[The role of occupational therapy in rehabilitating injured at work]

The evolution of social and health setting in its demographic, productive and welfare elements make work as a finalized activity oriented to different tasks, from individual indepencence to social integration. In this context, the word "re-habilitation" has a double value; on one hand consideration of lifetime acquired abilities; on the other hand recovery of residual activities, consistent with the disablement. In Italy, for years, rehabilitation activities were performed by physiotherapists, who had inadequate occupational knowledge and preferred technical skills of non-finalized function recovery. The acknowledgment of Occupational Therapist took place in the end of the '90s, so that the few organizations sensitive to Occupational Therapy, as "Fondazione Maugeri" and "Fondazione Don Gnocchi", found "prepared ad hoc" personnel only abroad, above all in Spain and Switzerland. Nowadays we have specific first degree courses, but what really obstacles the development of this field is the economic crisis which afflicts healthcare services and avoids the growth of new sectors.

Postural control in patients with total hip replacement

AIM

The aim of this study was to investigate the balance of the standing position and the motor responses by means of dynamic posturography (DP) in patients affected by hip osteoarthritis and treated by total hip replacement (THR).

METHODS

Data obtained from THR patients were compared with those of control adult groups ofage-matched subjects with normal hearing and no history of audio-vestibular symptoms. The statistical tests used were paired and unpaired Student's t-test. Significance was set for P<0.05. The study was carried out at the Department of Otorhinolaryngology and Department of Physiatrics and Rehabilitation of the A. Gemelli University Hospital of Rome (Italy). Twenty-three consecutive patients, without cochleo-vestibular or neurological pathologies (screened by accurate case-history), affected by hip osteoarthritis and treated by THR were enrolled. The main outcome measure were Sensory Organization Test (SOT), Motor control test (MCT) and Adaptation test (AT) obtained by means of Equi-Test Dynamic Posturography System by NeuroCom (Int. Inc., Clackamas, OR, USA).

RESULTS

When analysing the SOT and MCT, no statistically significant differences were observed between patients and controls. In the AT, the sway energy score decreased in the course of the test in an up and down perturbation both in healthy and in THR patients.

CONCLUSIONS

These data confirm a normal postural control and symmetrical responses in THR patients and confirm the absence of a detectable relationship between balance problems and fall risk. These results could be justified by an irrelevant role of intracapsular proprioceptors in maintaining balance. Moreover DP could be useful in osteo-articular diseases for understanding balance, evaluating surgical outcome and monitoring the rehabilitation program.

The factor structure of lifetime depressive spectrum in patients with unipolar depression

BACKGROUND

While previous attempts to elucidate the factor structure of depression tended to agree on a central focus on depressed mood, other factors were not replicated across studies. By examining data from a large number of items covering the range of depressive symptoms, the aim of the present study is to contribute to the identification of the structure of depression on a lifetime perspective.

METHODS

The study sample consisted of 598 patients with unipolar depression who were administered the Mood Spectrum Self-Report (lifetime version) in Italian (N=415) or English (N=183). In addition to classical exploratory factor analysis using tetrachoric correlation coefficients, an IRT-based factor analysis approach was adopted to analyze the data on 74 items of the instrument that explore cognitive, mood and energy/activity features associated with depression.

RESULTS

Six factors were identified, including 'Depressive Mood', 'Psychomotor Retardation', 'Suicidality', 'Drug/Illness related depression', 'Psychotic Features' and 'Neurovegetative Symptoms', accounting overall for 48.3% of the variance of items.

LIMITATIONS

Clinical information on onset of depression and duration of illness is available only for 350 subjects. Therefore, differences between sites can only be partially accounted using available data.

CONCLUSIONS

Our study confirms the central role of depressed mood, psychomotor retardation and suicidality and identifies the factors 'Drug/Illness related depression', 'Psychotic features' and the neurovegetative dysregulation not captured by the instruments most frequently used in previous studies. The identification of patients with specific profiles on multiple factors may be useful in achieving greater precision in neuroimaging studies and in informing treatment selection.

