The role and the interventions of the Hospital Social Service (HSS) for the integration of the health and social activities: a comparative survey between 2008 and 2014 in the Social Service of the "Azienda Ospedaliera Universitaria Policlinico Umberto I" in Rome, Italy.

INTRODUCTION: In the Azienda Ospedaliera Universitaria Policlinico Umberto I in Rome, the Hospital Social Services (HSS) is located within the Directorate of Health, reporting directly to the Chief Medical Officer, providing counselling and supporting clinical services. The HSS is part of a network with its own technical, professional and assessment independence. It often serves as liaison between the hospital and the territory, facilitating the development of services and contributing to public health recovery and maintenance, therefore improving the citizens' standard of living thanks to aid projects and specific interventions. METHODS: The present Report is based on two different studies carried out in 2008 and 2014, both examining the work of the Hospital Social Service in the "Azienda Ospedaliera Universitaria Policlinico Umberto I" in Rome. The purpose is to compare these surveys and work out the results. The data collection is based on a number of social records from the HSS archives (814 records in 2008 and 790 in 2014). The research project followed subsequent stages: planning a draft of the research, where ethnomethodology was used as empirical evaluation technique; collecting data from the HSS's paper and file archives (biographical, clinical and social data); revising, analysing and elaborating the data which showed relevant changes leading to interesting conclusions. RESULTS AND CONCLUSIONS: The comparative analysis of data showed a higher demand of HSS healthcare services, despite a smaller number of beds and hospitalisations available in standard regime. Also, it indicated an increase of patients below 18 years and a decrease of the over-65s age group. As for the geographical origin of patients reported to the HSS, there was a decrease in the percentage of Italian citizens, while the percentage of irregular non-EU and EU patients increased by over 5%. Significant results were found comparing the days between the report to the HSS and patient discharge. Data concerning the 'more than 7 days' group was steady over the years, being more consistent for both the variables considered and increasing in 2014. In the comparative analysis, the interventions with more significant differences were those aimed at promoting homecare and entering sheltered housing. In the former cases, a considerable decrease was observed, if compared to the activation of the integrated health and social homecare services, while there were more requests for homecare assistance; in the latter ones the analysis highlighted a sharp decrease in the percentage of the variable called "assessment to enter Extended Care Units". The causes of these changes are remarkable and have to be found in the political, historical and cultural scenario: - a first factor is the increase in the more recent migratory flow from non-EU countries to Italy, which could explain the rising percentage of foreigners taken over by the HSS; - regional policies, economic cuts imposed on healthcare and higher income limits in order to calculate the patient's economic participation in the costs of institutionalisation have affected the above-mentioned changes; - the innovations in the regulatory field of Latium Region have brought structural changes in long-term care facilities and in the level of care in Extended Care Units (ECU).

Italian Intersociety Recommendations on pain management in the emergency setting (SIAARTI, SIMEU, SIS 118, AISD, SIARED, SICUT, IRC).

BACKGRAUND: Pain is the primary reason for admission to the Emergency Department (ED). However, the management of pain in this setting is often inadequate because of opiophagia, fear of excessive sedation, and fear of compromising an adequate clinical assessment. METHODS: An intersociety consensus conference was held in 2010 on the assessment and treatment of pain in the emergency setting. This report is the Italian Intersociety recommendations on pain management in the emergency department setting. RESULTS: The list of level A recommendations includes: 1) use of IV acetaminophen for opioid sparing properties and reduction of opioid related adverse events; 2) ketamine-midazolam combination preferred over fentanyl-midazolam fentanyl-propofol in pediatric patients; 3) boluses of ketamine IV (particularly in the population under the age of 2 years and over the age of 13) can lead to impairment of the upper airways, including the onset of laryngospasm, requiring specific expertise and skills for administration; 4) the use of ketamine increases the potential risk of psychomotor agitation, which can happen in up to 30% of adult patients (this peculiar side effect can be significantly reduced by concomitant systemic use of benzodiazepines); 5) for shoulder dislocations and fractures of the upper limbs, the performance of brachial plexus block reduces the time spent in ED compared to sedation; 6) pain relief and the use of opioids in patients with acute abdominal pain do not increase the risk of error in the diagnostic and therapeutic pathway in adults; 7) in newborns, the administration of sucrose reduces behavioural responses to blood sampling from a heel puncture; 8) in newborns, breastfeeding or formula feeding during the procedure reduces the measures of distress; 9) in pediatric patients, non-pharmacological techniques such as distraction, hypnosis and cognitive-behavioural interventions reduce procedural pain caused by the use of needles; 10) in pediatric patients, preventive application of eutectic mixtures of prilocaine and lidocaine allows arterial and venous samples to be taken in optimum conditions; 11) in pediatric patients, the combination of hypnotics (midazolam) and N2O is effective for procedural pain, but may be accompanied by loss of consciousness. CONCLUSION: The diagnostic-therapeutic pathway of pain management in emergency should be implemented, through further interdisciplinary trials, in order to improve the EBM level of specific guidelines.

Nitric oxide and neuromodulation in the caudal neurosecretory system of teleosts.

