Knowledge and attitude of pain management among Italian nurses in intensive care unit: a multicentric descriptive study.

Aim: The main objective of the study was to document the current knowledge and attitudes towards pain management among Italian nurses working in intensive care unit (ICU). Methods: A multicenter cross-sectional study design was carried out. In order to assess the knowledge and attitudes of pain management, the KASRP questionnaire was used. The questionnaire was submitted online through Google Forms platform. Results: A total of 864 nurses completed and returned the study questionnaire (58% were males). The mean of the total correct answers was 31.21 (SD 2.92) out of 40 (total score if all items answered correctly) with range of 22-38. No significant differences were observed with regard to gender (t = 1.875, P = .061). Spearman's correlation test showed a positive significant relationship between knowledge and attitude of pain management and years of ICU experience (r = -.424, P <.001) and between knowledge and attitude of pain management and the attendance of a pain update course in the last 3 years (r= -0.83, P =.014). We haven't found any correlation neither between age and knowledge nor between age and attitude score (r = -0.32, P = .351). Conclusions: This study has shown that Italian ICU nurses have good level of pain management knowledge and attitudes of pain medication. It is recommended to consider pain management in the context of continuing professional development.

Incidence of pain at rest and during nursing procedures in ICU patients: a longitudinal observational study.

AIM: To evaluate pain monitoring in surgical and no-surgical ICU patients and to observe the presence of pain at rest and during nursing procedures. METHODS: A longitudinal, observational study was conducted at an intensive care unit in Italy. Based on the specific conditions of the patient the best rating scale was used (Numerical Rating Scale or the Critical-Care Pain Observation Tool). Two ICU nurses performed pain assessments before and during some nursing procedures that are considered nociceptive. RESULTS: The pain incidence rate in 1,602 days of observation was 0.06 patient/day (59/1000 days of observation). The incidence rate of intense pain was 0.012 patient/day (12/1000 days of observation). Pain at rest was detected in 67 (27.6%) patients. Pain during procedures was found 134 (36.1%) times. In the 96 patients who were in pain the ICU stay (15.4 days + 7.8 vs 11.4 days + 5.6) and the days of mechanical ventilation (13.4 + 7.9 vs 9.7 + 4.9) was increased. Surgical patients had an increased pain risk than non-surgical patients (RR = 2.7, CI = 2.0-3.6; p<.001). CONCLUSIONS: The incidence of pain was recorded in 39.5% of ICU patients. However further studies of larger patient samples are needed.

Morphological and histochemical characteristics of the epithelium of ovarian lamellae of Genypterus blacodes (Schneider, 1801).

The physiological significance of the glycoproteins (GPs) secreted by the epithelium of ovarian lamellae is discussed in reference to the reproductive biology of G. blacodes. Histochemical procedures for localising and characterising GPs were used to determine the cytoplasmic components of cells of the epithelium that covers the ovarian lamellae of pink cuskeel, Genypterus blacodes (Schneider, 1801) (Pisces, Ophidiidae), during spawning. This species is one of the most valuable demersal fish resources in the Argentine Sea, mainly due its large size and flesh quality. GPs with oxidizable vicinal diol groups, sialic acid with or without O-acyl substituents, O-acyl sugars, neutral sugars and GPs with carboxyl and sulphate groups were detected. Light microscope examination showed morphological changes in the epithelium of ovarian lamellae during the spawning season, associated with a secretory activity of mucus. Optical density studies revealed the presence of polyploid cells encompassing those morphological changes. Results of the present study suggest that the epithelium of ovarian lamellae of G. blacodes performs a secretory role, which is intensified during ovarian maturity, suggesting that G. blacodes could release masses of eggs enveloped in mucus.

Claustroneocortical projections studied in the cat by means of multiple retrograde fluorescent tracing.