Effects of rehabilitation treatment on thyroid function

OBJECTIVE

The aim of the study was to evaluate the effects of an intensive rehabilitation programme on thyroid metabolism, the relationship between disability and thyroid hormone level, and the occurrence of nonthyroidal illness syndrome (NTIS) before and after rehabilitation.

DESIGN, SUBJECTS AND MEASUREMENTS

This was a clinical prospective study. Orthopaedic surgery patients (n = 82) were classified into two groups: patients in whom early active mobilization and walking were possible (walking group, WG, n = 45), and patients in whom these were not recommended (nonwalking group, NWG, n = 37). Levels of free T3 (fT3), fT4, TSH and rT3 were measured before and after surgery, and then at 1, 3, 7, 14 and 30 days from the beginning of rehabilitation. Personal, nutritional and clinical data were acquired for all patients. The Barthel Index (BI) was used to assess disability before and after rehabilitation.

RESULTS

Immediately after surgery, both groups of patients showed a significant decrease in mean fT3 concentrations and a significant increase in rT3; mean fT4 values decreased significantly only in NWG patients. Once rehabilitation had been completed, fT3 and rT3 levels returned to baseline values in WG patients. In NWG patients mean fT3 and fT4 levels continued to decrease significantly and rT3 values remained significantly high until the end of rehabilitation. NTIS occurred in 38% of the NWG patients. No significant changes in TSH levels were observed in either group. Finally, we observed a direct correlation between fT3 levels and the BI in WG patients.

CONCLUSIONS

Our data suggest that early patient mobilization and physical activity during an active and intensive rehabilitation programme induce recovery of thyroid function and avoid occurrence of NTIS.

Effect of pre-operative physiotherapy in patients with end-stage osteoarthritis undergoing hip arthroplasty

OBJECTIVE

To examine the effect of pre-operative physiotherapy before hip arthroplasty in patients with end-stage hip osteoarthritis.

DESIGN

A prospective randomized controlled study.

SETTING

Physical medicine and rehabilitation and orthopaedic departments of Policlinico Gemelli of Rome.

SUBJECTS

Twenty-three patients randomized in study and control groups.

INTERVENTION

The study group took part in an educational and physiotherapy programme one month before surgery. Both groups took part in the same inpatient rehabilitation programme after surgery.

MAIN OUTCOME MEASURES

Both groups were evaluated one month (T0) and the day before arthroplasty (T1), after 15 days (T2), four weeks (T3) and three months (T4) post surgery, using the Barthel Index, the Short Form-36 (SF-36), the Western Ontario and McMaster Osteoarthritis Index (WOMAC), the Hip Harris Score (HHS), visual analogue scale (VAS), the British Medical Research Council (BMRC) measures of hip abductor and quadriceps strength and range of hip abduction and external rotation.

RESULTS

There were no significant differences between groups with regard to the Barthel Index, SF-36, WOMAC and HHS at T4. The study group presented significant improvements of the SF-36 physical composite score at T1. The hip external rotation was significantly higher in the study group at each evaluation and the visual analogue scale values were lower at T1, T3 and T4.

CONCLUSION

Pre-operative physiotherapy in patients undergoing hip arthroplasty does not improve impairment and health-related quality of life after intervention. Physiotherapy and educational therapy may be useful for end-stage osteoarthritis.

Immunomodulatory effects of BXL-01-0029, a less hypercalcemic vitamin D analogue, in human cardiomyocytes and T cells

