Nursing home case-mix instruments: validation of the RUG-III system in Italy

BACKGROUND AND AIMS

The current Italian reimbursement system for long-term care does not adequately consider the great variability in the health and functional status of older persons who are admitted to long-term care institutions. Furthermore, no procedure is implemented to monitor the quality of care provided to older residents. We conducted this study to verify whether the RUG-III (Resource Utilization Groups-version III), a tool for assessing the case-mix of nursing home residents, which is widely used in the United States and in many European countries, can be effectively used in the Italian health care system.

METHODS

We administered an Italian version of the RUG-III to 1000 older residents of 11 intermediate- and long-term care institutions. We also collected objective information on the amount of care provided directly or indirectly to each resident by nurses, physical therapists, and other health professionals.

RESULTS

The RUG-III 44 group classification system explained 61 and 44% of the variance in rehabilitative and nursing wage-adjusted care time, respectively.

CONCLUSIONS

Our findings provide strong evidence that the RUG-III classification, applied to Italian intermediate- and long-term care institutions, provides a robust estimate of the amount of nursing and rehabilitation resources consumed by older residents.

Serum levels of interleukin-18 and s-ICAM-1 in patients affected by psoriasis: preliminary considerations

OBJECTIVE

To find new aspects of the systemic involvement of the Immune System in psoriasis, we determined serum levels of interleukin-18 (IL-18) (Th1-inducing factor cytokine), CD30 (Th2 marker) and sICAM-1 (adhesion molecule). In addition we evaluated the correlation between these molecules and psoriasis area and severity index (PASI).

BACKGROUND

Psoriasis is associated to an overexpression of Th1 cytokines and a relative underexpression of Th2 cytokines. IL-18 plays an important role in inducing Th1 response because it is a potent inductor of synthesis of IFN-gamma, TNF and other mediators. The two major sources of IL-18 are monocytes and macrophages but also human keratinocytes constitutively synthesized IL-18.

SUBJECTS AND METHODS

We selected two groups of subjects: 16 healthy donors (HD) and 16 patients affected by psoriasis, matched for sex and age. Serum IL-18, CD30 and sICAM-1 levels were assayed by immunoenzymatic method with commercial kits.

RESULTS

IL-18 and sICAM-1 levels in the patients were significantly higher than in the HDs (385.94 +/- 193.89 vs. 227.38 +/- 92.76 pg/mL, P = 0.005 and 445.00 +/- 152.67 vs. 317.88 +/- 107.20 ng/mL, P = 0.02, respectively). On the contrary, no significant difference was found between serum sCD30 levels of patients in respect to those of HDs. A significant correlation was found between serum IL-18 and PASI (Rho = 0.695, P = 0.0071), serum IL-18 and sICAM-1 (Rho = 0.543, P = 0.0356) and between sICAM-1 and PASI (Rho = 0.659, P = 0.0107).

Involvement of interleukin-18 in patients on maintenance haemodialysis

Maintenance dialysis induces a clinical state of immunodeficiency. The pathway of circulating T cells from haemodialyzed patients is changed and characterized by an increase of Th1 cells. The unbalanced T helper differentiation derives from an altered regulation of interleukin-12 (IL-12), which represents an important inducer of Th1. IL-18 is a pro-inflammatory cytokine expressed by a variety of cell types that is structurally related to the Th1 family and shares biological properties with IL-12 as the promotion of Th1 responses. To explain the involvement of IL-18 in the typical disorders of dialysis, we analyzed IL-18 serum levels in a group of haemodialyzed patients. We enrolled 16 patients on chronic haemodialysis (HD) treatment for end-stage renal failure and 16 healthy volunteers as the control group. IL-18 levels were assessed by immunoenzymatic methods (detection limit was <12.5 pg/ml). HD patients strongly showed higher IL-18 serum levels compared to healthy donors (508.47 +/- 314.39 vs. 193.44 +/- 56.33 pg/ml, p < 0.005). Moreover, IL-18 levels in HD directly correlated to dialytic age (Rho = 0.544, p = 0.0419) and indirectly to Kt/V (Rho = 0.703, p = 0.0086). Our data represent the first evidence of the relation between IL-18 serum levels and HD. In the light of our results, we think that the unbalanced T helper differentiation may depend, at least in part, on an abnormality in the IL-18 production.

