculiarity of the study was the infrequence of the syndrome and the rareness of the description of PPGSS in rheumatology. This syndrome is usually described in dermatology, but it is also interesting for the rheumatologist because it comes in differential diagnosis with various autoimmune diseases.

Incidence of influenza-like illness into a cohort of patients affected by chronic inflammatory rheumatism and treated with biological agents.

This study aimed to evaluate the incidence of influenza-like illness (ILI), from October 2009 to May 2010, in a group of patients suffering from chronic inflammatory rheumatism and treated with biological therapies. At the end of 2009-2010 influenza season, 159 patients under biological therapies answered to a questionnaire distributed 8 months before and were deeply interviewed. The group included 69 men and 90 women (mean age 47.6); forty-nine suffering from rheumatoid arthritis, 61 with psoriatic arthritis, 32 with ankylosing spondylitis and 17 with other spondyloarthritis; 146 patients were treated with anti-TNF-α, 7 with rituximab and 6 with abatacept; 128 patients assumed DMARDs and 72 patients assumed low dose of steroids. A case of ILI was identified by anamnestic findings and according to the case definitions commonly used in Europe. Seventeen percent of the considered population reported at least one episode of ILI during the monitoring period; none of the patients during the acute influenza attack suffered particularly severe symptoms and no one was hospitalized due to complications. Despite the diversity among the considered subgroups, the statistical analysis did not show any significant difference when incidence of ILI was considered for different disease, different biological agent and different association therapy. None of the examined variables resulted statistically significant concerning the relative risk evaluation. The incidence of ILI into a cohort of 159 patients treated with biological agents during the influenza season 2009-2010 resulted higher than the value reported in a wide sample of Italian population in the same period. However, the pandemic impact was not heavy among the studied patients, considering that no important complications or hospitalizations have been reported.

Periprocedural variations of platelet reactivity during elective percutaneous coronary intervention.

BACKGROUND: Percutaneous coronary intervention (PCI) modulates platelet reactivity (PR). OBJECTIVES: To assess: (i) the impact of coronary interventions on periprocedural variations (Δ) of PR; (ii) whether ΔPR correlates with periprocedural myocardial infarction (PMI); and (iii) the mechanisms of these variations in vitro. METHODS AND RESULTS: We enrolled 65 patients on aspirin (80-100 mg day(-1)) and clopidogrel (600 mg, 12 h before PCI): 15 with coronary angiography (CA group), 40 with PCI (PCI group), and 10 with rotational atherectomy plus PCI (RA group). PR was assessed by ADP, high-sensitivity ADP and thrombin receptor activator peptide 6 tests prior to, immediately after and 24 h after the procedure. E-selectin and ICAM-1 were assessed prior to and immediately after the procedure. In vitro, PR was measured during pulsatile blood flow at baseline, after balloon inflation and after stent implantation in six porcine carotid arteries and five plastic tubes. PR declined in the CA group, but significantly increased in the PCI and RA groups immediately postprocedure, and decreased to baseline at 24 h. ΔPR increased across the three groups (P < 0.0001). In the PCI group, ΔPR was directly related to total inflation time (r = 0.435, P = 0.005) and total stent length (r = 0.586, P < 0.001). The change in E-selectin significantly and inversely correlated with ΔPR (P < 0.001). No correlation was found with sICAM-1. PR increased significantly more in patients with PMI than in patients without PMI (P = 0.013). In vitro, platelet activation was observed in the presence of carotid arteries but not in the presence of plastic tubes. CONCLUSIONS: Despite dual antiplatelet therapy, PCI affected platelet function proportionally to procedural complexity and the extent of vascular damage.

The role of fractional flow reserve to guide stent implantation.