Current immunosuppressive protocols have reduced rejection occurrence in heart transplantation; nevertheless, management of heart transplant recipients is accompanied by major adverse effects, due to drug doses close to toxic range. In allograft rejection, characterized by T-helper 1 (Th1) cell-mediated response, the CXCL10-CXCR3 axis plays a pivotal role in triggering a self-promoting inflammatory loop. Indeed, CXCL10 intragraft production, required for initiation and development of graft failure, supports organ infiltration by Th1 cells. Thus, targeting the CXCL10-CXCR3 axis while avoiding generalized immunosuppression, may be of therapeutic significance. Based on preclinical evidence for immunoregulatory properties of vitamin D receptor agonists, we propose that a less hypercalcemic vitamin D analogue, BXL-01-0029, might have the potential to contribute to rejection management. We investigated the effect of BXL-01-0029 on CXCL10 secretion induced by proinflammatory stimuli, both in human isolated cardiomyocytes (Hfcm) and purified CD4+ T cells. Mycophenolic acid (MPA), the active agent of mycophenolate mofetil, was used for comparison. BXL-01-0029 inhibited IFNgamma and TNFalpha-induced CXCL10 secretion by Hfcm more potently than MPA, impairing cytokine synergy and pathways. BXL-01-0029 reduced also CXCL10 protein secretion and gene expression by CD4+ T cells. Furthermore, BXL-01-0029 did not exert any toxic effect onto both cell types, suggesting its possible use as a dose-reducing agent for conventional immunosuppressive drugs in clinical transplantation.

The structure of lifetime manic-hypomanic spectrum

BACKGROUND

The observation that bipolar disorders frequently go unrecognized has prompted the development of screening instruments designed to improve the identification of bipolarity in clinical and non-clinical samples. Starting from a lifetime approach, researchers of the Spectrum Project developed the Mood Spectrum Self-Report (MOODS-SR) that assesses threshold-level manifestations of unipolar and bipolar mood psychopathology, but also atypical symptoms, behavioral traits and temperamental features. The aim of the present study is to examine the structure of mania/hypomania using 68 items of the MOODS-SR that explore cognitive, mood and energy/activity features associated with mania/hypomania.

METHODS

A data pool of 617 patients with bipolar disorders, recruited at Pittsburgh and Pisa, Italy was used for this purpose. Classical exploratory factor analysis, based on a tetrachoric matrix, was carried out on the 68 items, followed by an Item Response Theory (IRT)-based factor analytic approach.

RESULTS

Nine factors were initially identified, that include Psychomotor Activation, Creativity, Mixed Instability, Sociability/Extraversion, Spirituality/Mysticism/Psychoticism, Mixed Irritability, Inflated Self-esteem, Euphoria, Wastefulness/Recklessness, and account overall for 56.4% of the variance of items. In a subsequent IRT-based bi-factor analysis, only five of them (Psychomotor Activation, Mixed Instability, Spirituality/Mysticism/Psychoticism, Mixed Irritability, Euphoria) were retained.

CONCLUSIONS

Our data confirm the central role of Psychomotor Activation in mania/hypomania and support the definitions of pure manic (Psychomotor Activation and Euphoria) and mixed manic (Mixed Instability and Mixed Irritability) components, bearing the opportunity to identify patients with specific profiles for a better clinical and neurobiological definition.

Application of ''Protocollo di Minima per l'ictus'' (PMIC- Minimal Protocol for Stroke) for inpatient rehabilitation setting

AIM

The aim of this study was to describe the baseline characteristics of a sample of stroke patients admitted to rehabilitation settings with the use of a standardised stroke assessment named ''Protocollo di Minima per l'ictus cerebrale'' (PMIC), to verify the usefulness of the application of PMIC and to compare the data of the authors with the international literature.

METHODS

An observational cross sectional study was conducted on a sample of 102 first-time stroke patients (mean age: 71.9 [+/-11.6], 54 men), in three inpatient rehabilitation centres.

MEASUREMENT

PMIC.

RESULTS

Most patients were enrolled within 14 days of stroke onset. PMIC assessment took on average 20 minutes and provided the following information: 35% had architectural barriers in their homes; 82% of the cases had 1 or more family assistants; the educational level was low for 53%; 72% were retired; most cases were ischemic stroke without any side predominance being shown; 44% had partial anterior circulation infarcts (PACI) ischemic stroke; 18.6% presented dysphagia; 73% had sphincteral incontinence; there was no hypertone in more than 50% of the cases; 87% required assistance; the median Motricity Index Side Score (Miss) value was 44.1; 38% was affected by mood tone alteration.

CONCLUSION

PMIC appeared to be a useful tool for a standardized evaluation of stroke patients. These results provide data with a high correspondence in international reports.