Prevention of new sensitizations in monosensitized subjects submitted to specific immunotherapy or not. A retrospective study

BACKGROUND

Specific immunotherapy is the only currently available allergen-orientated treatment able to modify the natural history of respiratory allergic diseases. Safety and clinical efficacy of this treatment are well documented, but evidence about the ability to reduce new sensitizations is still poor.

OBJECTIVE

We report a retrospective study conducted in order to assess the prevention of new sensitizations in monosensitized subjects treated with specific immunotherapy vs. monosensitized patients treated with anti-allergic drugs.

METHODS

8396 monosensitized patients with respiratory symptoms were selected according to an open, retrospective design. Group A included 7182 patients submitted to specific immunotherapy (and anti-allergic drugs when needed) for 4 years and then treated with drugs for at least 3 years. Group B included 1214 patients treated only with drugs for at least 7 years. All patients underwent prick test with a standard panel of allergens and total and specific IgE determination before and after 4 years of treatment and again 3 years later.

RESULTS

Groups were well balanced. Polysensitized subjects were 23.75% in Group A and 68.03% in Group B after 4 years (P < 0.0001) and 26.95% and 76.77%, respectively, after 7 years (P < 0.0001). Asthmatic subjects were more prone to develop polysensitization in comparison to subjects suffering only from rhinitis (32.14% instead of 27.29% after 4 years, 36.5% instead of 31.33% after 7 years; P < 0.0001). Specific IgE decreased by 24.11% in Group A and increased by 23.87% in Group B (P < 0.0001). Total IgE decreased by 17.53% in Group A and increased by 13.71% in Group B (P < 0.0001).

CONCLUSIONS

Specific immunotherapy was observed retrospectively to reduce new sensitizations in monosensitized subjects suffering from respiratory allergic diseases.

Prevention of new sensitizations in monosensitized subjects submitted to specific immunotherapy or not. A retrospective study

BACKGROUND

Specific immunotherapy is the only currently available allergen-orientated treatment able to modify the natural history of respiratory allergic diseases. Safety and clinical efficacy of this treatment are well documented, but evidence about the ability to reduce new sensitizations is still poor.

OBJECTIVE

We report a retrospective study conducted in order to assess the prevention of new sensitizations in monosensitized subjects treated with specific immunotherapy vs. monosensitized patients treated with anti-allergic drugs.

METHODS

8396 monosensitized patients with respiratory symptoms were selected according to an open, retrospective design. Group A included 7182 patients submitted to specific immunotherapy (and anti-allergic drugs when needed) for 4 years and then treated with drugs for at least 3 years. Group B included 1214 patients treated only with drugs for at least 7 years. All patients underwent prick test with a standard panel of allergens and total and specific IgE determination before and after 4 years of treatment and again 3 years later.

RESULTS

Groups were well balanced. Polysensitized subjects were 23.75% in Group A and 68.03% in Group B after 4 years (P < 0.0001) and 26.95% and 76.77%, respectively, after 7 years (P < 0.0001). Asthmatic subjects were more prone to develop polysensitization in comparison to subjects suffering only from rhinitis (32.14% instead of 27.29% after 4 years, 36.5% instead of 31.33% after 7 years; P < 0.0001). Specific IgE decreased by 24.11% in Group A and increased by 23.87% in Group B (P < 0.0001). Total IgE decreased by 17.53% in Group A and increased by 13.71% in Group B (P < 0.0001).

CONCLUSIONS

Specific immunotherapy was observed retrospectively to reduce new sensitizations in monosensitized subjects suffering from respiratory allergic diseases.

