Restructuring the surgical process after regional reform in Emilia-Romagna: an action-research project at Rizzoli Orthopedic Institute.

BACKGROUND: Hospitals performing surgery in Italy underwent important transformations in recent years, with decreasing economic resources and higher expected standards of care. Regional authorities acted differently across the country to adapt to the new scenario, generating heterogeneous outcomes. The Rizzoli Orthopedic Institute (ROI) in the Emilia-Romagna region started its reorganization in 2017, after the issue of new regional regulations about surgical activity. Aim of this paper is to describe the actions taken at ROI and discuss their outcomes. STUDY DESIGN: Action-research. METHODS: From 2017 to 2019 an action-research project was developed to introduce organizational changes within ROI and close the existing gaps between regional requirements and actual features of the Institute. Four areas of intervention were identified: surgical scheduling, appropriateness of surgical setting, monitoring and management of the surgical path and accountability. Progress was monitored through the collection of performance indicators and qualitative investigation of the organizational culture. RESULTS: Changes were implemented in all areas of intervention. Key features were the introduction of Operating Room Management (ORM) skills and the establishment of multiprofessional teams to drive the changes. Performance indicators showed a positive trend in the comparison between 2017 and 2018. Improvements were observed in terms of productivity, scheduling, and respect of standard waiting time, while case-mix did not significantly change. CONCLUSIONS: Effective ORM and collaborative practices can successfully drive the change towards a more efficient surgical process without increasing resources consumption.

Knock-out of the neural death effector domain protein PEA-15 demonstrates that its expression protects astrocytes from TNFalpha-induced apoptosis.

Apoptosis is a very general phenomenon, but only a few reports concern astrocytes. Indeed, astrocytes express receptors for tumor necrosis factor (TNF) alpha, a cytokine demonstrated on many cells and tissues to mediate apoptosis after recruitment of adaptor proteins containing a death effector domain (DED). PEA-15 is a DED-containing protein prominently expressed in the CNS and particularly abundant in astrocytes. This led us to investigate if PEA-15 expression could be involved in astrocytic protection against deleterious effects of TNF. In vitro assays evidence that PEA-15 may bind to DED-containing protein FADD and caspase-8 known to be apical adaptors of the TNF apoptotic signaling. After generation of PEA-15 null mutant mice, our results demonstrate that PEA-15 expression increases astrocyte survival after exposure to TNF.

Evaluation of a score system for the severity and outcome of cytomegalovirus interstitial pneumonia in allogeneic bone marrow recipients.

We verified whether a clinical score system developed for renal transplant patients predicts the severity and outcome of cytomegalovirus interstitial pneumonia (CMV IP) in allogeneic bone marrow (BMT) recipients. The score system was retrospectively applied to 20 patients at the estimated date of onset of IP and 10-14 days later. Seven patients received ganciclovir (GCV), seven received GCV plus intravenous immunoglobulin (i.v. Ig), and six received only supportive care. Nine out of 14 patients who received GCV with or without i.v. Ig survived the episode of IP (the median score of these patients at diagnosis of CMV IP was 5 (range 3-8)), while the remaining five patients died of respiratory failure during IP and at the diagnosis had a median score of 10 (range 9-11) (P=0.01). The six patients who received only supportive care survived for a median time of 21 days (range 10-24 days) from the estimated onset of CMV IP, and the median score at the diagnosis of IP was 10 (range 8-12). The overall survival correlates strongly with low initial severity of IP as measured by this score system: 11 out of 20 patients who died of respiratory failure during IP had at the estimated onset of IP a score >8, while of the nine patients who survived IP, eight had at the onset a score <7 and the remaining one a score of 8 (P=0.0007). The sensibility, specificity, predictive positive value and predictive negative value of the score system (with a threshold value of 8) to identify patients who survived IP was: 100%, 88%, 91% and 100%, respectively. The use of ganciclovir alone or in combination was the most important determinant of outcome. These data support the relevance of this score system with a threshold value of 8; if prospective and controlled studies confirm our observations, it would help physicians to identify BMT recipients during CMV IP with high vs. low risk of poor outcome.

Prostaglandins in human brain tumors.