A four command BCI system based on the SSVEP protocol

This paper discusses the development of a four command BCI system. This system is composed of a wearable electroencephalogram acquisition unit interfaced to a computer by a wireless Bluetooth (BT) connection. The implemented system relies on the steady-state visual evoked potential (SSVEP) protocol applied to a four selection system. In order to achieve the maximum reliability against false positives a five class classifier was used considering the idle state as an independent class. In order to maximize the usability of the system a two channel solution was tested and adopted. The BCI algorithm was based on a supervised multi-class classifier implemented by combining different binary regularized linear discriminant analysis (RLDA) classifiers. The biofeedback was evaluated by combining the resultant time signed distance with quality index related to the number of coherent identification obtained with the one-vs-all approach.

Home mechanical ventilation patients: a retrospective survey to identify level of burden in real life

BACKGROUND AND AIM

Home care for patients under home mechanical ventilation (HMV) may cause dramatic physical and economic burden in addition to the burden of time on family/caregivers and health care service (HCS) with difficult resource allocation decision-making. Our aims were: 1. To identify conditions causing major care burden in managing HMV patients according to family and payer's perspectives related to characteristics of the disease, dependency and accessibility; and 2. To find, if any, differences among diseases.

METHODS

A questionnaire was sent to eight pulmonary centres to identify factors connected with the greater care burden. Retrospective data of 792 patients still alive and in HMV was reviewed.

RESULTS

Compared to neuromuscular disorders (NM) and chest wall deformities, the COPD group have presented a statistically greater number of hospitalisations/yr (1.37 +/- 0.77), greater length of stay (13 +/- 10 days), higher number of outpatient visits/yr (2.55 +/- 1.73) or emergency room accesses/yr (0.74 +/- 1.08). Patients with NM diseases need more home care. The prevalence of one, two and three among five selected burden criteria (needs of MV > 12 hrs/day, tracheotomy, high dependency, distance from hospital, frequent hospitalisations) was respectively 19%, 30% and 33% of the cases; the NM was the group most represented.

CONCLUSIONS

In HMV patients: 1. underlying disease, level of their dependency, hours spent under MV, presence of tracheotomy, home distance from hospital, hospital accesses are the causes of major care burden; and 2. as a novelty we have demonstrated that more than fifty percent of them present two or three contemporaneous criteria selected as care burden, being NM and COPD patients the most representative group necessitating of family's and HCS's care respectively.

An automated method for relevant frequency bands identification based on genetic algorithms and dedicated to the Motor Imagery BCI protocol

This paper presents an automated method for relevant frequency bands identification to be used in a left/right hand motor imagery based Brain Computer Interface system. The adopted optimization method aimed at maximizing the ratio between the mutual information and the error rate obtained using a Regularized Linear Discriminant Analysis (RLDA) based classifier and band-specific amplitude modulated envelopes as features. The search problem was handled by a genetic algorithm starting from an initial population determined on the basis of a-priori mu and beta relevant frequency bands identified by means of a standard power spectral density analysis between the idle and the left/right imagery data subset.

Assessment and correlation between clinical patterns, disability and health-related quality of life in patients with low back pain

AIM

Low back pain (LBP) is the main symptom of most lumbar spine diseases. This symptom, due to physical, psychological and social factors, is correlated to a real disability which can affect the quality of life (QoL.) The aim of this study is to evaluate the QoL and the disability in patients with LBP and to correlate them to clinical patterns.

METHODS

In this prospective multidimensional study, 108 patients underwent the following protocol: 1. collection of patient-oriented and disability data with the use of SF-36 and North American Spine Society (NASS); 2. collection of clinical, anamnestic and instrumental data (MRI, CT) with the use of DOVAC files; 3. assessment of disability with the use of Barthel index (BI) and deambulation index (DI).

RESULTS

A significant correlation was found between the BI and the physical composite score (PCS), but no significant correlation was noticed between BI and the mental composite score (MCS). DI was not correlated to the SF-36. A positive Lasegue and the absence of the osteo-tendinous reflexes are significantly correlated to the disability and QoL.

CONCLUSIONS

This study shows that there is no simple, linear correlation between QoL and disability.