In routine clinical practice, a sizeable proportion of patients with suspected coronary artery disease (CAD) undergo coronary angiography without prior non-invasive functional evaluation. In this situation, the decision wheter to perform revascularization is taken solely on the basis of angiographic parameters, which are often limited in assessing the lesions that are functionally significant and ultimately responsible for patients' symptoms. Fractional flow reserve (FFR) is a validated method for assessing hemodynamic significance of coronary stenoses based on the use of pressure wires and assessment of hyperemic pressure gradients across coronary lesions. FFR can guide clinical decision making in several anatomical settings: e.g. intermediate stenosis, left main stenoses, multivessel disease, bifurcation lesions. Treatment strategies guided by FFR have been shown to be equally safe and more efficacious than angiography-guided PCI. FFR is readily available in the catheterization laboratory, and can be easily measured during coronary angiography. FFR represents a unique tool for interventional cardiologists to combine anatomical and functional information, allowing the selection of optimal revascularization strategy in patients with CAD.

[Intra-articular therapy with infliximab in psoriatic arthritis: efficacy and safety in refractory monoarthritis]. / Terapia intra-articolare con infliximab nell'artrite psoriasica: valutazione di efficacia e tollerabilità nel trattamento della monoartrite refrattaria.

OBJECTIVE: To evaluate efficacy and safety of intra-articular therapy (IA) with infliximab (IFX), in patients with psoriatic arthritis (PsA) and refractory monoarthritis. METHODS: Four male and 1 female aged from 25 to 71 years and disease duration from 1 to 25 years, affected by PsA (CASPAR criteria) were observed . All patients were treated with immunomodulators (methotrexate, leflunomide, cyclosporin A), 3/5 with concomitant steroids, 4/5 with NSAID's. Only 1 patient were treated with IFX 5 mg/kg IV every 6 weeks. Before the IFX injection an amount of synovial fluid was aspired from the inflamed site and the anti-TNF injection was echographic guided. Patients were evaluated at regular intervals through clinical and echographic examination and retreated in case of flare. RESULTS: At follow-up visit after 7 days, in all patients treated with the first injection was detected total regression of the inflammation and no new inflamed synovial fluid was observed; power doppler examination shows reduction of local vascularization. Two patients experienced full remission after 6 months and only one injection, 1 patient (arthritis of the wrist) was in remission after 2 injections (3 months of interval). In 2 patients with knee arthritis and important synovial hypertrophy good results obtained after the first injection were not maintained afterwards and second injection was ineffective: these patients were evaluated for surgical intervention. CONCLUSIONS: Local injections of IFX were safe and well tolerated in all patients. The efficacy in short term was observed in all cases; our supposition is that presence of synovial hypertrophy is cause of worsening.

[Silica carcinogenicity: description of a clinical case]. / Cancerogenicità da silice: descrizione di un caso clinico.

BACKGROUND: Until the early 1980's there was a general consensus that no relationship existed between occupational silica exposure and lung cancer, in spite of a number of reports to the contrary. Confirmation arrived later from animal experiments and in 1997 the IARC modified its carcinogenic agents classification to include silica in group 1, human carcinogens. This fact brought about a change in insurance practice regarding occupational diseases due to silica, with greater attention dedicated to pneumoconiosis-related lung cancers. OBJECTIVE: To describe a clinical case of lung cancer due to occupational exposure to silica in a worker of a ceramics industry already receiving compensation for silicosis. METHODS: Diagnosis and recognition of the occupational origin of the disease were achieved via assessment of exposure to silica in the past and review of the medical examinations over the years. RESULTS: The pathogenesis and the causative relationship between pneumoconiosis and cancer is debated and lung cancer was recognized as an occupational disease. CONCLUSIONS: It is concluded that a causative relationship can exist more due to the presence of silicosis than due to occupational exposure to silica.

[Incidence of dysphonia in teaching staff of schools]. / Incidenza della disfonia nel personale docente della scuola.

