Academic literature on the topic 'SCUCCIMARRA'

Background:Kawasaki disease (KD) has been described across the globe, including the African continent, but none yet from Kenya.Objectives:To describe the clinical features and management strategies of pediatric patients diagnosed with Kawasaki Disease at a tertiary referral hospital in Kenya.Methods:A retrospective chart review was undertaken for the period January 2013 to December 2017 for all pediatric patients admitted at Aga Khan University Hospital Nairobi, Kenya. All medical records with a discharge diagnosis of Kawasaki disease were reviewed, de-identified and data extracted using a data collection tool.Results:Among the 15 cases identified, 8 (53%) had complete KD. The mean age was 1 year 10 months with a slight increase in males (53.3%). The mean duration of symptoms at diagnosis was 7.2 days (range 1-11 days). Fourteen patients (93.3%) received both intravenous immunoglobulin and aspirin but dosing varied from high dose aspirin (80-90 mg/kg/day) to low dose aspirin (3 mg/kg/day). Baseline cardiac evaluations were done among these 14 (93.3%) and one patient was found to have bilateral dilated coronaries. Only 5 patients (33.3%) had repeat echo examinations within 6 weeks after diagnosis all of which were normal.Conclusion:The challenges faced in the management of KD in Kenya include awareness of the disease, access and expertise to pediatric echocardiography, follow-up, access and cost of IVIG. Increasing awareness and improving health care resources is important in improving outcomes of KD in Kenya.Keywords: Kawasaki Disease, Pediatric Rheumatology, Kenya, Global Health, VasculitisReferences:[1]McCrindle BW, Rowley AH, Newburger JW, Burns JC, Bolger AF, Gewitz M, Baker AL, Jackson MA, Takahashi M, Shah PB, Kobayashi T, Wu MH, Saji TT, Pahl E. Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease: A Scientific Statement for Health Professionals From the American Heart Association. Circulation. 2017;135(17):e927-e999.[2]Kawasaki T. Acute febrile mucocutaneous syndrome with lymphoid involvement with specific desquamation of the fingers and toes in children. Arerugi (Japanese) 1967;16:178–222.[3]Singh S, Sharma A, Jiao F. Kawasaki Disease: Issues in Diagnosis and Treatment – A Developing Country Perspective. Indian J Pediatr 2016:83(2):140–145.[4]Scuccimarri R. Kawasaki Disease. Pediatr Clin N Am 2012; 59:425–445.Disclosure of Interests:None declared

Background:Increased awareness of the importance of MTX in rheumatic disease is leading to more MTX use in patients from TB-endemic areas. Current management guidelines for rheumatic disease address TB in the context of biologics but not MTX use.Objectives:To systematically review the published literature on TB rates with MTX ≤30 mg per week.Methods:We searched CINAHL, Embase, Global, MEDLINE and World of Science databases (Jan 1990 to May 2018) for terms including ‘methotrexate’ and ‘tuberculosis’. We also searched citations from review articles. Titles, abstracts or full manuscripts of the 4707 reports identified were screened independently by 2 reviewers to identify studies reporting TB in patients taking MTX. Study quality was assessed using the McGill Mixed Methods Appraisal Tool (MMAT). Data was extracted on TB incidence (new TB diagnosis vs reactivation of latent TB), and outcomes (pulmonary, dissemination, death) and safety of isoniazid, INH. Descriptive summaries are presented on studies providing outcomes in patients taking MTX ≤30 mg per week.Results:After removing duplicates and studies not meeting criteria or providing sufficient information, 31 studies were included (8 cohort, 7 case-control, 1 clinical trial, 15 case reports/case series). Only 27% of articles reported data from low to moderate human development index countries. Studies were of moderate quality. Seven case control studies were heterogeneous but most demonstrated a modest increased risk of TB with MTX (Table). Five cohort studies reported TB incidence rates in rheumatic disease (treated with MTX +/- biologics) ranging from 102-367.9/100,000 patient-years. These rates were generally higher than comparator general population rates. Two cohort studies of MTX in RA (without biologic) reported cumulative TB incidence in Maldova (12 TB cases in 44 RA patients, 27%) and in China (9/114, 7.9%). Other cohort studies generated rates of overt infection (143/100,000 patient years in Spain, higher if co-prescribed with corticosteroids and other immunosuppressants in South Africa), and latent TB rates detection (16/922 RA screened, 1.7%, in Canada). When reported, rates of extra-pulmonary TB were higher than comparator general population rates. One clinical trial (China), 2 cohorts (Japan, USA) and 2 case-series (Belgium, USA) evaluated safety of INH and MTX. Isoniazid-related hepatotoxicity and neutropenia were generally more common when taken with MTX, but were usually reversible.Conclusion:Despite a paucity of high-quality data, this review confirms that TB screening and clinical surveillance are needed in patients from TB-endemic areas who are prescribed MTX, particularly with co-administration of corticosteroids or other immunosuppressants. Isoniazid, if monitored, appears safe and prevents TB reactivation.References:Table .Case control studiesRegion (Year)DiagnosisTB with MTXTB without MTXOdds RatioMexico(1999)Mixed (4 RA)1/65/752.76Japan(2004)RA3/4717/1540.56Canada(2009)RA29/48321/10463.12Brazil(2010)Lupus2/31/57112Taiwan(2012)Psoriasis33/144464/23411.2Taiwan(2015)JIA4/3574/10262.90South Africa (2017)RA0/1340/18NAJIA=juvenile idiopathic arthritisAcknowledgments:Funded by the International League Against Rheumatism and McGill University Global Health Scholar AwardsDisclosure of Interests:Anna Davidson: None declared, Alize Gunay: None declared, Ines Colmegna: None declared, Diane Lacaille: None declared, Hal Loewen: None declared, Michele Meltzer: None declared, Rosie Scuccimarri: None declared, Yewondwossen Mengistu: None declared, Sasha Bernatsky: None declared, Carol Hitchon Grant/research support from: UCB Canada; Pfizer Canada

