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Invalid Form: Please fill out all of the required fields below. Home Explore Company.A patient with rheumatoid arthritis presented with increasing fatigue, fever, gingival bleeding, and petechial rash.
Her symptoms started 1 week after the first injection of etanercept Enbrel. Her only other medications methotrexate and hydroxychloroquine had been unchanged for years. Tests revealed severe pancytopenia and bone marrow aplasia. We report a patient with RA who presented with transient bone marrow BM aplasia associated with the first injection of etanercept, and review the literature on TNF-blocking agent-associated cytopenias.
Her recent treatment included methotrexate No other medications were used, and even methotrexate and hydroxychloroquine were discontinued by her rheumatologist when etanercept was commenced. On admission, she was febrile and tachycardic but stable, with unrewarding examination except for gingival bleeding, a profuse petechial rash over both legs and polysynovitis, which was not new. Laboratory tests showed hemoglobin Hb 7. Serum creatinine, electrolytes, and liver enzymes were normal.
Peripheral blood smear confirmed severe pancytopenia with absent reticulocytes 0. Bone marrow aspiration and biopsy revealed BM aplasia Fig. Methotrexate in serum was undetectable. Chest X-ray, urinalysis, and cultures were normal. She was discharged on the 12th hospital day, afebrile and stable absolute neutrophil count [ANC] One month later, the Hb was For example, neutropenia was reported in Indeed, 19 patients with significant thrombocytopenia were identified in a recent review of the literature and, as in the case of neutropenia, almost all were due to either etanercept or infliximab [ 6 ].
No other concomitant medication was reported in most of the patients. Rarely, patients may develop both severe neutropenia and thrombocytopenia [ 7 ], whereas anemia is not usually a feature of this treatment. However, this therapy, especially etanercept and infliximab, may mediate a more life-threatening adverse event than neutropenia or thrombocytopenia, namely, aplastic anemia and pancytopenia. A few such patients have been identified in post-marketing reports, although the attribution of pancytopenia to the TNF inhibitor remains unclear [ 9 ].
Our patient presented with symptoms and signs related to all three cytopenias: fatigue due to anemia ; fever that responded to broad spectrum antibiotics due to severe neutropenia ; and petechiae and gingival bleeding due to severe thrombocytopenia.
Biomarkers associated with cardiovascular disease in patients with early rheumatoid arthritis
The absence of concomitant drugs she had been receiving methotrexate and hydroxychloroquine for years as well as the temporal relationship between the appearance of her symptoms and the first injection of etanercept, strongly suggest a causal link. Moreover, BM recovery from toxic injury corresponded to the discontinuation of etanercept, whereas methotrexate was later continued uneventfully for months. Other than listing all hitherto-reported cases of TNF blocking agent-associated aplastic anemia and pancytopenia, the literature review reveals the rarity of the association, considering that hundreds of thousands of patients have been treated.
The other striking feature is the complexity of the pathogenesis. Thus, its blockade can also exert a deleterious effect on hematopoiesis [ 6 ]. Since autoimmune mechanisms are believed to have a key role in the pathogenesis of idiopathic aplastic anemia [ 25 ], the association between TNF-targeted therapies and induction of autoimmune diseases particularly, vasculitis and lupus predominantly with infliximab and etanercept is also a tenable mechanism [ 26 ].
Since a steadily increasing number of patients are being treated for longer periods, any serious adverse effect, however rare, may be encountered.
Monitoring blood counts of patients starting treatment seems advisable, and we also suggest that patients should be instructed to consult their physician when unexplained fever, fatigue, or bleeding manifestations appear. Ann Rheum Dis. Neutropenia while receiving anti-tumour necrosis factor treatment for rheumatoid arthritis. A comparison of etanercept and methotrexate in patients with early rheumatoid arthritis. N Engl J Med. Neutropenia in patients receiving anti-tumor necrosis factor therapy.
Arthritis Care Res Hoboken.The prediction of readmission or death after a hospital discharge for heart failure HF remains a major challenge.
Modern healthcare systems, electronic health records, and machine learning ML techniques allow us to mine data to select the most significant variables allowing for reduction in the number of variables without compromising the performance of models used for prediction of readmission and death.