It has been recently observed that arachidonic acid (AA) metabolites may modulate many of the mechanisms involved in tumor growth and metastasis. In order to clarify the role played in human brain tumors, authors have determined AA metabolic profiles in 63 surgical specimen of human intracranial tumors (mostly neuroepithelial tumors and meningiomas). The five metabolites via the cyclooxygenase pathway (PGD2, PGE2, TxB2, PGF2a, 6-Keto-PGF1a) were measured by high resolution gas chromatography-mass spectrometry after "ex vivo" metabolism of endogenous AA by tumor homogenates. The overall synthesis capacity of AA metabolites widely varied among different oncotypes, and, except in two cases of dermoid cysts, was higher than in normal brain tissue. AA metabolism seems more active in neuroepithelial tumors with the highest grade of anaplasia; some changes in the percentage of each metabolite is evident when anaplastic features changed. Thromboxane B2 was the most represented and 6-Keto-PGF1a the less abundant metabolite. Meningiomas and neuroepithelial tumors showed different relative proportion of AA metabolites which have in some cases reported to positively or negatively affect tumor growth. In histological subgroups of meningiomas AA metabolites synthesis capacity did not show any statistical difference. In the six cases of brain metastasis there is a wide range of overall synthesis capacity, with predominant synthesis of thromboxane B2 and prostaglandin E2, while the percentage of prostaglandin D2, reported as antimetastatic, is very low.

Suitability of orthopaedic day surgery in Emilia-Romagna.

The Emilia-Romagna Regional Authority has encouraged the development of day surgery practice in this healthcare program. This study analyzes the results of the program, with particular attention to the field of orthopaedics, with the aim of defining the type of operations that can be carried out in day surgery. There has been a marked increase in the rate of day surgery operations in all fields of surgery on the whole. However, in orthopaedics, the average rate was lower than the general trend. On the other hand, there has been an increased use of day surgery for some types of operations not included in those indicated by the region. Results of the data analyzed suggest that the use of day surgery for orthopaedics can be extended, and so can the regional indications for operations that can be performed by this method of treatment.

[Backache from exertion in health personnel of the Istituti Ortopedici Rizzoli in Bologna. A case-control study of the injury phenomenon in the 10-year period of 1987-1996]. / La lombalgia da sforzo nel personale sanitario degli Istituti Ortopedici Rizzoli di Bologna. Studio caso-controllo del fenomeno infortunistico nel decennio 1987-1996.

Low-back (lumbosacral) injuries are known as one of more important occupational health problems in health care workers, because of high prevalence and impact of socioeconomic costs. To investigate the risk of low-back pain in hospital workers into the Istituti Ortopedici Rizzoli in Bologna (Italy), a retrospective study was carried out. The adapted study design was the matched (1:1 for age) case-control, enlisting the first injuries occurred in the hospital staff like cases, and personnel in force, matched for age and year of happened case, like controls. Information about diagnoses and occupational data was obtained from the current informative systems. Comparison with a control group suggests the validity of the work-relatedness of low-back pain in nursing and health aides (OR: 21.67; LC: 4.69-196.56), in nurses (OR: 20.21; LC: 4.81-177.95), in therapists (OR: 16.36; LC: 2.80-163.54) and in X-ray technicians (OR: 13.64; LC: 2.25-138.99). The risk of occupational injury is not homogeneously allocated into the hospital, and significatively prevails in the orthopaedic wards, in the plaster-rooms, in the operating blocks and in the sterilization plants. Specific manual handling were associated with an increased risk of back pain, while some non occupational factors like cigarette smoking, previous trauma leading to hospital admission, and number of children in female, were resulted weakly associated.

[Orthopaedic day surgery in Emilia-Romagna]. / Il day surgery ortopedico in Emilia-Romagna.