Although evidence exists that nitric oxide (NO) mediates neuroendocrine secretion in mammals, the involvement of NO in the neuroendocrine regulation of non-mammalian vertebrates has yet to be investigated in detail. The present review conveys several recent data, suggesting that NO plays a modulatory role in the caudal neurosecretory system (CNSS) of teleosts. The presence and distribution of neuronal NO synthase (nNOS) was demonstrated in the CNSS of the Nile tilapia Oreochromis niloticus by means of NADPHd histochemistry, NOS immunohistochemistry, NOS immunogold electron microscopy, the citrulline assay for NOS activity and Western blot analysis. NO production by the caudal spinal cord homogenates was also evaluated by the oxyhemoglobin assay. On the whole, these findings indicate that caudal neurosecretory cells express NOS enzymes and presumably produce NO as a cotransmitter. Moreover, the comparison of the nNOS distribution with that of urotensins I and II (UI and UII) suggests that neurosecretory Dahlgren cells belong to two different functional subpopulations: a population of UI/UII secreting nitrergic neurons and a population of non-nitrergic neurons, which principally secrete UII. These results implicate NO as a putative modulator of the release of urotensins from the neurosecretory axon terminals. Therefore, like in mammals, NO appears to influence neuroendocrine secretion in teleosts.

Colocalization of neuronal NO synthase with urotensins I and II in the caudal neurosecretory neurons and the urophysis of the teleost oreochromis niloticus: a gold immunoelectron microscopic study.

The intracellular distribution of neuronal nitric oxide synthase (nNOS) was studied in the caudal neurosecretory system of a teleost, Oreochromis niloticus (Cichlids), by means of post-embedding immunogold labeling with a polyclonal antibody directed against nNOS of human origin. Ultrastructural examination demonstrated that neuronal NOS-like molecules are distributed within the Dahlgren cell perikarya, the neurosecretory axons, and the urophysial axon terminals. In the neurosecretory somata, gold particles for nNOS were mainly cytosolic, whereas in the neurosecretory axons and axon terminals they were associated with the membrane and/or the dense core of neurosecretory granules. Double immunogold labelings for nNOS/urotensin I (UI) and nNOS/urotensin II (UII) demonstrated that nNOS-like molecules are colocalized with UI and/or UII in the neurosecretory granules contained within the urophysial terminals. The present findings suggest that both a soluble cytosolic and a particulate neuronal NOS are expressed in the caudal neurosecretory neurons. They confirm previous biochemical data on the same species.

Development of the caudal neurosecretory system of the nile tilapia Oreochromis niloticus: an immunohistochemical and electron microscopic study.

The development of the caudal neurosecretory system (CNSS) of the Nile tilapia, Oreochromis niloticus, has been investigated by means of UI/oCRF (urotensin I/ovine corticotropin-releasing factor) immunohistochemistry and transmission electron microscopy. UI-like immunoreactive perikarya and fibers are first detected in the caudal spinal cord of larval fish about 4 days after hatching (stage 21). In the region of the future urophysis two bundles of strongly immunoreactive neurosecretory fibers are observed. At this stage, neurosecretory axons terminate on the meninx sheath of the spinal cord with immature neurosecretory terminals. The histogenesis of the urophysis begins at stage 24. The future neurohemal organ consists of a small ventral swelling of the spinal cord, which is associated with dilated vessels. At this stage, neurosecretory axons terminate on the basal lamina of the ingrowing blood vessels. Further development occurs by means of progressive branching of vessels and the concomitant increase in the number of neurosecretory terminals. In the caudal spinal cord, immunoreactive neurons also increase in number and progressively differentiate morphologically. Typical features of the mature CNSS are recognizable in 4-month-old juveniles. Data suggest that in tilapia both the synthesis and the release of urophysial hormones begin before morphogenesis of the neurohemal organ takes place.

The caudal neurosecretory system and its afferent synapses in the goldfish, Carassius auratus: morphology, immunohistochemistry, and fine structure.

Morphological features of the goldfish caudal neurosecretory system were investigated by means of immunohistochemical localization of urotensins I and II (UI and UII) and electron microscopic examination of the caudal neurosecretory neurons, the urophysis, and the synaptic neuropil. The aim of the work is to provide a detailed morphological description of the afferent synapses to the caudal neurons and to analyze their distribution through the rostrocaudal extension of the caudal neurosecretory system. Three morphologically different types of neurosecretory cells have been identified according to size and shape: large, medium, and small Dahlgren cells. The three different-sized cells share similar patterns of immunoreactivity with the UI (or oCRF) and the UII antisera. Electron microscopic examination of the synaptic neuropil throughout the caudal system revealed the presence of four types of terminals: dense-cored-vesicle end bulbs (DC), spherical-vesicle end bulbs (S), flattened-vesicle end bulbs (F), and granular-vesicle end bulbs (G). The present study demonstrates that the small Dahlgren cells receive different synaptic inputs from the large and the medium neurosecretory cells. Indeed, G terminals are only found on the small Dahlgren cells, whereas DC, S, and F terminals are distributed on the large, medium, and small Dahlgren cell bodies and proximal processes.

