[Health care safety: The discrepancies between experience and degree of satisfaction of hospitalized patients observed in interviews performed by user representatives]. / La sécurité liée aux soins : écarts entre l'expérience et la satisfaction de patients hospitalisés à partir d'entretiens menés par des représentants d'usagers.

INTRODUCTION: The purpose of this article is to present the results of a qualitative survey conducted by user representatives (URs) focusing on the health care safety experience of hospitalized patients. The authors wished to identify factors associated with safety of care and, more specifically, with the possibly ominous medical events reported by patients. METHODS: After being trained with these objectives in mind, eight URs conducted semi-directive interviews with fourteen patients hospitalized in eleven separate hospital units in nine different hospitals. RESULTS: Eight types of factors consisting in 30 contributing factors liable to be reported by patients were identified: 1) factors related to patients' basic needs; 2) personalization of care; 3) professional factors; 4) organizational factors; 5) communication factors; 6) caregiver responsiveness; 7) infectious risks; 8) continuity of care. Patients' overall feelings about their hospitalization remained excellent notwithstanding more tempered, even negative experiences. CONCLUSION: This paradoxical result shows that the patients' actual experience is far more instructive than their degree of satisfaction. In light of this study, the acceptability of this type of research (i.e. research conducted by URs) is excellent and it also appears highly feasible, whatever the limitations imposed by organizational considerations.

Clinical application of prismatic lenses in the rehabilitation of neglect patients. A randomized controlled trial.

BACKGROUND: Many studies reveal that neglect is a major cause of disability in stroke patients, and two months from onset neglect is still present in approximately 50% of individuals with a right brain lesion. Among the various methods of neglect rehabilitation, we have turned our attention to the prism adaptation treatment, developed by Rossetti in 1998. This treatment uses prismatic lenses, which produce a deviation of the fixation point of the visual field of 10 degrees to the right, 5 degrees below the coordinates of reference resulting from neglect. AIM: To set out the possible effectiveness of less powerful lenses, we studied the response of a group of neglect patients treated with prismatic lenses that produce a deviation of the fixation point of only 5 degrees to the right, comparing them with a group of patients receiving placebo lenses. DESIGN: Randomized controlled trial. SETTING: Outpatients. POPULATION: The study involved 29 patients with left visual neglect. METHODS: All patients were assessed with a battery of seven visual-spatial tests. All patients were randomized by the pilot center and assigned to two different groups: "A" treated with pointing exercises and prismatic lenses of 5° to the right; "B" treated with pointing exercises and neutral lenses. Each group was treated with 5 rehabilitation sessions, lasting about 30 minutes each, from Monday to Friday for one week in the morning, by the same investigator, in each center. CONCLUSION: The results showed that the prismatic lenses of only five degrees, used for the study, did not contribute to the variation in performance. Thus, this deviation of the fixation point of the visual field to the right is not sufficient to create a therapeutic effect. The improvement observed within the two groups, seems likely to be correlated with the pointing exercises, which force the subject to perform a visuomotor task with the healthy arm also in the neglected side. CLINICAL REHABILITATION IMPACT: We believe that in order to carry out an effective treatment with prismatic lenses they must have a grade of at least 20 prism diopters. Lower grades are unable to determine an effect. Finally, because of the severe impact of neglect on the work of the rehabilitation team, and since our data shows that only five sessions are sufficient to demonstrate a change in performance, we believe that it is appropriate to use this method, especially in the acute phase of the disease.

Knowledge of the anomalies of the big central veins reduces the morbidity during the cannulation for hemodialysis: Description of a case of persistent left superior vena cava and revision of literature.