Matrices containing NaCMC and HPMC

The aim of the present study is an investigation of the swelling behaviour of matrix systems containing a mixture of hydroxypropylmethylcellulose (HPMC) and sodium carboxymethylcellulose (NaCMC) with a model soluble drug to find the correlation between the morphological behaviour and the drug release performance. The swelling study was conducted on tablets containing only the drug and the two polymers mixture (MB) and on reference tablets containing each polymer and the same drug, at three different pHs. MB matrices show a similar swelling trend at pH 4.5 and 6.8, while they have different behaviour in acidic fluid. At pH 1 the gel layer formed by NaCMC is characterized by a rigid structure of a partially chemically crosslinked hydrogel while HPMC and MB matrices form a physical not crosslinked gel. At pH 4.5 and 6.8, all the systems show the typical morphological behaviour of a swellable matrix in which the macromolecular chains in the gel network are held together by weak bondings (physical gel). In these buffers, MB systems maintain a constant drug release rate coupling diffusion and erosion mechanism: the gel and infiltrated layers thicknesses are maintained constant and a zero-order release kinetics can be achieved.

Matrices containing NaCMC and HPMC 1. Dissolution performance characterization

In this study hydroxypropylmethylcellulose (HPMC) and sodium carboxymethylcellulose (NaCMC) were used as polymeric carriers to improve controlled release performances of matrix tablets containing a soluble drug. The drug release behaviour of the systems containing these two polymers mixture and each material separately was investigated. To evaluate the effect of the dissolution medium pH, on the drug release performance, release tests were conducted at pH 1, 4.5 and 6.8. In vitro release studies demonstrated that the mixture of the two cellulose derivatives enables a better control of the drug release profiles at pH 4.5 and at 6.8 both in term of rate and mechanism. Texture analysis on the swollen tablets helps to understand drug release kinetic and mechanism. In fact, the results obtained confirm that a gel, which is characterized by high strength and consistence is less susceptible to erosion and chains disentanglement and the drug release mechanism is mainly governed by diffusion. On the contrary, gels, which show a low strength and texture, have low resistance to the fluid erosion action and the release of the active molecule is manly due to polymer relaxation and chains disentanglement moving the drug delivery kinetic towards an erosion/relaxation mechanism.

Sublingual immunotherapy with Dermatophagoides monomeric allergoid down-regulates allergen-specific immunoglobulin E and increases both interferon-gamma- and interleukin-10-production

BACKGROUND

The clinical efficacy and safety of sublingual immunotherapy (SLIT) for aeroallergens has been demonstrated in several trials, whereas the immunological changes induced by this treatment, which may account for the clinical improvement, are still unclear.

OBJECTIVE

To investigate the effects of a successful SLIT on the in vitro allergen-driven T cell response and cytokine secretion as well as on the serum levels of chemokines and of IgE, IgG1 and IgG4 antibodies (Abs).

MATERIALS AND METHODS

Twenty-five Dermatophagoides pteronyssinus (Dp)-sensitive patients with perennial rhinitic and/or rhinitic and asthmatic symptoms were randomized into two groups (13 untreated (UT) and 12 SLIT-treated) for a 1 year and half study. The proliferative response of peripheral blood mononuclear cell (PBMC) to purified Der p1 allergen, their cytokines (IFN-gamma, IL-4, IL-10 and TGF-beta) production and serum levels of chemokines associated with T helper type 1 (Th1) (CXCL10) or T helper type 2 (Th2) (CCL22) responses and of Dp-specific IgE, IgG1 and IgG4 Abs were evaluated before and after 6 months of treatment.

RESULTS

SLIT induced a significant reduction of symptom medication scores after 6, 12 and 18 months of treatment in comparison with UT patients. SLIT-treated patients showed a significant decrease in serum levels of DP-specific IgE Abs, whereas total IgE, and specific IgG1 and IgG4 Abs remained unchanged. The proliferative response of allergen-specific T cells to Der p1 in vitro after 6 months of treatment was reduced, while no effect was observed on T cell proliferation to recall antigen (streptokinase). Moreover, Der p1-driven IFN-gamma and IL-10 were significantly increased in culture supernatants of PBMC from 6 month-treated patients in comparison with those detected at the beginning of therapy.