Immediate reaction to clarithromycin

We present the case of bronchospastic reaction to clarithromycin had during a drug challenge test. Personal allergic history was negative for respiratory allergies and positive for adverse drug reactions to general and regional anesthesia and to ceftriaxone. After the administration of 1/4 of therapeutic dose of clarithromycin the patient showed dyspnea, cough and bronchospasm in all the lung fields. The positivity of the test was confirmed by the negativity to the administration of placebo. The quickness and the clinical characteristic of the adverse reaction suggest a pathogenic mechanism of immediate-type hypersensitivity. On reviewing the literature we have found no reports of bronchospastic reaction to clarithromycin. Macrolides are a class of antibiotics mainly used in the last years in place of beta-lactams because of a broad spectrum of action and a low allergic power. In fact, there are few reports on allergic reactions to these molecules. Clarithromycin is one of the latest macrolides, characterised by the presence of a 14-carbon-atom lactone ring as erythromycin, active on a wide spectrum of pathogens.

Evaluation of interleukin-18 production by in vitro differentiated monocytes from breast cancer patients

Interleukin-18 (IL-18) is a multifunctional cytokine which may play an important role in cancer. In previous studies it has been reported that mononuclear cells from breast cancer patients were defective in cytokine production. In this report we examined in vitro IL-18 release by monocytes (Mo) and differentiated monocytes (Mphi) for 6 or 12 days from healthy donors (HD) and nonmetastatic breast cancer (BCa) patients prior to chemo-, hormonal or radiotherapy. Our results show no production of this cytokine by Mo and Mphi for 6 days in all the experimental conditions. HD Mphi cultured for 12 days were responsive to lipopolysaccharides only after 24 h of treatment, while significantly (p<0.05) lower amounts of IL-18 were produced by BCa Mphi cultures in the same experimental conditions. Since BCa Mphi are defective in IL-18 production, and this cytokine elicits in vivo protective antitumor effects, we hypothesize a future possibility for the use of IL-18 in cancer therapy.

Effect of fluticasone propionate on soluble CD30 release in patients with severe allergic asthma

Previous studies have demonstrated improvements in health-related quality of life in asthmatic patients after treatment with fluticasone propionate. CD30 is a marker of Th2 lymphocytes, which are key cells in the pathogenesis of allergic inflammation. There is also a soluble form of CD30 (sCD30) released by CD30+ cells. Since serum sCD30 levels are high in allergic patients, in our study we examined the possible role of fluticasone propionate in modulating sCD30 release in patients with severe allergic asthma. In addition, we evaluated a possible correlation between sCD30 and FEV1 in these patients. To this end two groups of subjects were enrolled: 20 healthy nonatopic control subjects (group A) and 20 atopic patients with severe bronchial asthma receiving fluticasone propionate at the total dosage of 1 mg/day for 8 weeks (group B). Serum samples were examined before and after the treatment period. sCD30 serum levels were determined by the commercial ELISA-kit (Dako). The limit of detection of the assay was 1 U/ml. Our data show that sCD30 basal serum levels were significantly (p <0.05) higher in patients of group B respect to group A subjects (8.35+/-4.88 vs. <1 IU/ml, respectively). In addition, we found that sCD30 serum levels were undetectable in patients of group B after fluticasone propionate therapy. In group B a positive correlation between serum sCD30 levels and FEV1 values before fluticasone propionate treatment was noted (Rho = -0.644, p <0.005). The fluticasone propionate inhibition of sCD30 release may partly explain how fluticasone propionate exerts its antiinflammatory activity, through the modulation of Th2 cells.

In vitro effect of lithium chloride on interleukin-15 production by monocytes from IL-breast cancer patients

Lithium salt compounds are used to limit the degree and duration of neutropenia in patients receiving chemotherapy for cancer. Interleukin-15 (IL-15) is a cytokine which possesses promoting activities on hematopoiesis and is also involved in antitumor response, activating NK, CTL and LAK cells. In this study we analyzed IL-15 production by monocyte cultures treated with lithium chloride (LiCl). Monocytes were obtained from patients affected by non-metastatic and metastatic breast cancer. LiCl treatment induced IL-15 production by monocytes mainly from non-metastatic patients. Combined lipopolysaccharide/LiCl treatment of monocyte cultures up-regulated IL-15 release compared to those treated with LPS alone (p<0.0001). The modulation of LiCl-induced IL-15 could counteract the immunosuppression state of cancer patients, which should be taken into account when developing new immunotherapeutic strategies.