Nitric oxide synthase in the caudal neurosecretory system of the teleost Oreochromis niloticus.

This study provides evidence that, within the caudal neurosecretory system of the teleost Oreochromis niloticus, neurons express nitric oxide synthase (NOS)-like molecules. The presence of NOS-like molecules was demonstrated by means of NADPH-diaphorase (NADPHd) staining and NOS immunohistochemistry. In the caudal spinal cord, NOS-positive neurosecretory cell bodies and neurosecretory fibers were observed. In addition, NOS-positive structures were found in the urophysis which correspond to neurosecretory axon terminals. Cellular co-localization of NOS and ovine corticotropin-releasing factor (oCRF) immunoreactivities confirmed that the NOS-positive structures belong to the caudal neurosecretory system. The present results suggest that NO may participate in the caudal neuroendocrine function.

Cervical and scalp recorded short latency somatosensory evoked potentials in response to epidural spinal cord stimulation in patients with peripheral vascular disease.

Somatosensory evoked potential (SEP) studies were performed in 14 patients with peripheral vascular disease who received epidural spinal cord stimulation (SCS) for chronic pain relief of the lower limbs. Signals were amplified and filtered between 20-2000 Hz and 200-2000 Hz to better identify activities in the high frequency range. In 7 patients bit-colour maps were also computed. In all the patients a homogeneous short-latency scalp evoked potential with a prevalent diphasic shape (P1-N1) was recorded. In all our scalp records, even with the wide bandpass, small short-latency positive deflections were observed on the descending front of the first major positive wave and they were better defined as a series of up to 6 wavelets, preceding the major negative scalp wave in the tracings filtered through the narrow bandpass. They appeared in an interval ranging from 5.5 to 15.6 msec. Bit-colour maps showed consistent positive fields, with a maximum at the vertex, starting mainly at about 5.5 msec; in 3 patients, a prominent positivity between 8.5 and 10.5 msec was recorded followed by smaller components preceding the major positive-negative (P1-N1) complex. More synchronous volleys during direct SCS produced clear short-latency SEPs. Although they were of larger amplitude, we regarded them as corresponding to those described by previous authors obtained by stimulation of nerves of the lower limbs, and probably arising from subcortical structures.

Epitope fine specificity of human anti-HLA-A2 antibodies. Identification of four epitopes including a haptenlike epitope on HLA-A2 at lysine 127.

Anti-HLA-A2 CREG antibodies were purified from seven individuals by affinity chromatography. The binding of the purified antibodies to single or multiple amino acid variants of HLA-A2.1 was measured with an inhibition RIA. Substitutions at 10 amino acid residues in the polymorphic alpha 1 and alpha 2 domains were important for human antibody binding; eight of these have previously been shown to be important in the binding of murine anti-HLA-A2 CREG antibodies. Unlike any previously reported murine mAbs, the binding of antibodies from two individuals was eliminated by a substitution at the HLA-A2, -24, -28 shared loop amino acid residue lysine 127. Conversely, when the asparagine at residue 127 on the non-cross-reactive HLA-A3 was replaced with lysine, antibody binding was completely restored. The results further suggest that both lambda- and kappa-containing human antibodies that bind to this region may recognize lysine 127 as a haptenlike epitope. Anti-HLA-A2 antibodies that recognized a conformational epitope defined by changes at glycine 62 in the alpha 1 domain were predominated by lambda light chains whereas those that recognize an epitope defined by a loop residue at tryptophan 107 in the alpha 2 domain were predominated by kappa light chains. The data are consistent with a model of restricted epitope recognition of HLA-A2 by human B cells that is similar to, but distinct from, epitope recognition by mouse B-cell hybridomas, and may help to explain the phenomenon of public or cross-reactive idiotypes in the HLA system.

[Chronic progressive obliterating arteriopathy and muscle fatigue: the role of frequency analysis of the electromyographic signal]. / Arteriopatia obliterante cronica progressiva e fatica muscolare: ruolo dell'analisi in frequenza del segnale elettromiografico.

Clinical evaluation of patients with peripheral arterial disease (PAD) is mainly based on Fontaine's classification, in which pain is the most important element. The use of objective techniques can allow a more precise evaluation, since pain is always subjective. In PAD patients, pain is frequently associated with early fatigue. Peripheral muscle fatigue can be easily assessed by a particular electromyographical method, based on the frequency analysis of the signal. In PAD patients, this method can provide objective information on muscular performance, with possible uses in medicine, surgery, rehabilitation and occupational medicine.

[Post-amputation pain in patients with vascular diseases: clinical characteristics]. / Dolor postamputación en los pacientes vasculares: características clínicas.

On the base of a study performed on 34 patients who underwent an amputation since 1981 to 1987, we evaluated the incidence of postamputation syndromes such as phantom limb, phantom pain, stump pain analyzing their variations during 6 years. The patients were divided in 6 groups according to the time gone by from the date of operation. The results reveals a not significant decrease of incidence of postamputation syndromes even though their frequency and intensity show a relative improvement.