Flumazenil therapy for a gabapentin-induced coma: a case report

Background

Spasticity and neuropathic pain are common in patients after spinal cord injury and negatively affect patients’ quality of life. Gabapentin and baclofen are frequently used to treat these conditions. We present a flumazenil-reversed gabapentin-induced coma case, which, to our knowledge, is the second one described in scientific literature.

Case presentation

A 70-year-old Caucasian man was admitted to our neurorehabilitation ward following a fall with cervical trauma that resulted in immediate tetraplegia. During his stay, he suffered from lower limb pain, both neuropathic and due to severe spasticity. Gradual baclofen and gabapentin administration was prescribed, with reduction in both pain and spasticity. One morning, the patient was found unresponsive, with a Glasgow Coma Score of 3. Head computerized tomography, electrocardiogram, electroencephalogram, vital signs, blood tests, breathing, and blood oxygenation were normal. Renal and liver failure were ruled out. Intravenous 0.25 mg of flumazenil (Anexate) was administered, resulting in complete neurocognitive recovery with a Glasgow Coma Score of 15.

Discussion and conclusions

This case report highlights the importance of the individual response to certain pharmacological agents and suggests that further studies need to be conducted both on flumazenil and gabapentin pharmacodynamics to better understand their molecular–receptor activity, and on possible multiple flumazenil mechanisms of action, beyond its classical strict benzodiazepine antagonist action.

Mass screening for hepatitis B and C viruses in a population of persons with disabilities with and without HIV status in Cameroon

Hepatitis viral infections are one of major threat to public health worldwide. The vast majority of people infected with viral hepatitis are found in resources limited countries of Africa and Asia. There is a lack of accurate data to better determine the burden of this disease in Cameroon, moreover among vulnerable people. The aim of this study was to estimate the seroprevalence of HBV and HCV viruses among persons with disabilities (PwD) with or without HIV status.

Role of Cachexia and Fragility in the Patient Candidate for Cardiac Surgery

Frailty is the major expression of accelerated aging and describes a decreased resistance to stressors, and consequently an increased vulnerability to additional diseases in elderly people. The vascular aging related to frail phenotype reflects the high susceptibility for cardiovascular diseases and negative postoperative outcomes after cardiac surgery. Sarcopenia can be considered a biological substrate of physical frailty. Malnutrition and physical inactivity play a key role in the pathogenesis of sarcopenia. We searched on Medline (PubMed) and Scopus for relevant literature published over the last 10 years and analyzed the strong correlation between frailty, sarcopenia and cardiovascular diseases in elderly patient. In our opinion, a right food intake and moderate intensity resistance exercise are mandatory in order to better prepare patients undergoing cardiac operation.

Dupilumab therapy of atopic dermatitis of the elderly: a multicentre, real-life study

BACKGROUND

Treatment of moderate-to-severe atopic dermatitis (AD) in the elderly may be challenging, due to side-effects of traditional anti-inflammatory drugs and to comorbidities often found in this age group. Furthermore, efficacy and safety of innovative drugs such as dupilumab are not yet well known.

OBJECTIVES

A multicentre retrospective, observational, real-life study on the efficacy and safety of dupilumab was conducted in a group of patients aged ≥65 years and affected by severe AD. Their main clinical features were also examined.

METHODS

Data of elderly patients with severe (EASI ≥24) AD treated with dupilumab at label dosage for 16 weeks were retrospectively collected. Treatment outcome was assessed by comparing objective (EASI) and subjective (P-NRS, S-NRS and DLQI) scores at baseline and after 16 weeks of treatment.

RESULTS

Two hundred and seventy-six patients were enrolled in the study. They represented 11.37% of all patients with severe AD. Flexural eczema was the most frequent clinical phenotype, followed by prurigo nodularis. The coexistence of more than one phenotype was found in 63/276 (22.82%) subjects. Data on the 16-week treatment with dupilumab were available for 253 (91.67%) patients. Efficacy of dupilumab was demonstrated by a significant reduction of all the scores. No statistically significant difference regarding efficacy was found in elderly patients when compared to the group of our AD patients aged 18-64 years, treated with dupilumab over the same period. Furthermore, only 18 (6.52%) patients discontinued the drug due to inefficacy. Sixty-one (22.51%) patients reported adverse events, conjunctivitis and flushing being the most frequent. One (0.36%) patient only discontinued dupilumab due to an adverse event.

