Current research funding methods dumb down health care and rehabilitation for disabled people and aging population: a call for a change

Health care systems in Western societies are faced with two major challenges: aging populations and the growing burden of chronic conditions. This translates into more persons with disabilities and the need for more Physical and Rehabilitation Medicine (PRM) services. We raise the point of how these emerging needs are faced by the actual research funding. We briefly present the results of an analysis we made about research funding by the Italian National Health Service as an interesting case study, since it relates to Italy (the financer) and the United States, where National Institutes of Health (NIH) reviewers were identified according to their classification of research topics. The topics of potentially greatest interest for aging Western societies, like chronicity, disability and rehabilitation, were among those least often funded and considered in the traditional method of financing research projects. These results could be based on those PRM peculiarities that make the specialty different from all other classical biomedical specialties, namely the bio-psycho-social approach and its specific research methodologies. Moreover, PRM researchers are spread among the different topics as usually classified, and it is probable that PRM projects are judged by non-PRM reviewers. There are at least two possible ways in which research can be better placed to meet the emerging needs of Western societies (chronicity, disability and consequently also rehabilitation). One is to create specific keywords on these topics so as to improve the match between researchers and reviewers; the second is to allocate specific funds to research in these areas. In fact, the not coherence between emerging needs and research priorities have already been periodically addressed in the past with specific "political" and/or "social" initiatives, when researchers were forced to respond to new emergencies: some historical examples include cancer or HIV and viral diseases or the recent Ebola outbreak.

The Italian National Registry of severe acquired brain injury: epidemiological, clinical and functional data of 1469 patients

BACKGROUND

The lack of knowledge about epidemiological and clinical data of patients with Acquired Brain Injury (ABI) admitted to Rehabilitation facilities in Italy led to the creation, in June 2008, of a data collection on-line registry.

AIM

To collect epidemiological and clinical data and to evaluate functional outcome of patients with severe traumatic and non-traumatic ABI admitted to Rehabilitation facilities in Italy between June 2008 and December 2011 and to compare data of patients with ABI of different aetiologies.

DESIGN

Observational retrospective study.

SETTING

The study involved 29 Italian Rehabilitation facilities.

POPULATION

The study enrolled 1469 patients with severe traumatic (TBI) and non-traumatic ABI (NTBI).

METHODS

Data collected included demographic (number of patients with TBI and NTBI, gender, age) and clinical characteristics (provenience, number of days elapsed between onset and rehabilitation admission, rehabilitation length of stay, discharge destination, death and vegetative state diagnosis, presence of percutaneous endoscopic gastrostomy, tracheostomy, pressure sores and paraosteoarthropathies). Functional outcome was evaluated using the Disability Rating Scale.

RESULTS

Of the whole population studied, 44.31% and 55.69% patients had suffered a TBI and a NTBI, respectively. In the NTBI group 40.09% had a cerebrovascular injury, 12.04% an anoxic brain damage, 3.6% had a brain injury of other causes. The mean age was 43.67 and 56.68 for subjects with TBI and NTBI, respectively. Patients with TBI showed a lower onset-admission interval (OAI), compared with NTBI group; no difference in rehabilitation length of stay (LOS) was recorded between groups. Patients with TBI presented a lower DRS score at admission and discharge and returned home more frequently than NTBI group.

CONCLUSIONS

The creation of a National registry allows the collection of data about patients with ABI in order to study the clinical course, the functional outcome and to establish a basis for comparison with other data sources. Clinical Rehabilitation Impact. Data collection could be useful in the evaluation and planning of rehabilitation pathways, and to assess the allocation of healthcare and rehabilitative resources.

Rehabilitation of acquired brain injuries: a multicentric prospective survey

BACKGROUND

The rehabilitation of the persons with Severe Acquired Brain Injury (ABI) is an important concern to be approached with a comprehensive program aimed to improve the recovery of patients.The efficacy of an early and intensive rehabilitation program has been shown in large number of studies. Few studies focused on the prevalence of TBI and the data are often extrapolated in indirect ways.

