Analysis of user-satisfaction with the use of a teleconsultation system in oncology

There is an increasing interest in assessing telemedicine as alternative method of delivering high quality cancer treatment to patients living in rural areas. In the Province of Trento (north-east Italy) a tele-oncology system was implemented to provide non-surgical oncological consultation to district general hospitals. The aim of this study was to explore user-satisfaction with the system after 6 months of experimentation. During the on-field validation two questionnaires with open and closed-response questions were distributed to 80 physicians and nurses 6 months apart to investigate the users' expected benefits vs. perceived ones. The two questionnaires were compared to assess how perceived benefits differed from expected ones. Significant differences were found regarding improvements in: the standardization of diagnostic-therapeutic procedures using the Electronic Patient Record (EPR)]; information sharing; data updating; consultation speed; and the possibility to diminish patients' travels through the use of teleconsultation (TC). Physicians' responses showed a significant difference regarding the EPR's effects on relationship with patient, the nurses' responses with regards to its effects on care quality. Physicians felt that both modalities of teleconsultation were useful in enhancing communication with colleagues (86% for the synchronous TC, 80% for the asynchronous TC). Responses indicated that the major difficulties encountered were in the introduction of the system into the daily routine. Despite this, user expectations for its future use in clinical field were considerably high.

Severe epilepsy preceding by four months the onset of scleroderma en coup de sabre

Juvenile localized scleroderma (JLS) includes several subtypes including plaque morphea, linear scleroderma and the en coup de sabre type which affects face and head. The latter variety may involve the eye and the brain with various appearance and clinical complications.We describe the case of a 6-year-old boy who presented partial complex seizures, with status epilepticus, four months before the appearance of sclerodermatous skin lesions on the face. This case report raises important questions on the pathogenesis of JLS and, particularly, on the issue whether it is a mere autoimmune condition or a neuro-cutaneous disease.

Mycophenolate mofetil for the treatment of juvenile onset SLE: a multicenter study

Mycophenolate mofetil (MMF) has proved to be an efficacious and safe therapy in adult lupus nephritis. Recently, this drug has been suggested as a possible new alternative treatment also for juvenile-onset SLE (juvenile-SLE). A multicenter study has been performed to evaluate the efficacy and safety of MMF in controlling the disease activity in children and adolescents with juvenile-SLE. Our results show that MMF was effective in reducing the disease activity or as a steroid-sparing agent in 14 of 26 patients (54%), stabilised the disease in 8 (31%) and was ineffective in 4 (15%). In particular, in patients without renal involvement, a good response was registered in 9 of 13 patients (69%). Among those patients with renal involvement, MMF was effective in 5 of 13 patients (38%), partially effective in 4 (31%) and ineffective in 4 (31%). No severe side effects have been observed; only two patients stopped the drug because of severe diarrhoea and abdominal pain. With the limits of a retrospective study, MMF seems to be effective and safe for the treatment of juvenile-SLE, especially in patients with no renal involvement.

Severe clinical course of systemic lupus erythematosus in the first year of life

Systemic lupus erythematosus (SLE) very rarely occurs before the age of 5. Herein we describe the clinical features of infantile SLE (iSLE) with onset during the first year of life. The clinical and laboratory characteristics of iSLE patients followed at the Department of Pediatrics of Padua were analyzed. They were combined with those collected from the literature by performing a systematic literature search on PubMed using the following keywords: SLE, infant, laboratory, therapy, and outcome. A total of 13 patients with iSLE, 2 from our Institution and 11 from the literature, are included in this review. Seven (53.8%) were females and 6 were males (46.2%). The age at disease onset ranged from 6 weeks to 11 months. In comparison with juvenile systemic lupus erythematosus (jSLE), iSLE showed a higher prevalence of positive family history for autoimmune diseases, systemic symptoms at presentation, internal organs involvement, and shorter time between symptoms onset and diagnosis. Anemia and thrombocytopenia were present in the majority of the patients at diagnosis, whereas leukopenia was rarely observed. The overall prognosis in iSLE was very poor: 5/13 infants died between 2 and 31 months after the onset, and 5/13 had severe disease course with residual organ damage. SLE can start as early as during the first year of life and is more severe than in the later age groups.

Genetic variation in the host and adaptive phenomena in Plasmodium falciparum infection

The in vitro culture of Plasmodium falciparum, after synchronization, lends itself well to an analysis of the asexual schizogonic cycle. We have found in this system that DNA synthesis and RNA synthesis are associated mainly with the trophozoite stage, with the latter peaking slightly ahead of the former. Distinctive patterns of protein synthesis are seen at serial times along the cycle, with a number of 'stage-specific' bands identifiable on SDS gels. The fate of the infection can be influenced by the genotype of the host cell. Thus, glucose-6-phosphate dehydrogenase (G6PD)-deficient erythrocytes are invaded normally, but maturation of intracellular parasites is delayed and impaired. However, the parasites that do develop will then have a normal behaviour in their next rounds in G6PD-deficient cells, suggesting that an adaptive change has taken place. These results fit well with the relative protection against P. falciparum in vivo of girls heterozygous for G6PD deficiency but not of hemizygous G6PD-deficient boys.