Incidence of sensitivity to Anisakis simplex in a risk population of fishermen/fishmongers

BACKGROUND

Anisakis simplex, a fish and cephalopodes parasite, can cause either gastrointestinal symptoms or allergic reactions in humans on eating/handling contaminated fish.

OBJECTIVE

The aim of our study was to determine the capacity of Anisakis simplex to induce specific IgE production and allergic reactions following eating and handling fish in a population at risk.

METHODS

We determined the levels of total IgE, specific IgE, and eosinophil count in 28 fishermen/fishmongers (group A) and 15 healthy donors (group B). A skin prick test (SPT) with extracts from Anisakis and the most common species of fish in our country, were also carried out.

RESULTS

Specific IgE to Anisakis were found in 14 subjects of group A (13 of them had a positive SPT to the same extract) and none of group B (only one subject had a positive SPT). The SPT with fish extracts was positive in 4 patients of group A but in none of group B. Subjects in group A with specific IgE to Anisakis showed higher total IgE levels and eosinophil counts compared with either other individuals of the same group or to those of group B.

CONCLUSIONS

These results indicate that fishermen/fishmongers are a population at risk for Anisakis simplex sensitization and suggest that this kind of sensitization should also be investigated not only in subjects like fishermen/fishmongers who live in countries where fish is likely to be contaminated with Anisakis simplex parasites, but also in those who handle fish for other reasons.

Burning mouth syndrome due to cadmium in a denture wearer

We report the case of a female denture wearer who was referred to our service due to burning of the lips and tongue but with no visible oral lesions. Her biochemical data, complete blood cell count, sedimentation rate, thyroid and sex hormones were normal. Tongue culture was negative. Patch tests, performed with a panel of 20 potential denture allergens, gave positive results (+++) only to a 2% petrolatum cadmium sulfate, which was present in the denture. Removal of the denture led to the clearing up of oral symptoms in 3 days. In light of these findings, carrying out patch tests with the allergens related to denture materials should be considered in these cases.

Aluminium allergy in a patient with occupational contact dermatitis

Case of a 57-year-old hospital attendant with hand eczema. Patch tests were read at 2 and 3 days using the 1+ to 3+ scoring system recommended by the Contact Dermatitis Research Group.

Sublingual immunotherapy: a double-blind, placebo-controlled trial with Parietaria judaica extract standardized in mass units in patients with rhinoconjunctivitis, asthma, or both

BACKGROUND

New routes of administering immunotherapy in respiratory allergy are being studied as an alternative to conventional injective immunotherapy. We carried out a study to evaluate the clinical efficacy and effects of sublingual immunotherapy in patients with Parietaria judaica-induced respiratory allergy.

METHODS

A double-blind, placebo-controlled design was followed. Thirty patients with P. judaica rhinoconjunctivitis, mild asthma, or both were randomly chosen for sublingual immunotherapy (14 patients) or placebo treatment (16 patients). The patients underwent preseasonal rush induction treatment followed by coseasonal maintenance treatment during the Parietaria pollen season. Symptom and drug scores, as well as specific IgE and specific IgG4, were recorded.

RESULTS

Significantly lower symptom and drug scores were found (P=0.04), especially during the Parietaria pollination period, in the immunotherapy group. No significant difference in specific IgE and specific IgG4 was detected between the active and placebo groups; a statistically significant increase of specific IgE was detected in both groups (P=0.05). No patient undergoing active sublingual immunotherapy reported local or systemic side-effects.

CONCLUSIONS

Our data suggest that sublingual immunotherapy is both clinically effective and safe in treating patients with Parietaria-induced rhinoconjunctivitis and mild asthma.

A controlled study on the effectiveness of loratadine in combination with flunisolide in the treatment of nonallergic rhinitis with eosinophilia (NARES)

BACKGROUND

Nonallergic rhinitis with eosinophilia (NARES), accounting for some 15% of perennial rhinitis, is a nasal disorder whose main features are eosinophil counts in nasal smear higher than 10% and negative IgE tests. The mainstay of treatment is topical corticosteroids.