The persistence of a left superior vena cava is the result of a lack of an embryological involution of the left anterior cardinal vein. This anomaly is very rare: about 0.3% of the general population. Its incidence increases remarkably from 3-10% in those patients affected with congenital heart disease. Described herein is a case of persistent left superior vena cava, discovered by chance, following the placement of a central venous catheter for hemodialysis. A chest X-ray in projection back-forward showed the central venous catheter along the left sternal margin simulating a placement in the aorta artery. This clinical picture, as described in the literature, is often accompanied by other anatomical anomalies, in our case, by the congenital agenesis of a solitary pelvic kidney. In agreement with the literature and in contrast with what has been reported recently, we sustain that a central venous catheter placed, for any reason, in the persistent left superior vena cava must be removed immediately because it can induce hyperkinetic arrhythmia and cardiac arrest as in our case. Our case report should be a warning that lack of awareness of the anomalies of the big central veins can cause a rise in morbidity.

[Acute kidney failure and losartan: a recently observed event of antagonists of angiotensin II AT1 receptors]. / Insufficienza renale acuta e losartan: una nuova recente segnalazione degli inibitori dei recettori AT1 dell'angiotensina II.

Losartan is the first of a new category of drug that inhibits angiotensin II (ANG II) AT1 receptors antagonists. This drug lowers blood pressure by inhibiting the activity of ANG II and reduces proteinuria and progression of chronic renal failure (CRF). It seems therefore an extremely interesting drug. Aim of this study is to describe 3 cases of acute renal failure (ARF), occurred during therapy with losartan. None of the patients showed renal arteries stenosis or other predisposing factors for the development of ARF. In conclusion, we want pointed out that losartan could affect renal function in a similar way as angiotensin converting enzyme inhibitors (ACEI). We suggested that use of losartan in risk situations, like old age, preexiting CRF, stenosis of renal arteries, solitary kidney and diuretic therapy, should be carefully monitored as well as that of ACE I.

[Evaluation of urea recirculation and dialysis efficiency of central venous jugular catheters when the venous lumen is used as an arterial lumen]. / Valutazione del ricircolo dell'urea ed efficacia dialitica del catetere giugulare venoso centrale quando il lume venoso è utilizzato come lume arterioso.

BACKGROUND: The dual lumen internal jugular venous catheter has proven to be the most useful temporary vascular access for hemodialysis. According to this evidence it was decided to evaluate urea recirculation rate during hemodialysis performed by dual lumen internal jugular catheter (IJC) under normal condition (R1) and when the arterial lumen of the catheter is used as venous lumen, and the venous lumen as arterial lumen (R2). METHODS: In 71 patients who underwent hemodialysis using a dual lumen IJC, urea recirculation rate was measured during a conventional bicarbonate hemodialysis, under normal condition R1 and during the experimental condition R2. RESULTS: Urea recirculation rate < 5% was achieved for almost all patients under normal condition R1. In the different condition R2, urea recirculation rate increased in all patients, from an average value of 3.7 +/- 1.7 to 5.1 +/- 1.8 p < 0.0001. This increment was expected ut surprisingly low. CONCLUSIONS: In conclusion during hemodialysis with dual lumen IJC efficient treatment can be provided in normal condition and also when the venous lumen is used as arterial lumen.

[Drugs used in the treatment of arterial hypertension in dialysis patients in the Piedmont. What correlations between personal and clinical data can be made from the registry data?]. / I farmaci utilizzati per il trattamento della ipertensione arteriosa nei pazienti in dialisi in Piemonte. Quali correlazioni con i dati anagrafici e clinici sono possibili dai dati del registro?