AIM

An analysis of the demographic characteristics of the population included in the GISCAR (Gruppo Italiano per lo Studio delle Gravi Cerebrolesioni Acquisite e Riabilitazione- Italian Group for the Study of the severe ABI) database, type and conditions associated to the index event; the treatment administered during hospitalization; and the prognosis according to outcome measures.

DESIGN

The study was an observational prospective survey looking at management of ABI (both traumatic and non-traumatic).

SETTING

In hospital rehabilitation.

POPULATION

Patients consecutively admitted in each of the 52 GISCAR centres.

METHODS

Every centre included a consecutive cohort and recorded demographic data and index event characteristics.

RESULTS

In the study population were included 2626 subjects suffering of a severe ABI. The difference of length of stay (LOS) was significantly different with 67.5 days for traumatic patients compared to the 80 days of non traumatic ones. In the study population the probability of discharge at home is significantly greater for the traumatic condition (odds ratio 0,4587; CI 0.3671-0.5731). The overall benefit of the rehabilitative treatment was encountered in a net gain in all disability scores taken into account: LCF classes; DRS as well as GOS scores. At discharge the main destination for severe ABI patients was home (67.2%).

CONCLUSIONS

A large number of patients admitted in Italian rehabilitative facilities for a severe ABI suffered from a TBI, more often these subjects were young male victims of road accident. The majority of subjects during the rehabilitative hospitalization demonstrated a significant recovery.

CLINICAL REHABILITATION IMPACT

Considering the evidence of an early treatment benefit the delay ofthe rehabilitation program start is far from being satisfactory. The high frequency of the home discharge indicate a good compliance of national family network.

THE TREVISO DEMENTIA (TREDEM) STUDY: A BIOMEDICAL, NEURORADIOLOGICAL, NEUROPSYChOLOGICAL AND SOCIAL INVESTIGATION OF DEMENTIA IN NORTH-EASTERN ITALY

The incidence of dementia increases exponentially with age but knowledge of real disease-modifying interventions is still limited. Objectives: To describe the study design and methods of a large prospective cohort study aimed at exploring the complex underlying relationships existing among cognition, frailty, and health-related events in older persons with cognitive impairment. Design: Prospective cohort study of a representative population of outpatients attending the Treviso Cognitive Impairment Center between 2000 and 2010. Setting: The TREVISO DEMENTIA (TREDEM) Study conducted in Treviso, Italy. Participants: 490 men and 874 women, mean age 79.1 ± 7.8 years (range 40.2–100 years). Measurements: Physiological data, biochemical parameters, clinical conditions, neuroradiological parameters (e.g., brain atrophy and cerebral vascular lesions identified by computerized tomography scans), neuropsychological assessment, and physical function markers were measured at baseline. Patients were followed-up to 10 years. Results: The final sample included in the study was predominantly composed of women and characterized by an initial physical function impairment and increased vascular risk profile. Cognitive function of the sample population showed moderate cognitive impairment (Mini Mental State Examination 20.2 ± 6.3; Clinical Dementia Rating 1.2 ± 0.7), and a prevalence of vascular dementia of 26.9%. Cortical, subcortical and hippocampus atrophy were all significantly correlated with age and cognitive function. Conclusion: Results obtained from the preliminary analyses conducted in the TREDEM study suggest that the database will support the accomplishment of important goals in understanding the nature of cognitive frailty and neurodegenerative diseases.

The evolution of the atheromatous plaque: ultrastructural evidence

Our understanding of endothelial physiology is overdue compared with other areas of study. For too many years the complex mysteries of this thin single-layered cellular lamina covering the whole of the vascular network, from the large conduction vessel to the smallest resistance and diffusion vessel, have been hidden by an organ-based science more focused on organ pathology than on ultrastructural physiopathology. We tried to follow chronologically the alteration stages of this system of membranes in relation to the development of the atherosclerotic plaque in human biopsy.

