Maria Felice Arezzo

Spinal epidural hematomas: personal experience and literature review of more than 1000 cases

OBJECTIVE The goal of this study was to identify factors that contribute to the formation of acute spinal epidural hematoma (SEH) by correlating etiology, age, site, clinical status, and treatment with immediate results and long-term outcomes. METHODS The authors reviewed their series of 15 patients who had been treated for SEH between 1996 and 2012. In addition, the authors reviewed the relevant international literature from 1869 (when SEH was first described) to 2012, collecting a total of 1010 cases. Statistical analysis was performed in 959 (95%) cases that were considered valid for assessing the incidence of age, sex, site, and clinical status at admission, correlating each of these parameters with the treatment results. Statistical analysis was also performed in 720 (71.3%) cases to study the incidence of etiological factors that favor SEH formation: coagulopathy, trauma, spinal puncture, pregnancy, and multifactorial disorders. The clinical status at admission and long-term outcome were studied for each group. Clinical status was assessed using the Neuro-Grade (NG) scale. RESULTS The mean patient age was 47.97 years (range 0-91 years), and a significant proportion of patients were male (60%, p < 0.001). A bimodal distribution has been reported for age at onset with peaks in the 2nd and 6th decades of life. The cause of the SEH was not reported in 42% of cases. The etiology concerned mainly iatrogenic factors (18%), such as coagulopathy or spinal puncture, rather than noniatrogenic factors (29%), such as genetic or metabolic coagulopathy, trauma, and pregnancy. The etiology was multifactorial in 11.1% of cases. The most common sites for SEH were C-6 (n = 293, 31%) and T-12 (n = 208, 22%), with maximum extension of 6 vertebral bodies in 720 cases (75%). At admission, 806 (84%) cases had moderate neurological impairment (NG 2 or 3), and only lumbar hematoma was associated with a good initial clinical neurological status (NG 0 or 1). Surgery was performed in 767 (80%) cases. Mortality was greater in patients older than 40 years of age (9%; p < 0.01). Sex did not influence any of these data (p > 0.05). CONCLUSIONS Factors that contribute to the formation of acute SEH are iatrogenic, not iatrogenic, or multifactorial. The treatment of choice is surgery, and the results of treatment are influenced by the patients clinical and neurological status at admission, age, and the craniocaudal site.

Pain in Postsurgical Orthopedic Rehabilitation: A Multicenter Study

OBJECTIVE The aim of this study was to quantify and characterize pain in patients undergoing lower limb postsurgical orthopedic rehabilitation and to investigate the impact of pain in slowing or interrupting their rehabilitation. DESIGN The study was designed as a multicenter cross-sectional study. SETTING The study was set in rehabilitation departments of the Don Gnocchi Foundation. SUBJECTS The study subjects were the inpatients attending rehabilitation. INTERVENTIONS There were no interventions used in the study. OUTCOME MEASURES Pain intensity was measured with a numeric rating scale (NRS); pain characteristics were assessed with the McGill Pain Questionnaire and the ID Pain (able to discriminate nociceptive from neuropathic pain). Quality of life (QoL) was measured with the Short Form 36 Health Status Survey. A semi-structured questionnaire on pain occurrence, impact, and management was administered by the physiotherapist in charge of the patients and by the physician. RESULTS We studied 139 patients, 82% of whom complained of at least moderate pain (NRS ≥ 3). According to ID pain, 45.6% patients complained of probable (33.8%) or highly probable (11.8%) neuropathic pain. A higher pain intensity was significantly related to the probability of having neuropathic pain (P < 0.001). Patients with more severe pain reported lower physical and mental QoL scores. In 38.6% of cases, pain interfered with the rehabilitation process, and in 18.5% it was the cause of physical therapy discontinuation. CONCLUSIONS In light of the high occurrence and intensity of pain in the sample, and of the significant impact on the rehabilitation program, clinicians should pay more attention to pain, especially neuropathic pain, in postsurgical patients. Tailored pain pharmacological therapy could possibly improve patient compliance during the rehabilitation process and enhance long-term outcomes.

