L'utilizzo dei casi di studio per favorire l'apprendimento di metodologie e strumenti per lo sviluppo organizzativo o di percorsi di cura nelle aziende sanitarie

La formazione, in ambito sanitario, è considerata una grande leva di orientamento dei comportamenti, ma la metodologia tradizionale di formazione frontale non è la più efficace, in particolare nella formazione continua o “long-life education”. L’obiettivo primario della tesi è verificare se l’utilizzo della metodologia dello “studio di caso”, di norma utilizzata nella ricerca empirica, può favorire, nel personale sanitario, l’apprendimento di metodi e strumenti di tipo organizzativo-gestionale, partendo dalla descrizione di processi, decisioni, risultati conseguiti in contesti reali. Sono stati progettati e realizzati 4 studi di caso con metodologia descrittiva, tre nell’Azienda USL di Piacenza e uno nell’Azienda USL di Bologna, con oggetti di studio differenti: la continuità di cura in una coorte di pazienti con stroke e l’utilizzo di strumenti di monitoraggio delle condizioni di autonomia; l’adozione di un approccio “patient-centred” nella presa in carico domiciliare di una persona con BPCO e il suo caregiver; la percezione che caregiver e Medici di Medicina Generale o altri professionisti hanno della rete aziendale Demenze e Alzheimer; la ricaduta della formazione di Pediatri di Libera Scelta sull’attività clinica. I casi di studio sono stati corredati da note di indirizzo per i docenti e sono stati sottoposti a quattro referee per la valutazione dei contenuti e della metodologia. Il secondo caso è stato somministrato a 130 professionisti sanitari all’interno di percorso di valutazione delle competenze e dei potenziali realizzato nell’AUSL di Bologna. I referee hanno commentato i casi e gli strumenti di lettura organizzativa, sottolineando la fruibilità, approvando la metodologia utilizzata, la coniugazione tra ambiti clinico-assistenziali e organizzativi, e le teaching note. Alla fine di ogni caso è presente la valutazione di ogni referee.

Efficacia del trattamento con concentrati piastrinici (P.R.P.) nelle lesioni condrali e tendinopatie

Purpose: Recent knowledge regarding tissue biology highlights a complex regulation of growth factors in reaction to tissue damage. Platelet Rich Plasma (P.R.P.), containing a natural pool of growth factors, can be obtained in a simple and minimally invasive way and be applied to the lesion site. The aim of this study is to explore this novel approach to treat cartilage degenerative lesions of the knee and tendon chronic lesions( patellar tendon, and achilles tendon). In this study we evaluated if the treatment with PRP injections can reduce pain and increase function in cases of patellar tendinosis (Jumper’s Knee), in chronic achilles tendinopathy and in patients with cartilage injuries of the knee. Materials and Methods: 40 patients with cartilage lesion of the knee, 28 male and 12 female with mean age 47 y. (min 18- max 52 years), were treated and prospectively evaluated at a minimum 6 months follow-up; in the same way, 12 patients with achilles tendon lesion (8 male and 4 female) with mean age 44,5 y. (min 32-max 58 years) and 10 patients with “Jumper’s Knee” (8 male and 2 female) with mean age 23,2 y. (min 18-max 37 years), were evaluated at 6 months follow up. The procedure involved 3 multiple injections , performed every two weeks. All patients were clinically evaluated at the end of the treatment and at 6 months follow up. IKDC, SF36, EQ-VAS, scores were used for clinical evaluation and patient satisfaction and functional status were also recorded. Results: Statistical analysis showed a significant improvement in the SF36 questionnaire in all parameters evaluated at the end of the therapy and 6 months follow-up in both group(tendinopathies and chondral lesions), and in the EQ VAS and IKDC score (paired T-test, p<0.0005) from basal evaluation to the end of the therapy, and a further improvement was present at 6 months follow-up. Whereas a higher improvement of the sport activity level was achieved in the “Jumper’s Knee” group. No complications related to the injections or severe adverse events were observed during the treatment and follow up period. Conclusion: PRP inhibits excess inflammation, apoptosis, and metalloproteinase activity. These interactive pathways may result in the restoration of tendon or cartilage, which can with stand loading with work or sports activity, thereby diminishing pain. PRP may also modulate the microvascular environment or alter efferent or afferent neural receptors. The clinical results are encouraging, indicating that PRP injections may have the potential to increase the tendon and cartilage healing capacity in cases with chronic tendinosis and chondropathy of the knee.

