Accidente e plasticità. Pensare filosoficamente l’invecchiamento

Giovanni Isetta, "Accidente e plasticità. Pensare filosoficamente l’invecchiamento", in: Esercizi Filosofici, vol. 10, n. 1 (2015), pp. 97-110Abstract: The rethinking of the concept of plasticity by French philosopher Catherine Malabou requires a revision of' the matter of the accident. Thanks to a unique mixture of Philosophy, Neuroscience, and Psychoanalysis and through the study of new forms of contemporary traumatisms. Malabou was able to unveil an original perspective on the accident. Within this paper I will focus on this concept in the attempt of showing how this new characterization of the accident will lead the fundamental philosophical foundations (accident, destruction, metamorphosis) to reconsider the contemporary form of old age

Did the first description of patients with polymyalgia rheumatica take place in Scotland or in Denmark?

The first description of polymyalgia rheumatica (PMR) is generally attributed to Dr. Bruce. In an 1888 article entitled Senile rheumatic gout, he described five male patients aged from 60 to 74 years whom he had visited at the Strathpeffer spa in Scotland. In 1945, Dr. Holst and Dr. Johansen reported on five female patients examined over several months at the Medical Department of Roskilde County Hospital in Denmark. These patients suffered from hip, upper arms, and neck pain associated with elevated ESR and constitutional manifestations such as low-grade fever or loss of weight. In the same year, Meulengracht, another Danish physician, reported on two patients with shoulder pain and stiffness associated with fever, weight loss, and an increased erythrocyte sedimentation rate. As in the five patients reported by Dr. Holst and Dr. Johansen, a prolonged recovery time was recorded. On reading and comparing these three accounts, we question whether it is correct to attribute the first description of PMR to Dr. Bruce and put forward shifting this accolade to the three Danish physicians

Clinical trials for elderly patients with multiple diseases (CHROMED) pilot study

The problem COPD (Chronic Obstructive Pulmonary Disease) is a significant socioeconomic burden which, particularly when associated with comorbidities such as Chronic Heart Failure (CHF), markedly affects patient outcomes. Care models based on telemedicine systems that enable early diagnosis and treatment of exacerbations are advocated to reduce the impact of chronic diseases on patient outcomes and health service costs. CHROMED (www.chromed.eu) is an international EU-funded project aimed at developing a multi-centre clinical trial to evaluate the impact of a new integrated home care approach to reduce care costs and improve quality of life in COPD. The approach We collaborated in a pilot study prior to the main trial which will include 300 patients from seven European countries (Italy, Spain, UK, Estonia, Slovenia, Sweden and Norway) with nine partners. The home monitoring system includes a novel forced oscillation technique (FOT) device for self-measurement of lung mechanics (RESMONPRO DIARY, Restech srl, Italy), a touch screen for collecting patients' symptoms and, where COPD is associated with CHF, by a device for measuring heart rate (HR), blood pressure (BP), pulse oximetry (SpO2) and body temperature (WRIST CLINIC, Medic4all, Israel). Findings The pilot included 16 patients (n=11 COPD, 5 COPD+CHF). The average monitoring period was 48.3±23.4 days resulting in a total of 504 patient days. The percentage of data correctly received within the period was: lung impedance and breathing pattern 90.0%; HR 91.7%, BP 91.7%; SpO2 74.0% and body temperature 71.4%. During the pilot, one patient was treated pharmacologically for an exacerbation of COPD. Offline processing demonstrated that the system identified warning of an exacerbation five days prior to admission. We also analysed qualitative data from patients and professionals about the acceptability of the telemedicine system and the interaction between patients, professionals and the monitoring system. Consequences The data suggest good acceptability and short-term compliance among patients with COPD. Lung function, HR and BP provided the most reliable data. The full RCT is currently under way and will be completed in August 2015

Resistencia de la garrapata común del bovino Rhipicephalus (Boophilus) microplus a los acaricidas químicos en Corrientes

La garrapata común del ganado bovino, Rhipicephalus (Boophilus) microplus, es responsable de importantes pérdidas económicas que afectan a la producción pecuaria de nuestro país. El control de esta garrapata se basa casi exclusivamente en la aplicación de acaricidas químicos a los cuales la garrapata ya ha desarrollado resistencia. Para conocer el estatus actual de resistencia acaricida en Corrientes y su dispersión, se realizó un muestreo por conveniencia donde se tomaron muestras de teleoginas e información sobre el tipo de acaricida empleado y su forma de aplicación. Las muestras provinieron de 44 establecimientos distribuidos en 15 departamentos de Corrientes de las Zonas de Control y Erradicación.Asociación Parasitológica Argentin