CONCLUSIONS

Therapy with dupilumab led to a significant improvement of AD over a 16-week treatment period, with a good safety profile. Therefore, dupilumab could be considered as an efficacious and safe treatment for AD also in the elderly.

Early balance training with a computerized stabilometric platform in persons with mild hemiparesis in subacute stroke phase: A randomized controlled pilot study

BACKGROUND

Along with conventional therapy, novel tools are being developed in balance training for the rehabilitation of persons with stroke sequelae. The efficacy of Computerized Balance Training thus far been the object of studies only in persons with chronic stroke.

OBJECTIVE

To investigate the effects of an early Computerized Balance Training on balance, walking endurance and independence in activities of daily living, in persons with mild hemiparesis in subacute phase.

METHODS

Thirty-two persons with a recent hemiparesis (within 4 weeks from stroke onset), able to maintain a standing position for at least 30 seconds, were randomly assigned to an experimental or control group. The control group (CG) were administered conventional physiotherapy of 40 minutes twice a day, 5 times a week for 4 weeks, while the experimental group (EG) underwent conventional physiotherapy 40 minutes once a day and Computerized Balance Training once a day, 5 times a week for 4 weeks. Outcomes were evaluated by means of Berg Balance Scale (BBS), Tinetti Balance Scale (TBS), Two Minutes Walk Test (2MWT), Barthel Index (BI) and stabilometric tests.

RESULTS

Twelve participants for each group completed the training. Each group experienced 8 dropouts. The mean age (years) was 58.1±20.4 for EG and 59.7±14,7 for CG; the days from stroke were respectively 27.9±15.5 and 20±11.7. The difference between the two groups was statistically significant in experimental group for BBS (p = 0.003), for TBS (p = 0.028), for Sensory Integration and Balance tests performed with closed eyes on steady (p = 0.009) or instable surface (p = 0.023). and for 2MWT (p = 0.008).

CONCLUSIONS

Computerized Balance Training is an effective therapeutic tool for balance and gait endurance improvement in persons with stroke in subacute phase.

The Technique of Intradiscal Injection: A Narrative Review

Background

Low back pain (LBP) is one of the most common spine diseases and represents the most frequent cause of absence from work in developed countries. Approximately 40% of chronic LBP is related to discogenic origin. The goal of the study is producing a review of literature to describe analytically the techniques of intradiscal injections.

Methods

PubMed database was searched for clinical studies with the different key terms: “intradiscal”, “injection”, “steroid” “procedures”, “techniques”, “CT”, “MRI”, “fluoroscopy”, “fluoroscopic”, “guidance”, “ozone”, “ultrasound”, “images”. Only studies written in English, French, or Italian in which the intradiscal injection represents the main procedure for the low back discopathy treatment on humans were considered. We excluded the articles that do not mention this procedure; those which indicated that the intradiscal injection had happened accidentally during other treatments; those reporting the patient’s pain was determined by other causes than the discopathy (facet joint syndrome, tumor, spondylodiscitis).

Results

Thirty-one articles dated from 1969 to 2018 met the criteria. The examined population was 6843 subjects, 52.3% male and 47.7% female, with a mean age of 45.9±10.1 years. The techniques are highly variable in terms of procedure: different operators, needle guidance, injection sites, drugs, tilt angle of the needle).

Conclusion

The efficacy and the safety of the intradiscal procedures are not easily comparable due to different types of studies and their limited number. Further studies are needed to standardize the intradiscal injection technique/procedure to improve safety, repeatability and effectiveness, and last but not least to reduce peri- and postoperative care and health-care costs.

The effectiveness of telerehabilitation after hip or knee arthroplasty: a narrative review

Telerehabilitation is defined as a set of tools, procedures, and protocols to deliver rehabilitation programs remotely. It involves the use of various communication technologies to efficiently provide rehabilitation services distantly or via some other remote environment. After an orthopedic procedure, physical rehabilitation is essential to restore joint's function, to improve quality of life as well as to relieve pain, to recovery independence. The effectiveness of telerehabilitation has been studied in literature. The aim of this narrative review is to update the current evidence, evaluate the efficacy of telerehabilitation after hip, and knee prosthesis surgery for end stage arthrosis. Results show that it is useful to integrate traditional interventions with telerehabilitation to accelerate efficiency in existing healthcare delivery systems. Future high-methodological-quality studies should be conducted to evaluate the long-term efficacy and safety of innovative technologies.