Moreover, ML methods based on transformation of variables may potentially further improve the performance. To use ML techniques to determine the most relevant and also transform variables for the prediction of day readmission or death in HF patients. We identified all Western Australian patients aged 65 years and above admitted for HF between — in linked administrative data.
We evaluated variables associated with HF readmission or death using standard statistical and ML based selection techniques. We also tested the new variables produced by transformation of the original variables. We developed multi-layer perceptron prediction models and compared their predictive performance using metrics such as Area Under the receiver operating characteristic Curve AUCsensitivity and specificity.
Following hospital discharge, the proportion of day readmissions or death was A small set of variables selected using ML matched the performance of the model that used the full set of 47 variables for predicting day readmission or death in HF patients.
Model performance can be further significantly improved by transforming the original variables using ML methods. This is an open access article distributed under the terms of the Creative Commons Attribution Licensewhich permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: We will consider requests for data sharing on an individual basis, with the aim to share data whenever possible for appropriate research purposes.
However, this research project uses data obtained from a third-party source under strict privacy and confidentiality agreements from Australian State and Federal government databases, which are governed by their ethics committees and data custodians.
The data were provided after approval was granted from their standard application processes for access to the linked datasets. Therefore, any requests to share these data with other researchers will be subject to formal approval from the third-party ethics committees and data custodian s. The NHMRC had no input into the study design, data collection, analyses and interpretation of the data, preparing the manuscript and the decision to submit for publication.
Competing interests: The authors have declared that no competing interests exist. Heart Failure HF is a prevalent cardiovascular disorder affecting more than 25 million people worldwide[ 1 ]. HF is also associated with a high rate of readmissions incurring significant economic costs, and driving healthcare policies to include financial penalties for hospitals that have high rates of readmissions for HF[ 2 ]. The adverse financial implications have served as a motivation to develop models that can accurately predict readmissions at the time of an index hospital discharge.
The enormous amount of clinical and administrative data generated in the healthcare sector can be used to personalise care, improve the quality of treatment and reduce treatment costs.
We and others have applied machine-learning ML techniques on administrative data previously to predict HF readmissions[ 45 ]. These techniques use patient data to learn hidden patterns that significantly contribute to the outcomes.Decreto legislativo 18 aprilen. Testo aggiornato e coordinato con la legge 14 giugnon. Oggetto e ambito di applicazione Art.
Competenze legislative di Stato, regioni e province autonome Art.
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Appalti e concessioni aggiudicati ad una joint venture o ad un ente aggiudicatore facente parte di una joint venture Art. Contratti di servizi aggiudicati in base ad un diritto esclusivo Art. Contratti nel settore dell'acqua, dell'energia, dei trasporti e dei servizi postali Art. Appalti aggiudicati da particolari enti aggiudicatori per l'acquisto di acqua e per la fornitura di energia o di combustibili destinati alla produzione di energia Art. Esclusioni specifiche nel settore idrico Art. Appalti aggiudicati a scopo di rivendita o di locazione a terzi Art.
Esclusioni nel settore delle comunicazioni elettroniche Art. Contratti e concorsi di progettazione aggiudicati o organizzati in base a norme internazionali Art. Esclusioni specifiche per contratti di appalto e concessione di servizi Art.
Altri appalti esclusi Art. Esclusioni specifiche per contratti di concessioni Art. Contratti di sponsorizzazione Art.
Opera pubblica realizzata a spese del privato. Programma degli acquisti e programmazione dei lavori pubblici Art. Trasparenza nella partecipazione di portatori di interessi e dibattito pubblico Art. Progettazione interna e esterna alle amministrazioni aggiudicatrici in materia di lavori pubblici Art. Verifica preventiva della progettazione Art.
Procedure di approvazione dei progetti relativi ai lavori. Contratti misti di appalto Art. Principi in materia di trasparenza Art. Ruolo e funzioni del responsabile del procedimento negli appalti e nelle concessioni Art. Fasi delle procedure di affidamento Art. Controlli sugli atti delle procedure di affidamento Art. Soglie di rilevanza comunitaria e metodi di calcolo del valore stimato degli appalti Art.