CONCLUSIONS

These data suggest that the allergen-driven enhancement of IL-10- and IFN-gamma-producing T cells precedes and associates with SLIT-induced down-regulation of specific IgE, thus providing a rationale to explain the clinical benefit of SLIT in allergic patients.

[A particular case of hard metal disease]

BACKGROUND

The production and the use of hard metal tools have becoming increasingly widespread since the second half of the last century also thanks to the great variety of applications that extends from DIY to the aeronautical industry. It has already been known for many years that occupational exposure to hard metals dusts (which occurs especially in people employed in production of the metals or in the sharpening of tools that contain them) can determine the onset of pulmonary fibrosis, bronchial asthma and contact dermatitis.

OBJECTIVES

clinical evaluation of a peculiar case of hard metal disease. Descriptions of cases with single pathological pictures due to hard metals, are, in fact, common in the literature, neither are cases with two different clinical pictures (more frequently asthma and pulmonary fibrosis) rare. However, cases in which all the signs and symptoms appeared simultaneously have never been reported.

METHODS

a male worker aged 41 years, employed i a hard metal factory for seven years in sintering, and then in grinding. A year later he developed dry cough, wheeze, and eczematous patches. The diagnosis of hard metal disease was based on the work-related symptoms, clinical evaluation, spirometry, chest x-ray, HRCT and patch tests.

RESULTS

during the working period, ventilatory function decreased substantially, and then normalized one month after the patient stopped working. Patch tests confirmed sensitivity to cobalt, and skin lesions improved, as did ventilatory function. Chest x-ray and HRCT showed a pulmonary fibrosis that, at the last radiological examination, was still unchanged.

CONCLUSIONS

The particular susceptibility to the development of the diseases, could, in our opinion, be in relationship with the race of the subject, many studies (particularly American) have shown that allergic diseases are more frequent, and often more serious, in African subjects, particularly in immigrants from Africa. In the case of occupational diseases attention also needs to be given to the fact that immigrants are often employed in duties that involve a greater exposure to harmful or sensitizing agents. The occurrence of a whole series of occupational allergic diseases among these workers is therefore to be expected.

Multivesicular release at developing Schaffer collateral-CA1 synapses: an analytic approach to describe experimental data

We developed and analytically solved a simple and general stochastic model to distinguish the univesicular from the multivesicular mode of glutamate release. The model solution gives analytical mathematical expressions for average values of quantities that can be measured experimentally. Comparison of these quantities with the experimental measures allows one to discriminate the release mode and to determine the most probable values of model parameters. The model has been validated at glutamatergic CA3-CA1 synapses in the hippocampus from newborn (P1-P5 old) rats. Our results strongly support a multivesicular type of release process requiring a variable pool of immediately releasable vesicles. Moreover, computing quantities that are functions of the model parameters, the mean amplitude of the synaptic response to the release of a single vesicle (q) was estimated to be 5-10 pA, in very good agreement with experimental findings. In addition a multivesicular type of release was supported by the following experimental evidences: 1) a high variability of the amplitude of successes, with a coefficient of variation ranging from 0.12 to 0.73; 2) an average potency ratio a2/a1 between the second and first response to a pair of stimuli >1; and 3) changes in the potency of the synaptic response to the first stimulus when the release probability was modified by increasing or decreasing the extracellular calcium concentration. Our results indicate that at Schaffer collateral-CA1 synapses of the neonatal rat hippocampus a single action potential may induce the release of more than one vesicle from the same release site.

A wearable device for continuous monitoring of heart mechanical function based on impedance cardiography

In this study we explored the possibility to realize a low power device for Cardiac Output continuous monitoring based on impedance cardiography technique. We assessed the possibility to develop a system able to record data allow an intra-subjective analysis based on the daily variations of this measure. The device was able to acquire and to send signals using a wireless Bluetooth transmission. The electronic circuit was designed in order to minimize power consumption, dimension and weight. The reported results were interesting for what concerns the power consumption and then noise level. In this way was obtained a wearable device that will permit to define specific clinical protocols based on continuous monitoring of the Cardiac Output signal.