One case of immunotactoid glomerulopathy: morphological-ultrastructural aspects

Starting from a group of 736 renal biopsy patients, evaluated by ultrastructural studies over a period of 22 years, the authors present a rare case of immunotactoid glomerulopathy, suggesting that these forms, until a few years ago considered in the same group as fibrillary glomerulonephritis, are in fact a separate entity; moreover, they may represent a very early manifestation of plasmacellular dyscrasia still at the initial stage.

Histologic findings and Helicobacter pylori in duodenal biopsies

We have studied the morphologic aspects of the duodenal bulb in relation to Helicobacter pylori infection in a large group of patients with endoscopically assessed duodenitis to learn more about the pathogenesis of nonspecific duodenitis (bulbitis) and to clarify the specific role of H. pylori. Eight duodenal biopsy specimens in the four quadrants of the first part of the bulb and four gastric antral biopsy specimens were taken in 208 patients. Specimens were fixed in formalin, or in glutaraldehyde, then slides were stained with hematoxylin and eosin, periodic acid-Schiff, and Alcian-Giemsa, and with toluidine blue for semithin sections. Duodenal histology revealed inflammation in 155 (74.5%) and H. pylori-like bacterial bodies in 153 (73.5%) of the patients; H. pylori infection in the gastric antrum was diagnosed in 173 (83.1%) of the patients. Distinguishing histologic aspects appeared to be related to the presence of H. pylori infection. We believe that the present histologic grading of duodenitis correlates better with the natural history of H. pylori infection in the duodenal bulb, and better fits the requirements of a modern classification than the classification commonly used in duodenitis. We conclude that the term H. pylori-linked bulbitis should be adopted as the proper term to identify the particular kind of duodenitis predisposing to peptic ulcer.

Localised proton MR spectroscopy of brain metabolism changes in vegetative patients

We examined 14 vegetative brain-injured patients with proton magnetic resonance single-volume spectroscopy (1H MRS) at 1.5 T to establish whether there were changes in relative concentrations of N-acetyl aspartate (NAA), choline (Cho) and creatine (CR) metabolites from those found in healthy brains. Spectra were obtained from two different (2 x 2 x 2 cm) volumes of interest in the left and in the right frontal cortex, normal on MRI. All spectra revealed abnormalities compared with normal spectra obtained from age-matched control subjects. Values outside the normal range for at least one of the metabolite ratios were observed in all patients. Cho/Cr was markedly higher and NAA/Cho and NAA/Cr were markedly lower than in the control subjects. At different times six patients regained awareness and the ability to obey commands, and four were re-examined; changes in metabolite ratios were observed, which were different in individual patients. The NAA/Cho ratio reaches statistical significance in discriminating between the patients with a poor outcome (death or prolonged vegetative state) and those who regained awareness; the dividing line appears to be at a value of about 1.6.

Ultrastructural patterns of Helicobacter pylori

Ultrastructural morphology of the bacterial bodies was studied in 40 Helicobacter pylori positive cases. Two bacterial patterns were identified, which were associated with different modes of contact with the epithelial cells and possibly with different stages of the natural history of the infection.

Partial hemispheric disconnection syndrome of traumatic origin

A patient presented left-sided apraxia, constructional disturbances with the right hand and left tactile anomia after a severe head injury. MRI showed a callosal lesion involving the middle and posterior third of the truncus. This finding supports the thesis that the posterior callosum plays a predominant role in the interhemispheric mediation for praxis, as well as in the right-left transfer of spatial information guiding constructional performance. Left-sided apraxia was evident on imitation, on verbal command and on visual presentation of an object, but not on tactual presentation and during the actual use of objects. Moreover, apraxia on imitation showed a more rapid recovery than apraxia on verbal command. These data are consistent with the hypothesis of a left-hemisphere dominance for praxis, which is almost absolute when the retrieval of the appropriate gesture requires a semantic analysis of the stimulus.