OBJECTIVE

To evaluate the adjunctive effect of loratadine, a non-sedating antihistamine with anti-allergic activity, on nasal symptoms and eosinophil counts in nasal secretions in patients with NARES.

METHODS

Thirty patients with NARES were divided in two groups, half receiving flunisolide two 25 microg puffs per nostril morning and night plus loratadine 10 mg u.i.d. and half the same doses of flunisolide plus placebo, according to a double-blind fashion, for 3 weeks. The effectiveness of the treatment in the two groups was evaluated by comparing symptom scores and eosinophil counts, and safety was assessed by comparing the adverse effects.

RESULTS

The loratadine treated group had better results both in nasal symptoms, with a decrease in sneezing (P < 0.000001) and rhinorrhoea (P < 0.006), respectively, corresponding with 73.4% and 66.7% with respect to 46.6% and 26.7% in the control group, and in eosinophil counts which decreased by 20% compared with 14.3% in patients treated with placebo and flunisolide. As to safety, only nasal irritation in two patients, one in each group, was reported.

CONCLUSION

Loratadine improves the effectiveness of flunisolide in treatment of NARES with no change in safety, and with no sedation.

Effect of fluticasone propionate on interleukin-12 and interferon-gamma production in patients affected by allergic bronchial asthma

Fluticasone propionate is a very effective topical treatment for asthma. Interleukin-12, which is produced by monocyte-macrophage and B lymphocytic cell lines, plays an important role in the induction of Th1 cells; whereas interferon-gamma (IFN-gamma), mainly produced by Th1 cells, exhibits a crucial effect on macrophage and natural killer cell activation. Since previous studies have demonstrated a reduced production of IL-12 and IFN-gamma in patients with allergic asthma, we examined whether fluticasone propionate therapy could influence the release of these cytokines in asthma. We selected two groups of subjects (15 per group): nonatopic healthy donors (group A) and asthmatic patients (group B). Cytokine release was assessed in sera as well as in supernatants of whole blood cultures after IFN-gamma priming and lipopolysaccharide stimulation. Venous blood and spirometric tests from patients in group B were obtained before and after treatment. Fluticasone propionate therapy significantly increased interleukin-12 levels in both supernatants of blood cultures (1,152.12 +/- 225.57 vs. 540.87 +/- 130.07 pg/ml; p < 0.05) or in sera (72.24 +/- 15.76 vs. 10.83 +/- 2.70 pg/ml; p < 0.05). Patients treated with fluticasone propionate also displayed increased levels of IFN-gamma in either blood culture supernatants (59.12 +/- 16.88 vs. 18.87 +/- 7.53 IU/ml; p < 0.05) or in sera (5.60 +/- 2.87 vs. < 1 IU/ml; p < 0.05). In addition, we observed a significant increase in FEV1 values in asthmatic patients after fluticasone propionate therapy (51.86 +/- 5.31 vs. 71.46 +/- 10.37% predicted). We propose that fluticasone propionate may exert at least in part of its antiinflammatory activity through the modulation of the cytokine output.

Interleukin-12 and interleukin-10 production by mononuclear phagocytic cells from breast cancer patients

Interleukin-10 (IL-10) and Interleukin 12 (IL-12) generation may be regulated by a complex monocyte and macrophage-derived cytokine network and an impairment of the immune system can be observed in neoplastic disease. In this study, we examined the production of these cytokines by phagocytic cells, obtained from breast cancer (BCa)-bearing patients. Our results suggest that an increased IL-10 formation may represent an important regulatory pathway of IL-12 production by BCa mononuclear cells. In this report, we show that mononuclear cells of patients affected by breast cancer have a defective IL-12 production capability while generating higher amounts of IL-10.