Background:Increased awareness of the efficacy of MTX in rheumatic disease is leading to more MTX use in patients from HIV endemic areas. While HIV related immunosuppression may contribute to improvement of some rheumatic diseases, immune reconstitution from highly active antiretroviral therapy (HAART) may lead to exacerbation or presentation of autoimmune disorders for which MTX therapy may be warranted. Most management guidelines for rheumatic disease do not address MTX use in the context of HIV.Objectives:To systematically review the published literature on the safety of using MTX ≤30 mg per week in HIV.Methods:We searched CINAHL, Embase, Global, MEDLINE and World of Science databases (Jan 1990 to May 2018) for terms including ‘methotrexate’ and ‘human immunodeficiency virus’. We also searched citations from review articles. Titles, abstracts or full manuscripts were screened independently by 2 reviewers to identify studies reporting HIV in patients taking MTX. Study quality was assessed using the McGill Mixed Methods Appraisal Tool (MMAT). Data was extracted on MTX and HIV adverse events (MTX toxicity, HIV viral load, CD4 count). Descriptive summaries are presented for studies providing outcomes in patients taking MTX ≤30 mg per week.Results:After removing duplicates and studies not meeting criteria or not providing sufficient information, 42 of the 2714 identified reports were included (1 clinical trial, 2 cohort, 1 cross-sectional study, 38 case reports/case series). Most reports (81%) originated from USA or Europe. Study quality was generally good with most studies fulfilling 50-100% of MMAT criteria. The randomized controlled trial (USA) assessing MTX on atherosclerotic disease in HIV showed that adverse events were more common in MTX versus placebo (12.8% vs 5.6%, p non-inferiority <0.05) and included infection, transient CD4 and CD8 drop, pulmonary toxicity, and death (1 attributed to MTX/HIV, 1 unrelated). One cohort study (South Africa) reported 43 RA patients on MTX who acquired HIV. In this cohort, RA generally improved despite only 5 individuals continuing MTX. No data on MTX adverse event rates was reported. One cohort study (USA) reported 13 HIV patients with myositis. One received MTX (with other immunosuppression) without MTX adverse effects but died due to AIDS. A cross-sectional study (France) of 43 HIV pts with autoimmune disease reported one patient on MTX (and other immunosuppression) developed an adverse event (cytopenia) compared to 5/33 patients not on MTX (cytopenia). The 38 case reports/series described 54 individuals with HIV receiving MTX. Of these studies, 27 (describing 42 subjects) reported on MTX adverse events and 35 (describing 46 subjects) reported on HIV adverse events. MTX adverse events developed in 29 subjects (hematologic 13, renal/hepatic 1, opportunistic infections 10, other events 2). HIV adverse events were noted in 23 subjects (Kaposi’s sarcoma 4, CD4 decrease 16, HIV viral titer increase 4). Five deaths were reported (2 infection, 1 infection and wasting, 2 HIV related deaths). Most subjects also received corticosteroids or other immunosuppressants including biologics.Conclusion:There remains limited data on the safety of low dose MTX in HIV. Surveillance for HIV is warranted for individuals on MTX who are at risk for acquiring HIV. Caution and careful monitoring for MTX toxicity, opportunistic infections and HIV state is suggested if MTX is used in the setting of HIV particularly if combined with other immunosuppression.References:[1] Clin Infectious Disease 2019:68[2] J Rheumatology 2014:41[3] Arthritis and Rheumatism 2003:49[4] Medicine 2017:96Acknowledgments :Funding from International League Against RheumatismMcGill University Global Health Scholar AwardsDisclosure of Interests:Alize Gunay: None declared, Anna Davidson: None declared, Ines Colmegna: None declared, Diane Lacaille: None declared, Hal Loewen: None declared, Michele Meltzer: None declared, Yewondwossen Mengistu: None declared, Rosie Scuccimarri: None declared, Zenebe Yirsaw: None declared, Sasha Bernatsky: None declared, Carol Hitchon Grant/research support from: UCB Canada; Pfizer Canada