Some categories of workers (actors, teachers, singers) use a particular working tool: their voice. In order to assess the spread of dysphonia and its possible causes across a specific class of workers--the teachers of some schools in the city of Catania--we have set up a ad hoc questionnaire. A special database has been subsequently arranged, aimed at the statistical analysis of the responses obtained. The analysis of the responses shows that the phenomenon is more present in female than male teachers, 48% versus 30%. The dysphonia occurs mainly at the end of the working day, lasts throughout the school year and improves in summer, demonstrating the importance of teaching activity in its pathogenesis. One aspect especially stands out: dysphonia occurs exclusively in those individuals suffering from diseases with possible alterations of the voice, such as allergopathies, tireopathies and gastropathies. Therefore, work activity alone does not seem able to cause a chronic dysphonia, whereas the presence of diseases causing disability of vocal cords appears to play an important role.

[Occupational hazards in management of an experimental constructed wetlands]. / Rischi professionali nella gestione di un impianto sperimentale di fitodepurazione.

The sewage from urban settlements is an important cause of water pollution. Recent Italian legislation offers new possibilities for intervention in the purification of wastewater. The "Decreto Legislativo" 152 of April 3, 2006, indicating "Environmental Standards", recommends the possible use of constructed wetlands considered particularly suitable for small and medium communities according to low operating costs, lack of energy, and manageability. The Authors, after describing the characteristics of these facility, analyze the occupational risks associated with the control and maintenance of a experimental subsurface constructed wetland (H-SSF, SubSurface Horizontal Flow) coming to the conclusion that the management of this type of facility has a low risk of exposure to biological agents.

[Radiation protection issues in brachytherapic treatment of prostatic cancer]. / Problematiche radioprotezionistiche nel trattamento brachiterapico del cancro della prostata.

Brachytherapy is an effective radiotherapeutic treatment for localized prostatic cancer. The permanent brachytherapy is a particular kind of radiotherapy which, US guided, uses permanently implanted seeds containing radioactive sources (Pd103 or I 125). The procedure is minimally invasive and allows to obtain high percentage of success which is comparable to surgery. The possibility to confine permanent radioactive implants in a well delimitated area doesn't exclude the exposition of both the medical staff and family's members of implanted patients. The radiation exposure involves the medical physicists, the radiotherapists, the Medical Radiology Technician, the anaesthetists, the surgeons, the professional nurses but also, after the brachytherapy treatment, public and family members, comforters and cares. It's necessary to consider radiation safety aspects of brachytherapy in order to reduce the risks of exposition. At the end, several studies showed that cremation of bodies could be a possible radiation source that remains in the patient's ashes, potentially inhaled by crematorium staff or members of the public.

Phagocytosis of apoptotic bodies by liver endothelial cells.

Using electron microscopy and cytofluorimetry we studied the role of carbohydrate-specific recognition systems in the interaction of apoptotic bodies with normal and interleukin 1-activated sinusoidal endothelial cells. Microfluorimetric observation of liver tissue sections revealed octadecylrhodamine B-labelled apoptotic body binding to the sinusoidal wall of mouse liver, when they were injected intraportally. Plate-scanning cytofluorimetry demonstrated that about 20-25% of Acridine Orange-labelled apoptotic bodies could adhere specifically to cultured endothelial cells after 15 minutes of incubation. Adhesion increased to 30% when the cells were incubated for 60 minutes. Using a mixture of galactose/N-acetylglucosamine/mannose as competition solution apoptotic body adhesion was significantly reduced especially after longer times of incubation, when the percentage of inhibition reached 50%. Following 4 hours exposure of liver endothelial cells to 1 ng/ml human recombinant interleukin-1 beta adhesion markedly increased after 60 minutes of incubation, whereas the co-incubation of interleukin-1 beta with the inhibitors brings down the adhesion to basal values obtained in controls. Electron microscopic observation of the adhesion process showed that the number of endothelial cells binding apoptotic bodies gradually increased from low to high values with time. After 60 minutes of incubation, the majority of apoptotic bodies were seen inside phagosomes and only a few remained at the cell surface. Liver endothelial cells bound and endocytosed apoptotic bodies through carbohydrate-specific receptors. Moreover, this scavenger action was interleukin-1 enhanced, thus suggesting its possible activation during inflammatory and immune processes.