Urticaria from Trichomonas vaginalis infection

We report the case of a 32-year-old woman who had pruritic urticarial skin lesions associated with episodes of arthralgia. The first site affected by the eruption was the inside surface of the thighs; the patient also reported the presence of leukorrhea. The woman had previously been treated with H1 antagonist with moderate and transitory results; skin lesions reappeared just after the interruption of the treatment. Her biochemical data showed increased levels of erythrocyte sedimentation rate, blood eosinophilia and hypocomplementemia. Antinuclear antibodies, rheumatoid factor, cryoglobulins and serological diagnosis for hepatitis or mononucleosis viruses resulted negative. Considering the initial site of the cutaneous features and the presence of leukorrhea, we requested a vaginal smear and a culture of the cervical secretion, which revealed the presence of a Trichomonas infection. Furthermore, the SDS-PAGE revealed the presence of a molecular mass of 230,000 Da (230-kDa) in the serum, which indicated a Trichomonas surface protein. The following treatment with oral metronidazole caused the eradication of the Trichomonas infection after 3 weeks and subsequently the resolution of the urticarial clinical features. We wish to underline that in the presence of a case of urticaria vasculitis syndrome which seems to be without cause, it is important to investigate every diagnostic suspicion scrupulously.

Non invasive assessment of cardiac function in patients with bronchial asthma (BA) or chronic obstructive pulmonary disease (COPD)

BACKGROUND

Most respiratory diseases involve the heart and can lead to acute or chronic pulmonary heart in the most serious cases. The common pathogenetic element is pulmonary arterial hypertension which es secondary to the resistance of the pulmonary circulation together with hypertrophy and/or dilatation of the right ventricle, caused mainly by chronic hypoxia.

METHODS AND RESULTS

In order to verify the effects induced on pulmonary circulation and right heart by BA or COPD the cardiac function was assessed by mono and bidimensional Doppler echocardiography in 10 patients with BA (group A), 10 with COPD (group B) and 10 healthy control subjects (group C). At the M-mode echocardiography examination no significant difference was observed among the three study groups. By Doppler pw the peak velocity of early tricuspidal flow (VmaxE) was significantly higher in the group A when compared to the group B (p = 0.03). No subject had pulmonary hypertension. The pulmonary acceleration time (PAT) using pw Doppler technique was similar in groups A and B but it was significantly different when compared to group C (p = 0.006:A vs C; p = 0.03:B vs C).

CONCLUSIONS

Our results suggest in patients either with BA or COPD, an early involvement of the right heart even if they had a clinical stable condition and no pulmonary hypertension.

Urticaria in a tattooed patient

We present a case of urticaria in a tattooed patient due to hypersensitivity to the cobalt chloride contained in the blue ink used for tattoo. The patch test with the series of International Contact Dermatitis Research Group was positive only for chloride cobalt. Cobalt is believed to be responsible for contact urticaria through a non-immunological mechanism. On reviewing the literature we have found no report of contact urticaria to cobalt in tattooed patients.

Comparative study between fluticasone propionate and cetirizine in the treatment of allergic rhinitis

Among the most frequently used drugs in the treatment of allergic rhinitis we have to mention topical nasal corticosteroids and H1 antihistamines used both systemically and topically. The present study focused the effectiveness and tolerability of cetirizine and fluticasone propionate in seasonal allergic rhinitis. 54 patients, divided into three homogeneous groups, underwent the following different treatments: Group 1: Placebo of fluticasone (2 puff per nostril once daily by aerosol) + cetirizine (10 mg/die per os) for 60 days. Group 2: Fluticasone (100 mg per nostril once daily by aerosol) + placebo of cetirizine (per os) for 60 days. Group 3: Cetirizine (10 mg/die per os) for 60 days + fluticasone (100 mg per nostril once daily by aerosol) for 20 days. The patients reported nasal symptoms (sneezing, obstruction, itching, rhinorrea) on a clinical diary. ECP levels in nasal secretions were investigated in all patients to determine the anti-inflammatory activity of both treatments. Cetirizine resulted very effective in the treatment of sneezing, itching and acqueous rhinorrea whereas not much effective on nasal obstruction. On the contrary, fluticasone, which acted effectively on nasal obstruction, resulted inefficacious on the other symptoms. The third group of patients achieved the best results on all four symptoms, including obstruction, which continued even after interrupting the treatment with fluticasone. The ECP levels were significantly reduced by both treatments. The side effects in all 3 groups were rare and not serious. From these results we can assert that the synergic action of the two drugs, achieves the best effectiveness, that the fluticasone treatment can be limited to 20 days cycles and finally that both molecules are well tolerated.