Proteolytic activity and calcium concentration in muscle wasting conditions

The Authors studied the role of proteolytic activity in specimens from denerved and dystrophic human muscles. The Calcium ions concentration was determined in the same samples, for evaluating the possibility of a correlation between these parameters. A significative increase in proteolytic activity was demonstrated for denerved and dystrophic muscles. Calcium ion's concentration was decreased in atrophic muscles compared to controls. No correlation was possible between the two parameters.

The frequency of multiple sclerosis in Mediterranean Europe. An incidence and prevalence study in Barbagia, Sardinia, insular Italy

Recent investigations on multiple sclerosis (MS) distribution in Italy, based on relatively small population groups, contradict the current thesis, derived from studies undertaken in populations exceeding 300,000, of a lower spreading of the disease in Mediterranean Europe. Intensive surveys on small populations strengthen the suggestion that Italy is a high-risk area, although MS studies based on prevalence rather than incidence could also be biased by geographic variables making prevalence unsuitable for comparing MS prevalence rates found in different years and/or zones. We report a further epidemiologic study in Barbagia, Sardinia, insular Italy, undertaken both to establish the MS incidence in the last 20 years, and to estimate a new prevalence rate. Based on 31 probable incident cases, the mean incidence per year for the years 1961-1980 was 2.9 per 100,000 (3.2 if age- and sex-standardized to the Italian population). On October 24, 1981, the prevalence per 100,000 was 65.3 (77.9 if standardized to the Italian population). These results confirm that in Barbagia, MS occurs more frequently than expected in a Mediterranean area, and give further support to the idea that MS frequency in Italy is similar to that established for most central and northern European countries.

Pure "aphasic" agraphia due to damage of the left superior parietal lobule

A case of pure agraphia, due to an ischaemic lesion of the left superior parietal lobule, is reported. The neuropsychological analysis of writing performances suggests an aphasic nature of this patient's pure agraphia. The authors discuss the role played by diffuse and/or localized brain lesions in writing function, emphasizing that the left superior parietal lobule in man may be crucial for the sensorimotor linguistic integration needed for writing.

Acute cerebrovascular insults in homozygous beta-thalassaemia: a case report

Neurological complications following vascular thrombotic crises are frequent and occur in sickle cell anaemia and its variants, but are less well recognized in thalassaemias. A case of beta-thalassaemia major is reported complicated by an ischaemic lesion involving the right cerebellar hemisphere. The probable pathogenesis is considered and the literature on the matter briefly reviewed. In agreement with other reports, the interference of risk factors provided by or occurring in association with multiple blood-transfusions is hypothesized. Consequently, caution is recommended in giving large blood-transfusions to thalassaemic patients.

[Tactile recognition and cognitive tasks. Preliminary results]

In a basic experiment, a tactual recognition task was given to 28 normal blindfolded subjects. The subject were asked to explore the stimuli with the left or the right hand, and to choose out of 4 cavities the target form. Two cognitive concurrent tasks varied in terms of their verbal (left hemisphere) and non-verbal (right hemisphere) attributes were then given to other two groups of subjects (both of 24 Ss) performing the basic task. A consistent right hemisphere advantage was obtained in experiment I. For the non-verbal condition left hand performance was disrupted as well as for the concurrent verbal task condition. These findings were interpreted in terms of brain lateralisation of cognitive functions. For the "verbal" condition the results suggests that in case of a different task difficulties the normal mode of operation of the hemispheres is one of cooperative interaction, affecting, in this case, the hemisphere doing the processing.

Semicarbazide Complexes with Metal Chlorides

Complexes of semicarbazide with bivalent metal chlorides were characterized. Crystal data are reported, together with some optical properties and general relations among their crystal structures.