Novel approach to simulate sleep apnoea patients for evaluating positive pressure therapy devices

Bench testing is a useful method to characterize the response of different automatic positive airway pressure (APAP) devices under well-controlled conditions. However, previous mod- els did not consider the diversity of obstructive sleep apnea (OSA) patients ' characteristics and phenotypes. The objective of this proof-of-concept study was to design a new bench test for realistically simulating an OSA patient ' s night, and to implement a one-night exam- ple of a typical female phenotype for comparing responses to several currently-available APAP devices. We developed a novel approach aimed at replicating a typical night of sleep which includes different disturbed breathing events, disease severities, sleep/wake phases, body postures and respiratory artefacts. The simulated female OSA patient example that we implemented included periods of wake, light sleep and deep sleep with positional changes and was connected to ten different APAP devices. Flow and pressure readings were recorded; each device was tested twice. The new approach for simulating female OSA patients effectively combined a wide variety of disturbed breathing patterns to mimic the response of a predefined patient type. There were marked differences in response between devices; only three were able to overcome flow limitation to normalize breathing, and only five devices were associated with a residual apnea-hypopnea index of < 5/h. In conclusion, bench tests can be designed to simulate specific patient characteristics, and typical stages of sleep, body position, and wake. Each APAP device behaved differently when exposed to this controlled model of a female OSA patient, and should lead to further understanding of OSA treatment

Are antifibrinolytic drugs equivalent in reducing blood loss and transfusion in cardiac surgery? A meta-analysis of randomized head-to-head trials

BACKGROUND: Aprotinin has been shown to be effective in reducing peri-operative blood loss and the need for re-operation due to continued bleeding in cardiac surgery. The lysine analogues tranexamic acid (TXA) and epsilon aminocaproic acid (EACA) are cheaper, but it is not known if they are as effective as aprotinin. METHODS: Studies were identified by searching electronic databases and bibliographies of published articles. Data from head-to-head trials were pooled using a conventional (Cochrane) meta-analytic approach and a Bayesian approach which estimated the posterior probability of TXA and EACA being equivalent to aprotinin; we used as a non-inferiority boundary a 20% increase in the rates of transfusion or re-operation because of bleeding. RESULTS: Peri-operative blood loss was significantly greater with TXA and EACA than with aprotinin: weighted mean differences were 106 mls (95% CI 37 to 227 mls) and 185 mls (95% CI 134 to 235 mls) respectively. The pooled relative risks (RR) of receiving an allogeneic red blood cell (RBC) transfusion with TXA and EACA, compared with aprotinin, were 1.08 (95% CI 0.88 to 1.32) and 1.14 (95% CI 0.84 to 1.55) respectively. The equivalent Bayesian posterior mean relative risks were 1.15 (95% Bayesian Credible Interval [BCI] 0.90 to 1.68) and 1.21 (95% BCI 0.79 to 1.82) respectively. For transfusion, using a 20% non-inferiority boundary, the posterior probabilities of TXA and EACA being non-inferior to aprotinin were 0.82 and 0.76 respectively. For re-operation the Cochrane RR for TXA vs. aprotinin was 0.98 (95% CI 0.51 to 1.88), compared with a posterior mean Bayesian RR of 0.63 (95% BCI 0.16 to 1.46). The posterior probability of TXA being non-inferior to aprotinin was 0.92, but this was sensitive to the inclusion of one small trial. CONCLUSION: The available data are conflicting regarding the equivalence of lysine analogues and aprotinin in reducing peri-operative bleeding, transfusion and the need for re-operation. Decisions are sensitive to the choice of clinical outcome and non-inferiority boundary. The data are an uncertain basis for replacing aprotinin with the cheaper lysine analogues in clinical practice. Progress has been hampered by small trials and failure to study clinically relevant outcomes

Lung function assessed by home forced oscillation and self reported symptoms during COPD exacerbations