Use of wearable systems for the detection of chest-abdominal wall movement aimed at respiratory monitoring in sport: a scoping review on available data

There is a significant request for wearable systems for vital signs and athletic performance monitoring during sport practice, both in professional and non-professional fields. Respiratory rate is a rather neglected parameter in this field, but several studies show that it is a strong marker of physical exertion. The aim of the present scoping review is to evaluate the number and kind of existing studies on wearable technologies for the analysis of the chest wall movement for respiratory monitoring in sport and fitness. The review included studies investigating the use of contact-based wearable techniques for the detection of chest wall movement for respiratory monitoring during professional or amateur sport, during fitness and physical activity. The search was conducted on PubMed/Medline, Scopus and Google Scholar electronic databases using keywords. Data extracted were entered into a Microsoft Excel spreadsheet by the leading author and then double-checked by the second author. A total of 25 descriptive studies met the inclusion criteria. Few studies on small number of athletes were found, technologies were often evaluated without a reference system, data on participants are sometimes missing. To date, we are not able to draw conclusions on which is the best and most reliable device to use during sport practice.

Robotic hand treatment of patients affected by chronic stroke: a monocentric longitudinal pilot study

Few studies investigated the effects of a robotic treatment in hand motor recovery after stroke. Aim of the present study was to evaluate the efficacy of treatment by means of Gloreha Sinfonia® robotic glove in hand motor recovery of a chronic stroke sample of patients with different impairment severity. Thirteen chronic stroke subjects were assigned to either active-assisted robotic treatment or passive robotic treatment according to their ability to actively extend wrist for at least 20 degrees. All subjects underwent 20 sessions of treatment with Gloreha Sinfonia® and were evaluated before (T0), after treatment (T1) and after one month (T2) with clinical scales testing motor performance [Motor Power (MP); Fugl Meyer Upper-Extremity (FMUE)] and spasticity [Modified Ashworth Scale (MAS)]. Both groups showed significant motor recovery and spasticity reduction. Further randomized controlled trials with larger samples are needed to confirm our results.

Use of Dupilumab for 543 Adult Patients with Moderate-To-Severe Atopic Dermatitis: A Multicenter, Retrospective Study

BACKGROUND

Dupilumab has been demonstrated to be an effective treatment for patients with moderate-to-severe atopic dermatitis (AD) in clinical trials. However, evidence of real-world experience with dupilumab in a broader population is limited to date.

METHODS

Adult patients with moderate-to-severe AD, defined as an Eczema Area Severity Index (EASI) score of 24 or higher, treated with dupilumab at ten Italian academic centers, were included in the study. Physician-reported outcome measures (EASI), patient-reported outcome measures (pruritus and sleep score, Dermatology Life Quality Index, DLQI) and serological markers [immunoglobulin (Ig) E and eosinophil count] after 16 weeks were analyzed.

RESULTS

We enrolled 543 patients with moderate-to-severe AD. Two patients (0.4%) discontinued treatment. The median ± interquartile percentage change from baseline to 16 weeks of treatment in the EASI score was -87.5±22.0 (p<0.001). EASI-50, EASI-75 and EASI-90 response rates were 98.1%, 81.5%, and 50.8% after 16 weeks. At 16 weeks, 93.0% of the patients had achieved a 4- point or higher improvement in DLQI from baseline. During dupilumab treatment, 12.2% of the patients developed conjunctivitis, and total IgE significantly decreased (p<0.001). Interestingly, in the multivariate logistic regression model, the risk of developing dupilumab-related conjunctivitis was associated with early AD onset [OR, 2.25; 95%CI, 1.07-4.70; p=0.03] and presence of eosinophilia [OR, 1.91; 95%CI, 1.05-3.39; p=0.03].

CONCLUSION

To date, this is the broadest real-life study in AD patients treated with dupilumab. We observed significant improvements induced by dupilumab in adult patients with moderate-to-severe AD, to a greater extent than those reported in clinical trials.

Radial extracorporeal shock wave therapy: a novel approach for the treatment of Dupuytren's contractures: A case report

INTRODUCTION

While the efficacy of focused Extracorporeal Shock Wave Therapy (ESWT) in the treatment of Dupuytren's disease (DD) is supported by one positive trial, the effects of radial ESWT is unclear.

PATIENT CONCERNS

A 79-year-old man with a 4-year history of impairment of left-hand function and pain due to DD with weakness and flexion deformities of middle and ring fingers. He has not been treated before for this impairment.

DIAGNOSIS

The diagnosis of DD was based on clinical features and ultrasound images.