The therapeutical approach to arterial hypertension in the general population is now relatively well classified, whereas it remains a controversial problem in dialytic patients. The aim of this study was to evaluate the antihypertensive drugs used in dialytic patients in Piedmont and to identify correlations with other personal and clinical data. The authors analysed the data in the Piedmont Dialysis and Transplant Register concerning new patients admitted to dialysis during the period 1990-1995 (2,664 patients at 31/12/1995) and 1,373 patients who began dialysis during the period 1990-1993. A study of the antihypertensive drugs using in single and combined therapy over the five-year period shows major variations in the 45-65 year-old age bracket (increased ACE-inhibitors in single therapy, 15.5-25.6%, increased vasodilators in combined therapy, 15.3-21%). In patients aged > or = 65 years old a slight increase was found in the use of beta-blockers in monotherapy. Antihypertensive drugs at the 1st control (1990-1995 entries) appeared to be stable over the five-year period. From the 1,373 patients who started dialysis in the period 1990-1993, with at least three subsequent controls, the authors selected those hypertensive or normotensive patients receiving ACE-inhibitor therapy (best survival in general population) and compared their survival with that of patients receiving alternative antihypertensive treatment. No significant differences were found. The stability of the antihypertensive drugs taken by these patients over the past 5 years backs the hypothesis of a greater attention paid by nephrologists to the introduction of new drugs, both because of the frequent onset of collateral effects and owing to the special pharmacokinetics present in dialytic patients.

Platelet-neutrophil interactions in uremic patients: effects on neutrophil superoxide anion production and chemiluminescence.

Isolated resting platelets are able to limit neutrophil activation and then can control the tissue-damaging potential of activated neutrophils. In the present study, platelet-neutrophil interactions have been evaluated in 10 uremic patients; the blood samples have been collected before the hemodialysis session. Twelve normal subjects served as controls. Platelets and neutrophils have been isolated and recombined in an autologous ex vivo system. Anion superoxide production and chemiluminescence (which is related to hypochlorous acid production) have been evaluated after stimulation with N-formyl-methionyl-leucyl-phenylalanine. Coincubation of platelets from normal subjects with autologous neutrophils led to a dose-dependent inhibition of both superoxide anion generation induced by N-formyl-methionyl-leucyl-phenylalanine and chemiluminescence. Instead, platelets from uremic patients have not affected superoxide anion production by autologous neutrophils. The chemiluminescence was reduced by coincubation with autologous platelets only at the highest platelet-neutrophil ratio (100:1). In conclusion, the modulation exerted by platelets towards neutrophil activation can be impaired in chronic uremia. Therefore, the tissue-damaging potential of circulating neutrophils, due to toxicity by superoxide anion and hypochlorous acid, may be increased.

Sculpting present and future: a systemic intervention model applied to psychosomatic families.

We present a therapeutic intervention model for use with psychosomatic families. This method, the result of our extensive research on various psychosomatic disorders, uses family sculptures of the "present" and "future": each family member is requested to represent the family as it now "is," and how it "will be" in the future. We discuss the theoretical reasons for our choice of this method: (a) the opportunity to use a therapeutic language that is similar to the nonverbal language of the psychosomatic symptom, and (b) the usefulness of reinserting temporal dimensions into family systems that seem to have lost their evolutionary potential and to be in a sort of "time lock." Two clinical cases are discussed (a child with chronic asthma and an anorexic adolescent); the use of sculptures in both cases revealed the underlying problems and made positive therapeutic interventions possible. Finally, we point out how the use of sculpture as a therapeutic technique enables therapists to deal with multiple systemic levels.

Dipsogenic factors operating in chronic uremics on maintenance hemodialysis.

Thirst and hyperdipsia of anuric chronic uremics on maintenance hemodialysis and the possible dipsogenic factors were studied. Exaggerated thirst was present in 213 (86%) of the 247 studied patients. It usually started 4-6 h after the end of the dialysis session, persisted during the whole interdialytic period and often disappeared during the subsequent dialysis. Hyperdipsia, as indicated by the high body weight gain (> 4%) in the interdialytic periods, was present in 33.6% of patients. The highest rate of increase of body weight occurred in the first hours following the end of dialysis sessions. Hypernatremia, potassium depletion, increasing plasma urea levels and elevated plasma angiotensin II levels were considered as the possible dipsogenic factors of a nonpsychic nature. Sodium is certainly of paramount importance for its obliged extracellular position, and when sodium intake is elevated, hypernatremia is very likely the cause of exaggerated thirst and weight gain in patients on hemodialysis. Potassium depletion may cause thirst in animals, but this condition is extremely rare in patients on maintenance hemodialysis, who often accumulate it. In these patients it is, therefore, unlikely that potassium depletion is a dipsogenic factor. Increasing serum urea levels exert an evident dipsogenic effect in anephric rats and urea, when infused into normal volunteers, stimulates thirst. The extracellular urea levels in the interdialytic period are certainly higher than the intracellular ones, as a consequence of its continuous accumulation, and this creates an osmotic gradient with a dipsogenic effect. When this gradient is reversed, following hemodialysis (which removes first the extracellular urea), the dipsogenic effect disappears.(ABSTRACT TRUNCATED AT 250 WORDS)