Esophageal involvement in juvenile localized scleroderma: a pilot study

OBJECTIVES

To evaluate the esophageal involvement in patients with juvenile localized scleroderma (JLS).

METHODS

A cohort of patients with JLS underwent esophageal stationary manometry to evaluate esophageal motility and lower esophageal sphincter (LES) function, distal esophagus 24-hour pH-monitoring to detect gastroesophageal reflux (GER) and upper gastrointestinal (GI) endoscopy to evaluate the presence of esophagitis.

RESULTS

Fourteen patients (10 female, mean age 13.3 yrs, mean disease duration 4.7 yrs), took part in the study. Ten had linear scleroderma, three deep morphea, and one generalized morphea. Esophageal abnormalities were found in 8/14 patients (57%): pathological acid exposure on 24-hour pH-monitoring was found in 7; non-specific esophageal motor abnormalities in 5 and endoscopy-proved esophagitis in 5 symptomatic patients. Interestingly, 5 out of 8 patients with esophageal abnormalities were found to be ANA positive, and 2 were also RF positive.

CONCLUSION

Esophageal involvement is not unusual in patients with juvenile localized scleroderma, even in the absence of specific symptoms. These preliminary findings, if confirmed in a larger cohort of patients, may support the indication for an extensive GI evaluation especially in presence of positive autoantibodies or specific GI symptoms.

A new computerized method for the assessment of skin lesions in localized scleroderma

OBJECTIVE

Up to now, no validated tools are in use for the assessment of the skin lesions in localized scleroderma (LS). The aim of this study is to evaluate the performance of a new computerized skin score (CSS) method for the measurement of circumscribed lesions in LS.

METHODS

The study consisted of three phases: set up of the CSS technique, measurement of target lesions of LS patients, assessment of intra- and inter-rater reliability. The CSS technique consists in delimitating the indurate lesion on an adhesive transparent film, transferring it over a cardboard and then calculating the affected area with a specifically created software. The technique was explained to a panel of 10 physicians with different expertise in LS (three paediatric rheumatologists, two dermatologists, five paediatric residents). All participants, singularly and blindly to the others, examined 10 consecutive patients twice after a time interval of at least 6 h. The intra-observer variability was evaluated by the repeatability coefficient and the inter-rater reliability by the intra-class correlation coefficient (ICC).

RESULTS

The repeatability coefficients were good, ranging between 1.90 and 7.03. The mean values of skin scores were not significantly different among the examiners. The ICC for indurate area calculation were high in both the experts (0.97) and the residents (0.91-0.94).

CONCLUSIONS

CSS has shown to be a reliable method to assess the skin lesions in patients with LS. It is reproducible, easy to use and, with the support of the CSS software, applicable worldwide.

Serum OPG and RANKL levels before and after intravenous bisphosphonate treatment in Paget's disease of bone

Paget's disease of bone (PDB) is a focal disorder of bone remodeling characterized by increased osteoclast-mediated bone resorption. Even though increasing evidence indicates enhanced nuclear factor-kB (NF-kB) signaling as a common mechanism involved in PDB and other related disorders, few studies investigated circulating osteoprotegerin (OPG) and receptor of activator of NF-kB-ligand (RANKL) levels in PDB patients. In this study we explored the relationships between OPG or RANKL levels and bone turnover markers in a group of patients with PDB, before and after intravenous bisphosphonate treatment (pamidronate 60 mg). Both OPG and RANKL were markedly elevated in PDB patients with respect to control groups (healthy or osteoporotic postmenopausal women and elderly men) and were positively associated with bone turnover markers. Higher levels of these cytokines were observed in polyostotic than monostotic PDB cases. The ratio between RANKL and OPG was more than 3-fold higher in PDB patients than in controls. Interestingly, in the group of patients treated with pamidronate, we found an increase in OPG levels that become statistically significant after 3 and 6 months from treatment. A trend toward a decrease in RANKL levels after treatment was also observed. The RANKL/OPG ratio was significantly reduced after 3 and 6 months of therapy. In contrast, in patients classified as non-responders, OPG and RANKL levels after pamidronate infusion did not significantly differ with respect to pre-treatment values. Thus, the positive effect of amino bisphosphonates in the treatment of PDB may be due to either direct or indirect suppression of RANKL-induced bone resorption through decreased RANKL and increased OPG production.

Bone metabolism in men: role of aromatase activity

Sex steroid hormones play an important role in the maintenance of bone mass in males and in females. Even though androgens are the major sex steroids in men, direct and indirect evidence emerged suggesting that estrogens may also play a major role in male skeletal health. Since the testes account for only 15% of circulating estrogens in males, the remaining 85% comes from peripheral aromatization of androgen precursors in different tissues, including bone. Human models of aromatase deficiency clearly demonstrated the critical importance of the conversion of androgens into estrogens in regulating male skeletal homeostasis. Aromatase- deficient men showed tall stature due to continued longitudinal growth, unfused epiphyses, high bone turnover, and osteopenia. Interventional studies in adult men using aromatase inhibition confirmed that estrogens are important in controlling bone remodeling. Importantly either inherited (i.e. due to common polymorphisms at the human aromatase CYP19 gene) or acquired (i.e. by diseases or different compounds) variation in aromatase ability to convert androgen precursors into estrogen may also be relevant for skeletal homeostasis.