INTERVENTIONS

Four weekly sessions of radial ESWT with 1400 impulses 3 bar each, 12 Hz.

OUTCOMES

The limitations in activities of daily living were analyzed through the Disabilities of Arm Shoulder and Hand Questionnaire (DASH) and Michigan Hand Outcome Questionnaire (MHQ) at baseline, after four sessions of radial ESWT and at 4-months follow-up. Data analysis showed a significant reduction of hand deformities and an improvement of daily living performance. The effects continued at the 4-months follow-up.

CONCLUSION

This case report demonstrates the feasibility of radial ESWT. Radial ESWT sessions may be carried out by a physiotherapist in outpatient clinics with cost reduction compared with surgical treatment and focused ESWT. Radial ESWT is a non-invasive, well tolerated therapy, so it should be considered in the DD treatment.

A Literature Review of the Quality of Life, Health Status and Prosthesis Satisfaction in Older Patients With A Trans-tibial Amputation

BACKGROUND

Several reviews have been published regarding quality of life (QoL) and Health Status (HS) in persons with lower limb amputation (LLA). However, little has been discussed in the literature with respect to older populations (i.e. age>60 years) with trans-tibial amputation. Furthermore, the perceived satisfaction with prosthesis is another important aspect for consideration in the amputees' life.

OBJECTIVE

The purpose of this review was to evaluate the impact of trans-tibial amputation on the QoL, HS and prosthesis satisfaction, in order to determine the appropriate intervention to improve these aspects in older population of trans-tibial amputees (TTA).

METHODS

Research articles, published between January 2000 to March 2019, were found using Scopus, PubMed and Google Scholar databases. The methodological quality of the selected articles was assessed using the Critical Review Form-Quantitative Studies checklist.

RESULTS

Ten articles that met the inclusion criteria were selected. In these papers, we can summarize that people with trans-tibial amputation have a better QoL compared to those with above knee amputation. Moreover, physical functioning and mobility are the most influencing factors for QoL and HS in older people with lower limb amputation. Finally, the prosthesis weight reduction may improve satisfaction with the prosthetic limb.

CONCLUSION

Efforts have to be made in order to improve mobility in older population with transtibial amputation for better QoL and HS. This can be accomplished by means of adequate rehabilitation, pain management and an accurate choice of appropriate prosthetic components. We observed that the quality of evidence in the literature available is inadequate and future research would benefit from more prospective observational cohort studies with appropriate inclusion criteria and larger sample sizes to better understand the QoL and HS in this population.

Assistive products and childhood neurodisability: a retrospective study on factors associated with aids/orthoses prescription

BACKGROUND

Children affected by pathologies causing neurodisability go through motor, cognitive, sensory and other limitations. The selection of assistive products can influence their level of independence and quality of life.

AIM

The present study investigated the possibility to assess the equipment needs of children with neurodisabilities, based on their clinical characteristics.

DESIGN

A retrospective observational study.

SETTING

Outpatients.

POPULATION

Inclusion criteria: diagnosis of cerebral palsy or genetic/chromosomal/syndromic disorders, age range 0-18 years, intelligence quotient evaluation, medical history of positive or negative presence of epilepsy and of communication disorders, admission at our neurorehabilitation service between 2007 and 2017, and registration of all equipment prescribed to each child.

METHODS

In 192 children (111 males, 57.81%) we evaluated the relationship between several independent variables (diagnosis, sex, Gross Motor Function Classification System level, intelligence quotient, history of epilepsy and communication disorders) and equipment prescription by means of logistic regression models.

RESULTS

Our data showed significant correlation between the Gross Motor Function Classification System level and the equipment prescribed. A history of seizures was negatively correlated with walker prescriptions (the log odds of prescription decreases by -2.156; CI: -4.16 to -0.65) and positively with those of stroller (the log odds increases by 1.427; CI: 0.22 to 2.69). Stroller and knee-ankle-foot orthoses and hip-knee-ankle-foot orthoses prescriptions were negatively correlated with the cerebral palsy diagnosis. The prescription of foot orthoses was positively correlated with mental retardation (the log odds increases by 0.358; CI: 0.12 to 0.61). A negative correlation between communication disorders and the prescription of ankle-foot orthoses and communication/learning devices was also found (the log odds decreases by -0.833; CI -1.66 to -0.01).

CONCLUSIONS

Several clinical characteristics correlate with specific equipment needs.