Micromorphometric evaluation of changes in symmetry of sarcoplasmic reticulum membranes induced by vanadate.

Electron micrographs of light sarcoplasmic vesicles fixed with glutaraldehyde and osmium tetroxide followed by contrasting with uranyl acetate and lead citrate have been evaluated by registering their membrane profiles with a microdensitometer. The asymmetric arrangement of the two layers of the vesicular membrane could be ascertained by demonstrating a ratio of 1.5 for the thickness of the outer versus the inner membrane layer which is in general agreement with the proposed protein structure of the calcium transport enzyme. Treatment of the vesicles with low concentrations of vanadate (0.1 mM) results in a significant lowering of the symmetry ratio by 20% by reducing mainly the thickness of the outer membrane leaflet. Removal of the membrane lipids by treating the vesicles with phospholipase A2 and bovine serum albumin diminishes the membrane surface by 50% resulting in a significant increase of both the membrane thickness and the asymmetry ratio by 30 and 12% respectively. The vanadate induced reduction of membrane asymmetry is accentuated after delipidation indicating that the membrane lipids are not essential for the asymmetric appearance of the native membrane. The stability of the spherical form of the vesicles to delipidation implies that the transport molecules are conically shaped allowing strong mutual interactions. At a measured height of the molecule of 80 A in the membrane, the vanadate induced change in symmetry would be brought about by compensatory changes of less than 3 A of the outer (35 A) and the inner (25 A) diameter of the cone.

Expression of myosin heavy and light chains and phosphorylation of the phosphorylatable myosin light chain in the heart ventricle of the European hamster during hibernation and in summer.

We investigated the expression of myosin subunits (myosin heavy chains) as well as light chains and the in vivo phosphorylation of the phosphorylatable myosin light chain in the heart ventricle of the adult male European hamster (Cricetus cricetus L.). Two myosin heavy chain isoenzymes could be detected under native and denaturing electrophoretic conditions having high (alpha-myosin heavy chain) and low (beta-myosin heavy chain) enzymatic activity. Enzymatic activity of alpha- and beta-myosin heavy chain revealed a different temperature dependency. When temperature increased ATPase activity of the alpha-myosin heavy chain isoenzyme increased relatively more than ATPase activity of the beta-myosin heavy chain isoenzyme. Summer animals expressed predominantly the beta-myosin heavy chain (79% of total myosin) while during hibernation the alpha-myosin heavy chain expression increased to 53% of total myosin. Winter-active hamsters kept at 22 degrees C and 12 h day/night rhythm showed the same myosin heavy chain isoenzyme pattern as summer-active animals. Two myosin light chain forms were expressed in the ventricle of all animal groups. The in vivo phosphorylation level of the phosphorylatable myosin light chain decreased from 45% in summer-active hamster to 23% during hibernation.

Removal of beta 2-microglobulin by hemodialysis and hemofiltration: a four year follow up.