Teriparatide's effects on quantitative ultrasound parameters and bone density in women with established osteoporosis

This study aimed to evaluate the effects of teriparatide [hPTH (1-34)] on quantitative ultrasound (QUS) parameters and bone mineral density (BMD) at the axial and appendicular (hand) skeleton in women with established osteoporosis who had been previously treated with antiresorptive drugs. Sixty postmenopausal women (age 71.1+/-6.8 years) were randomly assigned to either receive once-daily 20-mug subcutaneous teriparatide (n=30) or continue the antiresorptive treatment (n=30). At baseline and at 2-month intervals we measured QUS parameters at the calcaneus using the Achilles Plus (GE, Lunar), measuring speed of sound (SOS), broadband ultrasound attenuation (BUA), and stiffness index; QUS parameters at the phalanxes using the Bone Profiler (IGEA), measuring amplitude-dependent speed of sound (AD-SoS), bone transmission time (BTT), and fast wave amplitude (FWA); and BMD values at the right hand using dual x-ray absorptiometry. BMD at the lumbar spine, femur, and whole body were measured on a 6-monthly basis. After 1 year of teriparatide treatment, the changes in BMD were 7.1% at the lumbar spine, 2.6% at the femoral neck, -0.8% at the total hip, and -0.6% for the whole body. Teriparatide induced a significant and persistent decrease in BMD at the hand (-3.6% at month 6 and -2.7% at month 12). In the teriparatide group at month 12, AD-SoS was slightly increased (0.7%; not significant), whereas BTT significantly decreased (-16.4%, p<0.001) and FWA significantly increased (17.5%, p<0.001). The FWA/BTT ratio increased by 26.6% and 32.9% at months 6 and 12, respectively, in the teriparatide group and remained unchanged in the antiresorptive group. In women with established osteoporosis who had previously been treated with various antiresorptive drugs, 1 year of teriparatide treatment determined the expected increase in BMD at the axial skeleton and a significant and prolonged decrease in BMD at the hand. Moreover, teriparatide determined important changes in BTT and FWA, two parameters obtained from the analysis of ultrasonographic trace at the phalanxes, which could be considered in monitoring for the early effect of teriparatide on bone.

Localized and systemic forms of scleroderma in adults and children

Systemic sclerosis (SSc) presents a great deal of variability in the extent and severity of skin and internal organ involvement. The diagnostic and prognostic significance of autoantibodies in SSc is undisputed and the patient's autoantibody profile represents a fundamental tool for clinicians. Scleroderma is a rare condition in children. Unlike adults, localized scleroderma is more frequent than the systemic sclerosis, nevertheless it represents a disabling condition. In both conditions, no validated outcome measures and proven effective treatment is available to date.Raynaud's phenomenon (RP) is one the most common and significant clinical symptoms of SSc and therefore in patients with RP a capillaroscopic analysis should be carried out as soon as possible. The actual and select advantage of the early nailfold videocapillaroscopic (NVC) analysis is to distinguish between the primary RP and the secondary RP and to allow the early detection of SSc.

Juvenile localized scleroderma: clinical and epidemiological features in 750 children. An international study

OBJECTIVE

Juvenile localized scleroderma (JLS) includes a number of conditions often grouped together. With the long-term goal of developing uniform classification criteria, we studied the epidemiological, clinical and immunological features of children with JLS followed by paediatric rheumatology and dermatology centres.

METHODS

A large, multicentre, multinational study was conducted by collecting information on the demographics, family history, triggering environmental factors, clinical and laboratory features, and treatment of patients with JLS.

RESULTS

Seven hundred and fifty patients with JLS from 70 centres were enrolled into the study. The disease duration at diagnosis was 18 months. Linear scleroderma (LS) was the most frequent subtype (65%), followed by plaque morphea (PM) (26%), generalized morphea (GM) (7%) and deep morphea (DM) (2%). As many as 15% of patients had a mixed subtype. Ninety-one patients (12%) had a positive family history for rheumatic or autoimmune diseases; 100 (13.3%) reported environmental events as possible trigger. ANA was positive in 42.3% of the patients, with a higher prevalence in the LS-DM subtype than in the PM-GM subtype. Scl70 was detected in the sera of 3% of the patients, anticentromere antibody in 2%, anti-double-stranded DNA in 4%, anti-cardiolipin antibody in 13% and rheumatoid factor in 16%. Methotrexate was the drug most frequently used, especially during the last 5 yr.

CONCLUSION

This study represents the largest collection of patients with JLS ever reported. The insidious onset of the disease, the delay in diagnosis, the recognition of mixed subtype and the better definition of the other subtypes should influence our efforts in educating trainees and practitioners and help in developing a comprehensive classification system for this syndrome.