The paravertebral injections were first referred in 1989 by Dr. Cesare Verga [1], an italian orthopedist. He used them to treat disc herniation. We call them “classical paravertebral injections”. Later on, one colleague of him, Dr. Scuccimarra [2], used longer needles to inject ozone close to the foramen, under the hypothesis of improving the results, and he succeeded. They are known as “deep paravertebral injections”. Other techniques have been developed in order to improve the results, reduce the risks and shorten the treatment.[3-9] The classical paravertebral approach is done locating the upper part of the spinous process of the superior vertebrae involved in the disco-radicular conflict and injecting 2,5 cm to the left and right of the spinous process with a 0,8 x 40 mm needle an amount of 5-10 mL per point depending on the size of the patient. Some authors(63) have proved that using lower ozone concentration (10 µg/mL) can be as useful as standard concentration (20 µg/mL). Our advice is to use a 0,4 x 40 mm needle or thinner if available. Local, topic anesthesia or cryotherapy can be used to reduce the pain of the needle. Injection should be done slowly. Using local anesthesia in the muscle can reduce the effect of ozone injection. The “deep paravertebral injection” uses a similar procedure, but the distance from the middle line is narrower (1,5 cm for cervical and dorsal injection and 2 cm for lumbar injection) and it is necessary using longer needles (0,4 or 0,5 x 90 mm spinal needle) to be able to locate the posterior joints with the tip of the needle an inject periarticularly. The amount of ozone used is the same. It is also possible to inject over the laminae, close to the foramen, instead of around the facet joints, but risk of accidental dura or radicular puncture is greater (although without permanent side effects); this can be done for nerve root de-inflammation. Dr Verga modified his technique for cervical and dorsal disc herniation, narrowing the distance from the spinous process to 1,5 cm left and right, using shorter needles (25 or 30 mm) and decreasing the ozone volume per point to 3-7 mL. Dorsal approach uses the same technique as for cervical paravertebral injections. The classical paravertebral injection produce a relaxation in the muscle spam of the lumbar spine in low back pain. The deep paravertebral injection produce an anti-inflammatory effect that can reduce inflammation on the facet joint or nerve root, depending on the point of injection. Based on this empirical approach, and the publications that have already used them , the indications of these injections are: -Disc herniation [1-2] -Spondylolysis [10] -Spondylosis [11-14] -Lumbar spinal stenosis [7, 15] -Symptomatic treatment of facet joint disease [7] -Mechanical low back pain These injections may have side effects due to the technique itself, not the ozone, but we have few reports on anecdotal cases, most of them without aftermath.

Seguendo l’approccio metodologico della storia dei concetti (Begriffsgeschichte), l’elaborato mira a descrivere i cambiamenti dell’assetto politico-costituzionale italiano attraverso l’evoluzione semantica di sintagmi linguistici come ‘governo parlamentare’, ‘governo rappresentativo’, ‘governo costituzionale’, ‘parlamentarismo’. Tale analisi si concentra grossomodo in un periodo di tempo che va dalla seconda metà dell’Ottocento, fino alla prima metà del Novecento. Come fonti, accanto ai classici prodotti della dottrina politico-costituzionale, quali monografie accademiche, corsi universitari, prolusioni e discorsi parlamentari, si sono utilizzate voci di dizionari e enciclopedie, opuscoli, fonti giornalistiche, periodici e riviste di taglio più o meno specialistico e di orientamento politico diverso (liberale/moderato, cattolico, socialista, repubblicano, nazionalista, fascista). L’evoluzione concettuale di lemmi-cardine come ‘governo parlamentare’ e altri sintagmi ad esso finitimi permette di ricostruire i mutamenti della forma di governo italiana, evitando anche spiacevoli anacronismi a livello storiografico. Infatti la forma di governo non dovrebbero essere descritta attraverso quadri concettuali elaborati nella nostra contemporaneità e poi applicati retrospettivamente al passato, ma con sintagmi e concetti appartenenti alla realtà storica che si intende prendere in esame.