The topographical interrelations of claustroneocortical cells and their degree of divergent collateralization were investigated in cat by means of retrograde fluorescent double labeling. The tracers Fast Blue (FB) and Nuclear Yellow (NY) were injected in several combinations in two different cortical fields. FB-labeled and NY-labeled cells were found in all cases in the insular portion of the ipsilateral claustrum (CII). The distributions of labeled cells confirmed the organization reported in previous studies. In some cases the two labeled cell populations were segregated in different parts of the CII; in other cases there was more or less overlap in the two distributions. The degree of overlap was not simply related to the topographic proximity of the injected cortical territories. In all cases the vast majority of cells were single labeled. In one case both FB and NY were injected in the same cortical area in order to control that claustral axons can retrogradely transport two tracers back to the same parent cell bodies. In this control case CII cells were double labeled. All together these data indicate that widely divergent claustroneocortical projection take origin mainly from separate cells.

The organization of the claustroneocortical projections in the cat studied by means of the HRP retrograde axonal transport.

The projections from the claustrum to the cerebral cortex were examined in the cat by means of horseradish peroxidase (HRP) injections in various different areas of the lateral and medial surfaces of the neocortex. In all cases retrogradely labeled cells were observed in the ipsilateral claustrum insulare (ClI). In most of the cases some labeled cells were also observed in the contralateral ClI. The number of labeled cells was higher following large HRP injections in some cortical areas, such as the motor and visual cortex, than following large HRP injections in other areas, such as the second somatic sensory cortex. The patterns of distribution of labeled cells in the ClI following the different HRP injections evidenced a prevalent anteroposterior and dorsoventral topographical arrangement. However, some degree of overlapping was evident in the distribution of cells retrogradely labeled from injections in different cortical fields. The results of the present study indicate that: a) in all likelihood the claustral projections are distributed upon the entire neocortex; b) they are not uniformly distributed upon the neocortex from the quantitative point of view; c) the arrangement of the claustrocortical projections is predominantly but not strictly topographical. The widespread distribution of the claustral inputs suggests that they must be integrated in different models of cortical activity.

Multiple cortical targets of one thalamic nucleus: the projections of the ventral medial nucleus in the cat studied with retrograde tracers.

The organization of the cortical projections of the ventral medial thalamic nucleus (VM) was studied in the cat with retrograde tracers. The extent of the VM-cortical projections was first investigated with horseradish peroxidase injected in different cortical fields. The results obtained in the experiments indicated that the main target of VM efferents is represented by a large territory anterior to the cruciate sulcus involving area 6 and the gyrus proreus and extending into the anterior part of the medial cortical surface. The afferents to these precruciate fields arise from throughout the VM. In addition, the lateral third of VM projects upon the lateral precruciate cortex that is coextensive with the precruciate part of area 4, whereas VM efferents do not extend into the posterior sigmoid gyrus. A second major target of VM efferents is represented by the insular cortex in the anterior sylvian gyrus. VM projections also reach the prepyriform cortex and the cingulate gyrus. An anteroposterior decrease of density was found in the VM-cingulate projections. Sparse VM projections reach the temporal cortex, the adjacent posterior sylvian and ectosylvian fields, and the anterior ectosylvian gyrus. No VM projections were found either upon the visual areas 17 and 18 or upon the primary auditory cortex. The interrelations between some VM-cortical cell populations and their divergent collateralization were studied by using double retrograde labeling with fluorescent tracers. The results of these experiments demonstrated that a relatively high number (at least 20%) of VM cells projecting to the insula are also connected to the precruciate fields by means of axon collaterals. This finding indicates that VM is a highly collateralized structure of the cat's thalamus. Very few branched cells were found in the other combinations of cortical fields here examined (precruciate vs. posterior sylvian fields, lateral precruciate vs. proreal cortex, anterior vs. posterior cingulate fields). Altogether these data indicate that VM branched cells preferentially interconnect the two main cortical targets of the nucleus, i.e., precruciate and insular fields. The results of the present study are discussed in regard to the literature on the VM projections in the rat and the previously available data in the cat, to the afferent VM organization in the cat, to the relationships between VM and the nucleus submedius, and to the anatomical and functional role of VM in relation to the so-called "nonspecific" thalamocortical system.

Mapping subcortical extrarelay afferents onto primary somatosensory and visual areas in cats.