CLINICAL REHABILITATION IMPACT

The definition of the clinical characteristics with a potential predicting value, may facilitate the task of physician on choosing what is more appropriate to prescribe, as well as the authorizing office responsible for evaluating the appropriateness of prescriptions. Furthermore, it could be possible to foresee the care needs in terms of type and number of aids/orthoses and to guarantee every disabled child the possibility to take advantage of the same opportunities.

Morphological and morphometric analysis of cutaneous squamous cell carcinoma in patients with recessive dystrophic epidermolysis bullosa: a retrospective study

BACKGROUND

Recessive dystrophic epidermolysis bullosa is a highly disabling genodermatosis characterized by skin and mucosal fragility and blistering. Cutaneous squamous cell carcinoma (cSCC) is one of the most devastating complications, having a high morbidity and mortality rate. Patients with recessive dystrophic epidermolysis bullosa were reported to have up to a 70-fold higher risk of developing cSCC than unaffected individuals. Immune cells play a role in cancer evolution.

OBJECTIVE

The aim of our study was to evaluate immunohistological differences between cSCC in patients with and without recessive dystrophic epidermolysis bullosa.

METHODS

A retrospective study of 25 consecutive cases was performed; five were biopsies of cSCC taken from five patients with recessive dystrophic epidermolysis bullosa; as controls we analysed 10 cSCC in subjects without recessive dystrophic epidermolysis bullosa (5 primitive, 3 postburns and 2 postradiotherapy), 5 cSCC in renal transplant recipients and 5 cutaneous pseudoepitheliomatous hyperplasia in patients with recessive dystrophic epidermolysis bullosa.

RESULTS

A significant reduction of CD3+, CD4+ and CD68+ between the cSCC in patients with recessive dystrophic epidermolysis bullosa compared to primary cSCC and a significant reduction of CD3+, CD4+, CD8+ and CD20+ were observed in cSCC in patients with recessive dystrophic epidermolysis bullosa compared to secondary cSCC. On the contrary, there was no difference in CD3+, CD8+, CD20+ and CD68+ expression when comparing cSCC in patients with recessive dystrophic epidermolysis bullosa to cSCC in renal transplant recipients. No significant difference was found in size, histopathology, grading, number of mitoses and EGFR expression between the different groups.

CONCLUSIONS

Our data show a reduction in immune cell peritumoral infiltration. Considering the well-known evolution of cSCC in patients with recessive dystrophic epidermolysis bullosa, as well as the younger age at diagnosis, it can be assumed that immune dysfunction might contribute to the cSCC aggressiveness in these patients.

Efficacy of a Single Intra-Articular HYMOVIS ONE Injection for Managing Symptomatic Hip Osteoarthritis: A 12-Month Follow-Up Retrospective Analysis of the ANTIAGE Register Data

Purpose

The use of ultrasound (US) guidance has allowed hip osteoarthritis to be treated with intra-articular (IA) injections. HYMOVIS ONE (HYADD4-G) is a new hyaluronic acid (HA) derivative product with unusual characteristics, and it has been used with good results in knee osteoarthritis (OA). This study assessed the efficacy and safety of a single HYMOVIS ONE injection in patients affected by symptomatic hip OA.

Patients and Methods

This post-marketing cohort study assessed data from the ANTIAGE Register. Inclusion criteria were age ≥40 years, symptomatic hip OA (Kellgren-Lawrence grade I-III) of ≥1-year duration, and ≥12 months follow-up. All patients received a single HYMOVIS ONE (32 mg/4 mL) injection at baseline. Values for 10-cm visual analogue scale (VAS) pain scores, the Lequesne index, and nonsteroidal anti-inflammatory drug (NSAID) consumption were evaluated at 6 and 12 months. Adverse events were also recorded.

Results

The included patients (n = 198) consisted of 42.5% women, with a mean (± SD) age at baseline of 62 (± 14.2) years and a mean (± SD) body mass index of 26.3 (± 2.5). The mean (SD) Lequesne index and VAS pain scores at baseline were 11.5 (± 4.6) and 6.4 cm (± 2.2), respectively. All groups exhibited statistically significant reductions at all time points compared to baseline. At 12 months, the VAS pain score was reduced by 17.2%, the Lequesne index by 33.7%, and NSAID consumption by 41.7%.

Conclusion

Our study supports the clinical efficacy and safety of a single HYMOVIS ONE injection for managing symptoms in patients with hip OA, confirming previous data on the use of HYMOVIS as a background therapy in the management of knee osteoarthritis.