CHROMED (clinical trials for elderly people with multiple diseases, www.chromed.eu) is an EU-funded project involving 9 partners from 7 European countries aimed at evaluating the impact of a new home care approach to reduce costs and improve quality of life in elderly patients with COPD and comorbidity. The trial involves 300 patients with a prior history of exacerbations randomly assigned to a monitoring or observational arm. Monitored patients performed daily self-assessment of lung mechanics with a FOT (Forced Oscillation Technique) device (RESMON PRO DIARY, Restech srl, Italy) and completed a symptom diary card on touchscreen device (HOME PATIENT MONITOR, EBM srl, Italy). Any detected worsening in lung mechanics generated an alert triggering a phone interview directed at verifying the patient's status and optimizing treatment. By the end of March 2015, 70 monitored patients had completed the trial resulting in 16198 measurements with an adherence of 90.1%. Based on lung mechanics, 311 worsening events were detected, resulting in 0.65±0.3 alerts/patient/month. At least one major symptom (dyspnea, sputum purulence and volume) was reported in 70% of events and 41% were associated with an exacerbation according to diary cards (Seemungal et al., Am J Respir Crit Care Med 1998). A total of 77 exacerbations were confirmed during the phone interview and treated, but 48% of them were not associated with an exacerbation defined by diary cards only. These results suggest that a significant percentage of exacerbations cannot be identified by diary cards only. Self-assessment of lung mechanics using FOT provides complementary information which can be useful to manage COPD patients at home

Randomised controlled trial of telemonitoring with addition of daily forced oscillation in older people with COPD and co-morbidity

Evidence of clinical benefit and cost-effectiveness from daily symptom and simple telemonitoring in COPD is unproven. The CHROMED study explored the effect of telemonitoring in older people with COPD and significant co-morbidity who performed daily forced oscillation measurements via RESMON PRO DIARY to identify early physiological change associated with an exacerbation. Six centres in 5 countries randomised 312 people to 9 months telemonitoring (154) or daily symptom questionnaires (158). Each day the monitored group recorded symptoms, pulse, BP, oxygen saturation and airway resistance and reactance. An alert was generated if results exceeded pre-determined parameters and the participant was contacted by their local clinical centre to consider additional treatment. Baseline characteristics were evenly matched: mean age 71 years, FEV1 1.3L (50% predicted) and SGRQ score 49. 61% of subjects had 2+ exacerbations and 42% had been hospitalised in the previous year. Time to first hospitalisation did not differ albeit the monitoring group had fewer hospitalisations (79 vs 103; p=ns) and days in hospital (329 vs. 650; p=ns). However, subjects hospitalized with an AE COPD in the previous year (n=128) had a lower hospitalisation rate (p<0.04). Quality of life (EQ-5D) and health status (CAT) did not differ between groups. Mean cost in the monitored group was marginally lower (€4,615 vs €4,831; p=ns). Telemonitoring including daily forced oscillation impacted neither time to first hospitalisation nor health status. Reduction in hospitalisation rate in subjects with previous hospitalisation suggests these individuals may benefit from telemonitoring and earlier treatment

A Bayesian cost-effectiveness analysis of a telemedicine-based strategy for the management of sleep apnoea: a multicentre randomised controlled trial

BACKGROUND: Compliance with continuous positive airway pressure (CPAP) therapy is essential in patients with obstructive sleep apnoea (OSA), but adequate control is not always possible. This is clinically important because CPAP can reverse the morbidity and mortality associated with OSA. Telemedicine, with support provided via a web platform and video conferences, could represent a cost-effective alternative to standard care management. AIM: To assess the telemedicine impact on treatment compliance, cost-effectiveness and improvement in quality of life (QoL) when compared with traditional face-to-face follow-up. METHODS: A randomised controlled trial was performed to compare a telemedicine-based CPAP follow-up strategy with standard face-to-face management. Consecutive OSA patients requiring CPAP treatment, with sufficient internet skills and who agreed to participate, were enrolled. They were followed-up at 1, 3 and 6 months and answered surveys about sleep, CPAP side effects and lifestyle. We compared CPAP compliance, cost-effectiveness and QoL between the beginning and the end of the study. A Bayesian cost-effectiveness analysis with non-informative priors was performed. RESULTS: We randomised 139 patients. At 6 months, we found similar levels of CPAP compliance, and improved daytime sleepiness, QoL, side effects and degree of satisfaction in both groups. Despite requiring more visits, the telemedicine group was more cost-effective: costs were lower and differences in effectiveness were not relevant. CONCLUSIONS: A telemedicine-based strategy for the follow-up of CPAP treatment in patients with OSA was as effective as standard hospital-based care in terms of CPAP compliance and symptom improvement, with comparable side effects and satisfaction rates. The telemedicine-based strategy had lower total costs due to savings on transport and less lost productivity (indirect costs)