Projections from the claustrum (Cl) and the thalamic anterior intralaminar nuclei (AIN) to different representations within the primary somatosensory (S1) and visual (V1) areas were studied using the multiple retrograde fluorescent tracing technique. The injected cortical regions were identified electrophysiologically. Retrograde labeling in Cl reveals two different projection patterns. The first pattern is characterized by a clear topographic organization and is composed of two parts. The somatosensory Cl shows a dorsoventral progression of cells projecting to the hindpaw, forepaw, and face representations of S1. The visual Cl has cells projecting to the vertical meridian representation of V1 surrounded dorsally by neurons projecting to the representation of retinal periphery. A second pattern of Cl projections is composed of neurons that are distributed diffusely through the nucleus. In both somatosensory and visual sectors, these intermingle with the topographically projecting cells. Neurons retrogradely labeled from cortical injections are always present in the AIN. In the central medial nucleus, the segregation of modality is evident: The visual-projecting sector is dorsal, and the somatosensory is ventral. Projections from the central lateral nucleus display detectable somatotopic and retinotopic organization: Individual regions are preferentially connected with specific representations of S1 or V1. In the paracentral nucleus, no clear regional preferences are detectable. Also performed were comparisons of the proportions of neurons projecting to different sensory representations. Projections to V1 from both AIN and Cl are biased towards the retinal periphery representation. S1 projection preference is for the forepaw representation in Cl and for the hindpaw in the AIN. The quantitative analysis of multiply labeled cells reveals that, compared to Cl, the AIN contains a higher proportion of neurons branching between different representations of S1 or V1. The concept of topographic vs. diffuse projecting systems is reviewed and discussed, and functional implications of quantitative analysis are considered.

Fatal familial insomnia: genetic, neuropathologic, and biochemical study of a patient from a new Italian kindred.

Fatal familial insomnia (FFI) is an inherited prion disease linked to a mutation at codon 178 of the PRNP gene that results in aspartic acid to asparagine substitution, in coupling phase with methionine at position 129. The disease is characterized clinically by insomnia with disturbances of the autonomic, endocrine, and motor systems and neuropathologically by selective degeneration of the thalamus. Phenotypic variability is well known and has been linked to homozygosity or heterozygosity at PRNP codon 129. We report the clinical, neuropathologic, and biochemical findings and genomic analysis of a patient with FFI from a new Italian kindred. Although homozygous for methionine at codon 129, this patient showed some clinical and pathologic features most commonly found in heterozygotes.

Polymorphism at codon 129 or codon 219 of PRNP and clinical heterogeneity in a previously unreported family with Gerstmann-Sträussler-Scheinker disease (PrP-P102L mutation).

We present a new, large, Italian family affected by Gerstmann-Sträussler-Scheinker syndrome (GSS) associated with the Pro to Leu point mutation at codon 102 of the prion protein gene (PRNP). The affected members of this family show a remarkable phenotypic variability of the disease: three of them had a clinical picture characterized by dementia and a brief illness duration (less than 1 year), while the other five members presented an ataxic, slowly evolving syndrome (a clinical duration of 3 to 4 years) with no evidence of cognitive impairment. Despite these remarkable clinical differences among affected members, we found no correlation between the clinical presentation and the codon 129 or codon 219 genotypes. These data suggest that factors as yet unidentified may influence the clinical expression of the disease.

Potentiation of electroencephalographic spindles by ibotenate microinjections into nucleus reticularis thalami of cats.

It is well known that the electroencephalogram of the cat in the early stages of slow wave sleep is mainly characterized by rhythmic wave activity at 7-14 Hz, termed spindles, which recur periodically with a slow rhythm of 0.1-0.2 Hz. From early stimulation, decortication and transection studies (see Ref. 14), spindle oscillations were thought to originate in the thalamus. The search for the anatomical substrate of thalamic spindling, however, moved from medial (intralaminar nuclei) to lateral thalamic nuclei, and recently focused on the extreme shell-shaped collection of GABA-ergic cells, the nucleus reticularis thalami. This proposition was based on its structural, hodological, and physiological aspects. There is accumulating evidence that the nucleus reticularis may act as a conditional pacemaker, synchronizing the activity of cortically projecting thalamic neurons. The introduction of glutamate analogues with excitotoxic properties such as ibotenic acid provided the opportunity of studying the immediate effects of chemical excitation of this nucleus on synchronized electroencephalographic activity. We found that, in cats, spindle density was dramatically increased following infusion of ibotenic acid into the rostral pole of the nucleus, supporting the role of this sector in spindle-related rhythmicity.