Estimating the Probability of Moonlighting in Italian Building Industry

It’s well known that black market economy and especially undeclared work undermines the financing of national social security programs and hinders efforts to boost economic growth. This paper goes in the direction of shedding light on the phenomenon by using statistical models to detect which companies are more likely to hire off the books workers. We used database from different administrative sources and link them together in order to have an informative system able to capture all aspects of firms activity. Afterward we used both parametric and non parametric models to estimate the probability of a firm to use moonlighters. We have chosen to study building industry both because of its importance in the economy of a country and because its a wide spread problem in that sector

Carpal tunnel syndrome treatment with palmitoylethanolamide: neurophysiology and ultrasound show small changes in the median nerve

We have read with attention the paper by Güner et al. about the use of lower-power laser and kinesio taping in carpal tunnel syndrome (CTS) [1]. The authors enrolled 37 patients presenting mild or moderate CTS, diagnosed by neurophysiology [1]. The patients were divided into three groups, to compare the effects of low-power laser therapy, kinesio taping associated with the same type of laser and sham laser. This specific treatment was applied for 3 weeks. The authors considered different outcome measures: visual numeric pain scale, hand grip strength, finger pinch strength, Boston Carpal Tunnel Questionnaire. The evaluations were performed before the therapy, after the treatment and three months later. Güner et al. found the patients managed with the two real treatments showed significant improvements in comparison with the sham one [1]. This work sheds light on specific conservative treatments of CTS, not only throughout questionnaires, but also with more objective measurements (like hand grip strength). The authors explored the effects of the mentioned treatments in a relative small amount of patients and in a relative short-term evaluation. The paper is extremely important for clinic and research activity. It shows the potential effectiveness of conservative approaches in treating CTS. Güner et al. evaluated the effects of an instrumental therapy and a particular device, but some drugs may be considered, in particular for pain relief in CTS. A possible and safe painkilling approach could be based on specific nutraceuticals able to treat pain with limited side effects. Among these, palmitoylethanolamide (PEA) may be a choice, because of its anti-inflammatory properties. However, besides promising data about its effectiveness for pain relief, evidence about its interactions with nerve function is scarce [2]. We have investigated PEA effects in CTS, through a double-blind study, comparing it with a placebo. We enrolled 56 patients presenting minimum and mild idiopathic CTS, diagnosed by clinical, neurophysiological and ultrasonographic (US) examination, following Padua’s classification [3]. We excluded patients with other neuropathies and orthopedic, endocrinological and rheumatological diseases. The patients were directly involved in the study and each one signed a written informed consent. The study was approved by the Local Ethical Committee of Fondazione Don Carlo Gnocchi (number 4_17/6/2009, date June 17, 2009). The patients were randomly assigned to group A (treated with PEA 600 mg/die) and group B (placebo treated). The treatment was one-month long. PEA and the placebo were administered as tablets with the same aspect, thus they were undistinguishable. During the treatment period, the patients were asked to avoid wrist overuse and no other drugs or specific therapy were administered. From the affected hand, we collected: (1) sensory nerve conduction velocity and amplitude of the first and the third digits; (2) distal motor latency and Rheumatology INTERNATIONAL

Estimation of the Healthy Life Expectancy in Italy Through a Simple Model Based on Mortality Rate

We use an advanced methodology based on the mortality rate of a population to explore the healthy life expectancy (HALE) estimates of the World Health Organization (WHO) from the Global Burden of Disease Study. First we calculate the loss of healthy life year estimator (LHLY) and then the healthy life expectancy (HLE). We use the full life tables from the Human Mortality Database (HMD). Our estimates are compared with the HALE estimates for Italy and other countries. Another direct estimation based on the mx and qx quantities provided from the Life Tables is also introduced and tested.

Social Capital, Income Inequality and the Health of the Elderly

It is of common knowledge that the improvement of medicine and living conditions in the twentieth century have greatly contributed to the formidable increase of life expectancy. Therefore many key factors that influence health are well known. What it is less understood and has increasingly grasping the attention of researchers are the social determinants of health. In this paper we will focus in particular on two: income inequality and social capital. After a thorough analysis that explains the nexus at the theoretical level, we will empirically evaluate it by mean of a mixed effects logistic model for the European individuals who are older than 60 in 2011. We find a strong significant association between self-perceived health and social capital, but no link with income inequality.