Efficient removal of total body burden beta 2-Microglobulin (beta 2-M) in uremia is a continuing challenge, as dialysis-related amyloidosis represents a major complication of chronic renal replacement therapy. To investigate long-term beta 2-M removal we studied 3 groups of stable end-staged renal failure patients over a period of 4 years; we compared low flux (cuprophane) hemodialysis (n = 12), high flux (polysulfone) hemodialysis (n = 12) and hemofiltration using high flux polysulfone (n = 8). In contrast to the cuprophane membrane, the polysulfone membrane eliminated considerable amounts of beta 2-M. This was associated with a sustained reduction of predialysis serum beta 2-M-levels (by 20%). Compared with high flux hemodialysis, hemofiltration provided a 50% higher elimination of beta 2-M. Thus, our long-term evaluation of beta 2-M removal suggests that hemofiltration rather than hemodialysis may be the treatment of choice for delaying the incidence of dialysis-related amyloidosis.

The modulation of the calcium transport by skeletal muscle sarcoplasmic reticulum in the hibernating European hamster.

Calcium transport of skeletal muscle sarcoplasmic reticulum was comparatively studied in hibernating and summer active European hamsters (Cricetus cricetus L.). Crude homogenates from psoas, soleus and mixed skeletal muscles were used. Protein yield was strongly reduced in the muscle homogenates of hibernating hamsters. The calcium concentration in the muscle of hibernating hamsters was increased to a much higher content than in the serum. In the same animals the maximal rate of calcium uptake and the calcium storing capacity of sarcoplasmic reticulum were augmented by 43% and respectively 17%. Kinetic experiments with various concentrations of free calcium revealed in the hibernating animals higher uptake rates and a lower apparent calcium affinity than in the summer active hamsters. Some shift of calcium uptake rate and calcium affinity similar to that of a fast-twitch muscle was also observed in winter active animals kept at 22 degrees C under natural photoperiod. By contrast, the activity of the calcium dependent ATPase was not increased, suggesting a tighter coupling during hibernation between calcium dependent ATP-hydrolysis and calcium transport. No seasonal difference was observed in the calcium release by KCl-caffeine from calcium loaded vesicles of sarcoplasmic reticulum. Proportion and size of fibre types were studied with cold cross sections from psoas and soleus muscles. An average atrophy of about 25% was found during hibernation in both muscles. Cytochemistry revealed, however, a different reduction of cross area between type-I- and type-II-fibres, which reaches values up to 46% in the type-II-fast-fibres of the slow soleus muscle. Electron microscopy did not show any definite change in the distribution and amount of sarcoplasmic reticulum. The results suggest that during hibernation a modulation in the properties of calcium transport ATPase of sarcoplasmic reticulum occurs to better support the calcium transport function at low temperatures, which in turn warrants the restoration of ion homeostasis in the course of the arousal.

On the problem of season and cold dependence of calcium transport by skeletal muscle sarcoplasmic reticulum.

Calcium transport of skeletal muscle sarcoplasmic reticulum from golden hamsters was studied in January and in June on animals kept at 22 degrees C under natural photoperiod and in January after cold-acclimation at +/- 2 degrees C in the dark for 55 days. Crude homogenates from psoas and soleus muscles and from mixed skeletal muscles were used. No differences were observed in the calcium storing capacity of sarcoplasmic reticulum among the three groups of animals. Kinetic studies on the dependence of the calcium uptake rate on the concentration of free calcium revealed a significant increase of the uptake rates and a decrease of the calcium affinity in the control animals sacrificed in winter as compared to those killed in June. Cold-acclimation in winter leads to a further small reduction of the calcium affinity. This shift of calcium uptake rate and affinity in the sense of that of a fast-twitch muscle may be related to the functional demands of the cold season and cold-acclimation respectively.

Thyroxine induced transformation in sarcoplasmic reticulum of rabbit soleus and psoas muscles.