The organization of the ipsi- and contralateral claustrocortical system in rat with notes on the bilateral claustrocortical projections in cat.

The organization of the claustrocortical system was investigated in rat by means of cortical injections of either lectin-conjugated horseradish peroxidase or retrograde fluorescent tracers. The latter were also employed in cat. Evans Blue, Fast Blue, True Blue, Nuclear Yellow and Diamidino Yellow were used in different combinations and were injected, uni- or bilaterally, in different cortical fields. Cells retrogradely labeled from each cortical injection were observed in the ipsi- and contralateral claustrum. Anterogradely labeled terminals were also seen in the claustra of both sides in the horseradish peroxidase experiments. The topographic and quantitative study of the distribution of labeled neurons showed a topographic organization of the rat's claustrocortical system, although a certain degree of overlap of the cell populations projecting to frontal and occipital fields was also evident. Four types of branched claustrocortical neurons were observed in the double labeling experiments: neurons branching ipsilaterally (A) or contralaterally (B) to anterior and posterior cortical fields; neurons branching bilaterally to homotopic (C) or heterotopic (D) cortical fields. Each population of branched neurons was equivalent to a different percent value of the total labeled cell populations; the percent value decreased from type A to type D. Type C branched neurons were also identified in the claustrofrontal system of the cat. The intricate organization of the claustral-ascending projections suggests that the nucleus is involved in different cortical activities and that its efferents may also provide the substrate of a powerful subcortical mechanism of interhemispheric communication.

A procedure for the simultaneous visualization of two anterograde and different retrograde fluorescent tracers. Application to the study of the afferent-efferent organization of thalamic anterior intralaminar nuclei.

The present report describes a method for the simultaneous visualization, in the same structure, of two different sets of afferent pathways and the neurons of origin of some efferent projections. This method has been applied in the cat for studying, in the thalamic anterior intralaminar nuclei, the topographical relationships of afferent arising from the spinal cord and deep cerebellar nuclei with neurons projecting to different cortical areas. Spino- and cerebello-thalamic terminals were anterogradely labeled by injections of the fluorescent dyes fast blue (FB) and 1,1'-dioctadecyl-3,3,3',3'-tetramethyl-indocarbocyanine perchlorate (DiI) in the spinal cord and cerebellum. Thalamo-cortical neurons were retrogradely labeled by injections of fluorescent tracers in the precruciate and anterior suprasylvian cortices. The findings show that spinal and cerebellar afferent fibers and the cells of origin of intralaminocortical projections are organized in a clear modular manner and indicate that the method used here is suitable for analyzing simultaneously, in light microscopy, multiple input-output interrelationships of a single structure.

Quantitative data on cell loss and cellular atrophy of intralaminar nuclei following cortical and subcortical lesions.

Morphological changes in the intralaminar nuclei centralis medialis, paracentralis and centralis lateralis of the thalamus of adult cats after cortical excisions have been determined by means of a quantitative method. The number and size of the remaining neurons on the operated side have been compared with those of the normal side. The differences between the normal and the operated side have been compared to those found between the two sides in the control animals. The most important result is the demonstration that after cortical ablations the intralaminar nuclei show not only chromatolytic or atrophic changes of their cells but also a true cell loss. These reactions are qualitatively similar to those observed in the specific nuclei of the thalamus, the only difference being a quantitative one. As a consequence it can be suggested that some intralaminar nuclei project to certain areas of the cerebral cortex which also receive projections from one or other specific thalamic nucleus. A large essential connection of the intralaminar nuclei, in particular the nucleus centralis medialis, with subcortical structures is confirmed.

Diffuse thalamic degeneration in fatal familial insomnia. A morphometric study.