Contratti sotto soglia. Aggregazioni e Centralizzazione delle Committenze Art. Qualificazione delle stazioni appaltanti e centrali di committenza Art. Obbligo di uso dei mezzi di comunicazione elettronici nello svolgimento di procedure di aggiudicazione Art. Misure di semplificazione delle procedure di gara svolte da centrali di committenza Art. Conflitto di interesse Art. Appalti che coinvolgono amministrazioni aggiudicatrici e enti aggiudicatori di Stati membri diversi. Digitalizzazione delle procedure Art.
Operatori economici Art. Requisiti per la partecipazione dei consorzi alle gare Art. Raggruppamenti temporanei e consorzi ordinari di operatori economici Art. Condizioni relative all'AAP e ad altri accordi internazionali Art.The data used for this study contain protected health information. Patients with rheumatoid arthritis RA have an increased mortality and morbidity due to cardiovascular disease CVD.
The aim of this study was to find out whether the RA-disease per se affect these biomarkers and if those could be associated with the progression of atherosclerosis, as measured by intima media thickness IMT among patients with early RA. Patients from northern Sweden diagnosed with early RA, are consecutively recruited into an ongoing prospective study on CVD comorbidity.
The patients were clinically assessed. Blood was analysed for lipids, ESR and CRP and several biomarkers known to be associated with atherosclerosis in the general population. Here, MMP3 was identified as influential.
This study indicates that the RA disease itself could affect several of the biomarkers in this study, and possibly also the processes involved in the development of atherosclerosis. Patients with rheumatoid arthritis RA have an increased atherosclerosis compared with the general population [ 1 — 5 ]. Atherosclerosis is now recognised as an inflammatory disease per seand the two diseases, atherosclerosis and RA, are considered to share many similarities [ 6 ], albeit the link between them is, as yet, not evident.
Even though, all stages of the atherogenic process appear to be enhanced in RA, all the way to increased incidence of cardiovascular disease CVD events [ 78 ]. Sub-clinical atherosclerosis precedes CVD and an increased intima media thickness IMTmeasured by ultrasonography, is regarded to be an early indicator of a generalized atherosclerosis [ 910 ]. We, and others, have previously shown that patients with established RA have a premature atherosclerosis as measured by an increased IMT of the common carotid artery CCA compared with controls [ 11 — 13 ].
However, this ultrasound measured indicator is not easily available and, further, has disadvantages like lack of possibility to detect the very early phases of the development of atherosclerosis. Therefore, to increase both the benefits of health and cost effectiveness, it is important to enhance the accuracy of the identification of the individuals at risk for increased atherosclerosis and subsequently CVD. In recent years, an interest has been growing to identify new molecular mechanisms associated with the developmental process of atherosclerosis [ 14 ].
The identification of such new biomarkers may improve the prediction of cardiovascular events and death. The aim of this study was to find out whether the RA-disease per se affects biomarkers known to be associated with atherosclerosis in the general population. Further, to find out whether these biomarkers are associated with the progression of subclinical atherosclerosis among patients with early RA.
As described in detail previously [ 15 — 17 ] this study is a part of a continuing structured programme involving patients with early RA from Northern Sweden for the prospective analysis of the development of CVD using the nationwide Swedish Rheumatology Quality Register SRQ.
All eligible patients with newly diagnosed RA i.Ta en titt! Disse hanskene er laget for arbeid. It means living in the comfort zone, Where they do not have to think about risk — about danger.
For some people, this is fine. Not for the thrill of it. Not as a joke. But because there is a job to be done.
And someone has to do it: Someone with bold blood, Who does not choose the easy route, But adventure; Who can be called upon, And relied upon, When there is difficult work to be done.
Not because no one else is willing, But because no one else is better. EN standarden tar for seg de generelle kravene til vernehansker. Passer til: Mekanikk Olje og gass Raffinerier Byggfag. EN Passer til: Montering osv. EN, CE Cat. Les mer om Myke og fleksible hansker med lang levetid. En av de vanligste er at de kommer i direkte kontakt med huden. Alle hansker reagerer forskjellig etter som hvilken kjemikalie de blir utsatt for.
Skal ikke brukes i direkte kontakt med fettholdig mat. Inneholder ingen kjente allergener. Passer til: Profesjonelt renhold Storhusholdning etc.