The properties of the sarcoplasmic reticulum membranes isolated from slow-twitch type I soleus and fast-twitch type II psoas muscles of control and thyroxine treated rabbits were comparatively studied. Membrane yield, maximal calcium storing capacity, ATP-supported calcium uptake, calcium-dependent ATPase activity and calcium-dependent phosphoprotein formation were found to be 3-10 fold higher in psoas than in soleus preparations. Membrane yield, calcium-dependent ATPase activity, ATP-supported calcium transport and calcium-dependent phosphoprotein are at least twice enhanced in the membranes from soleus muscles of animals treated for 14-21 days with thyroxine. The corresponding capacities of the membranes from psoas muscles are not further augmented by the same thyroxine treatment. The maximal calcium storing capacity of the psoas membranes is their sole specific property which is significantly increased. The changes in the properties of the soleus muscles' sarcoplasmic reticulum membranes are engendered by an increase from 5 to 30-50% in the number of type II fibres. Since the calcium transporting properties of the sarcoplasmic reticulum membranes from type II fibres qualitatively differ from those of type I fibres, thyroxine does not only affect quantitative but also qualitative parameters of the muscles' sarcoplasmic reticulum membrane system.

A conformational transition of the sarcoplasmic reticulum calcium transport ATPase induced by vanadate.

Vanadate binding to sarcoplasmic reticulum vesicles results in the loss of the externally located high affinity calcium binding sites of the calcium transport ATPase. Conversely the occupation by calcium of the internally located low affinity sites in the vanadate enzyme complex leads to the release of vanadate. Since the total number of calcium binding sites is not diminished by vanadate binding but slightly increases we conclude that vanadate binding induces a transition of the enzymes external high to internal low affinity calcium binding sites. The transposition of external to internal calcium binding sites is accompanied by a definite change in the structure of the sarcoplasmic reticulum membranes. On vanadate binding the asymmetrically arranged electron dense protein particles become symmetrically distributed.

The formation of intravesicular calcium phosphate deposits in microsomes of smooth muscle. A comparison with sarcoplasmic reticulum of skeletal muscle.

The calcium uptake in the microsomial fraction isolated from the smooth muscle of the antrum of the pig stomach is stimulated by phosphate. The microsomial vesicles which are loaded with calcium phosphate can be purified by differential centrifugation. A purification of 36 times in terms of calcium content was reached. Electron microscopy of the freshly prepared material revealed calcium phosphate deposits in the form of needles of crystalline calcium phosphate. This structure differs from that of the deposits which appear in the fragmented sarcoplasmic reticulum of skeletal muscle. Their morphology is that of non-crystalline calcium phosphate. However, on standing these deposits convert slowly into crystalline calcium phosphate. This difference reflects different kinetics of crystallization of the precipitates in the two preparations. After negative staining of the calcium phosphate loaded microsomes of skeletal and of smooth muscle, only few deposits are preserved because a release of calcium occurs as a consequence of the action of the stain and also of the dilution and warming up of the suspension. Smooth muscle microsomes partially purified by loading with calcium phosphate were studied by freeze etching and rotary replication. Membrane fragments displaying subunit intramembrane particles similar to those observed in sarcoplasmic reticulum of skeletal muscle could be identified. However, in the smooth muscle microsomes the intramembrane particles were much less densely packed. Part of these particles could correspond to calcium transport sites.

Electron cytochemistry of oxalate-stimulated calcium uptake in microsomes from the smooth muscle of the pig stomach.

A microsomal fraction was isolated from the smooth muscle of the antrum of the pig stomach by differential centrifugation. Electron microscopy of the negatively stained material showed that this fraction is heterogeneous in composition. The microsomes accumulated calcium in the presence of ATP, magnesium and oxalate. The amount of calcium taken up per mg protein was in the same range as observed for other smooth muscle microsomal preparations. Although this amount is much smaller than that in the microsomal fraction of skeletal muscle, calcium oxalate crystals were formed in some vesicles, as occurs in the skeletal muscle fragmented sarcoplasmic reticulum. Through the presence of the calcium oxalate crystals, many of these vesicles acquired sufficient mass and density to allow them to be isolated by centrifugation. A purification of about 40 fold in terms of calcium content was reached.