A morphometric investigation disclosed most thalamic nuclei severely degenerated in two patients with fatal familial insomnia. Associative and motor nuclei lost 90% neurons, and limbic-paralimbic, intralaminar and reticular nuclei lost 60%. These findings point to the disorganization of most thalamic circuits as a condition necessary for the sleep-wake rhythm being affected.

Early MRI findings in Creutzfeldt-Jakob disease.

We describe the MRI changes preceding the onset of myoclonus in two patients whose post-mortem examination confirmed the diagnosis of Creutzfeldt-Jakob disease (CJD). MRI showed changes in the striatum early in the course of CJD (2-6 months after the onset of apathy, interpreted as depression, and 1-2 months before the onset of further clinical symptoms). Only in one patient did electroencephalography record the typical triphasic sharp-waves, 1 month after MRI.

The cortical projections of the thalamic intralaminar nuclei, as studied in cat and rat with the multiple fluorescent retrograde tracing technique.

Two retrograde fluorescent tracers were injected in two different areas of the cerebral cortex in rats and in cats. In all the experiments many single labeled cells and only some double labeled ones were seen in the thalamic intralaminar nuclei. The present results suggest that the diffusely distributed intralaminar-cortical projections mainly consist of axons of separate cells, and only to a minor extent of axon collaterals of the same cells.

The basolateral amygdaloid projections to the neocortex in the cat.

Retrogradely labeled cells have been found in the ipsilateral basolateral nucleus of the amygdala (BL) following injections of horseradish peroxidase (HRP) in various neocortical areas in the cat. The number of labeled neurons was small in the majority of the cases; however the amygdaloid projections to the prefrontal, anterior cingulate, insular and posterior sylvian cortices appeared heavier. HRP injections in the parietal associative and visual areas did not result in labeled cells in the amygdala. The present data suggest that the cortical projections arising from BL are more widely distributed than previously reported.

Spinal afferents and cortical efferents of the anterior intralaminar nuclei: an anterograde-retrograde tracing study.

The topographical relations among the terminal field of spinothalamic fibers and the cells projecting upon areas 4 and 5 were studied in the anterior intralaminar nuclei of the cat. Terminals anterogradely labeled from the spinal cord and cell populations retrogradely labeled from the lateral pericruciate and anterior suprasylvian cortex were simultaneously observed by means of a multiple fluorescent tracing strategy. The present findings confirm that spinal afferents in the central lateral and paracentral nuclei overlap with the cells projecting to area 4. Further, the present data demonstrate that spinal terminals are largely segregated from the intralaminar cell population projecting to area 5.

The cortical projections of the thalamic intralaminar nuclei restudied by means of the HRP retrograde axonal transport.

Following multiple injections of HRP in different cortical areas in the cat, labeled cells were, in some cases, found in the thalamic intralaminar nuclei. The following cortical zones were found to constitute the preferential target for the projections from the respective intralaminar nuclei: motor and anterior suprasylvian areas for the nucleus centralis lateralis, cingulate cortex for the nuclei paracentralis and centralis medialis, sensory and motor areas for the nucleus centrum medianum. These data are compared with the results previously obtained by means of the retrograde degeneration technique.

On the white matter lesions of the Creutzfeldt-Jakob disease. Can a new subentity be recognized in man?

One case of CJD with severe involvement of the white matter is discussed. The patient was admitted after a 3-month clinical course with rapidly increasing mental deterioration, coma vigil-like state, myoclonic twitching of the limbs and of the facial muscles. The EEG showed the typical features of CJD. The first CT scan, performed 3 months after onset, revealed only a mild cortical and subcortical atrophy of the brain. The second CT scan, 12 months later, showed a considerable cortical and subcortical atrophy of the brain. The patient died 18 months after onset. Neuropathological examination showed a severe degeneration in the gray matter, with spongiosis, loss of neurones and hypertrophic glial reaction. The white matter was also involved with severe spongiosis, demyelination and hypertrophic glial proliferation. The case is discussed in relation to the data in the literature. It is argued that cases of CJD with severe involvement of the white matter should be classified as a new neuropathological subentity of CJD.