Biomedicine and pain

The focus of my research is on contemporary biomedical construction of pain as an object, i.e. the different ways in which pain has been conceptualized and approached as a specific site of investigation in biomedicine. A significant shift in the scientific conception of pain occured in the second half of XXth century. In 1965, Ronald Melzack and Patrick D. Wall propose the Gate Control theory of pain mechanism. This theory denies a fixed and direct relationship between stimulus and pain perception, and emphazises the role played by psychological factors in pain. The IASP utilizes this perspective on the phenomenon, describing pain as “an unpleasant sensory and emotional experience associated to an actual or potential tissue damage or described in the terms of such a damage.” The relationship between pain and damage is pivotal in the definition of pain as a pathological entity. In particular, the biomedical approach to pain appears to be strongly characterized by a dualistic view of its aetiology. Disease conceptions such as “psychogenic pain” and chronic pain are deeply influenced by the ways in which psychological factors have been interpreted as components, or as causes of pain. In the second part of my dissertation, I focus on fibromyalgia, which is emblematic of the problematic acknowledgment of chronic pain as a disease. Even if fibromyalgia is actually treated in Rheumatology, its status as a disease is blurred, mainly because of its complex symptomatology including both physiological manifestations and psychological ones. In the conclusion, I present a scenario of the different ways in which this disease is dealt with in biomedical knowledge, through medical literature, clinical practice, and patients’ accounts. The findings of an ethnographic enquiry in the Rheumatology Division of a local clinic and a visual research on patients’ experiences are analyzed and discussed.

Evaluation of Antitumoral activity of bone targeted drugs/conventional chemotherapies and identification of biomarkers for the selection of patients with breast cancer for the bone targeted therapy in adjuvant setting

Bone metastases are responsible for different clinical complications defined as skeletal-related events (SREs) such as pathologic fractures, spinal cord compression, hypercalcaemia, bone marrow infiltration and severe bone pain requiring palliative radiotherapy. The general aim of these three years research period was to improve the management of patients with bone metastases through two different approaches of translational research. Firstly in vitro preclinical tests were conducted on breast cancer cells and on indirect co-colture of cancer cells and osteoclasts to evaluate bone targeted therapy singly and in combination with conventional chemotherapy. The study suggests that zoledronic acid has an antitumor activity in breast cancer cell lines. Its mechanism of action involves the decrease of RAS and RHO, as in osteoclasts. Repeated treatment enhances antitumor activity compared to non-repeated treatment. Furthermore the combination Zoledronic Acid + Cisplatin induced a high antitumoral activity in the two triple-negative lines MDA-MB-231 and BRC-230. The p21, pMAPK and m-TOR pathways were regulated by this combined treatment, particularly at lower Cisplatin doses. A co-colture system to test the activity of bone-targeted molecules on monocytes-breast conditioned by breast cancer cells was also developed. Another important criticism of the treatment of breast cancer patients, is the selection of patients who will benefit of bone targeted therapy in the adjuvant setting. A retrospective case-control study on breast cancer patients to find new predictive markers of bone metastases in the primary tumors was performed. Eight markers were evaluated and TFF1 and CXCR4 were found to discriminate between patients with relapse to bone respect to patients with no evidence of disease. In particular TFF1 was the most accurate marker reaching a sensitivity of 63% and a specificity of 79%. This marker could be a useful tool for clinicians to select patients who could benefit for bone targeted therapy in adjuvant setting.