It is well known that the organizational model of day surgery, concerning surgical problems defined by the literature as minor, has the aim of optimising the use of hospital resources and facilitating patients and their families, from a psychological and social point of view, by reducing hospitalisation time and the associated complications, and ensuring the same efficacy and more appropriateness of treatment. This study is firstly aimed at analysing the impact that the healthcare policy of the Emilia Romagna Region has had on the development of day surgery practice. Secondly, it compares the patients treated in orthopaedic day surgery in the hospitals of Bologna, Modena, Ferrara, Parma, Reggio Emilia, Maggiore hospital of Bologna and Rizzoli Orthopaedic Institute of Bologna (II.OO.R). In the period 1997-2000 there was a marked increase in the number of operations carried out in day surgery in all of the above-mentioned hospitals. Also in the unispecialistic orthopaedic hospital there was a surprising increase in the percentage of operations carried out in day surgery with respect to the total number of operations performed. The aim of the Rizzoli Orthopaedic Institute and the Emilia Romagna Region is to further implement this form of healthcare, contextually potentiating the appropriateness of hospital admission and avoiding, when not necessary, other forms of healthcare.

Effects of hypericum extract (LI 160) in biochemical models of antidepressant activity.

Since the mechanism of the antidepressant activity of hypericum extract is not yet understood, we tested possible effects of standardized hypericum extract (LI 160) in several biochemical models relevant for the mechanism of action of other antidepressant drugs. While LI 160 was only a weak inhibitor of MAO-A and MAO-B activity, it inhibited the synaptosomal uptake of serotonin, dopamine and norepinephrine with about equal affinity-2 micrograms/ml). Moreover, subchronic treatment of rats with hypericum extract led to a significant down-regulation of beta-receptors and to a significant up-regulation of 5-HT2-receptors in the frontal cortex. The data might suggest that hypericum extract acts via similar biochemical mechanisms to other antidepressants (e.g. tricyclics).

Postoperative scars and recurrent disk herniation: clinical, neuroradiological, and surgical findings.

Authors present 36 patients with recurrent sciatica or low-back pain after lumbar disk operation. All patients were submitted to clinical and instrumental devices. CT-scan was performed in 36 patients, 12 underwent myelography and 4 EMG. Authors verified reliability of clinical and instrumental devices on the basis of surgical results. We believe that myelo-CT is actually the first choice investigation in the neuroradiological ones. In the near future MRI will take its place in investigating spinal pathology.

Hyperforin represents the neurotransmitter reuptake inhibiting constituent of hypericum extract.

Hydroalcoholic hypericum extract inhibits the synaptosomal uptake of serotonin, norepinephrine, and dopamine with about similar affinities and leads to a significant down-regulation of cortical beta-adrenoceptors and 5-HT2-receptors after subchronic treatment of rats. While neither hypericine nor kaempferol did show any reuptake inhibiting properties, hyperforin was identified as the unspecific reuptake inhibitor of hypericum extracts with half-maximal inhibitory concentrations for the three synaptosomal uptake systems mentioned above between 80 and 200 nmol/l. Moreover, a hyperforin-enriched (38%) CO2 extract also leads to a significant beta-receptor down-regulation after subchronic treatment. The data suggest hyperforin as the active principle of hypericum extracts in biochemical models of antidepressant activity.

Stress-induced stimulation of early growth response gene-1 by p38/stress-activated protein kinase 2 is mediated by a cAMP-responsive promoter element in a MAPKAP kinase 2-independent manner.

The p38/stress-activated protein kinase2 (p38/SAPK2) is activated by cellular stress and proinflammatory cytokines. Several transcription factors have been reported to be regulated by p38/SAPK2, and this kinase is involved in the control of expression of various genes. In human Jurkat T-cells, induction of the early growth response gene-1 (egr-1) by anisomycin is completely inhibited by SB203580, a specific inhibitor of p38/SAPK2a and -b. Northern blot and reporter gene experiments indicate that this block is at the level of mRNA biosynthesis. Using mutants of the egr-1 promoter, we demonstrate that a distal cAMP-responsive element (CRE; nucleotides -134 to -126) is necessary to control egr-1 induction by p38/SAPK2. Pull-down assays indicate that phospho-CRE binding protein (CREB) and phospho-activating transcription factor-1 (ATF1) bind to this element in a p38/SAPK2-dependent manner. In response to anisomycin, two known CREB kinases downstream to p38/SAPK2, MAPKAP kinase 2 (MK2) and mitogen- and stress-activated kinase 1 (MSK1), show increased activity. However, in MK2 -/- fibroblasts derived from mice carrying a disruption of the MK2 gene, the phosphorylation of CREB and ATF1 and the expression of egr-1 reach levels comparable with wild type cells. This finding excludes MK2 as an involved enzyme. We conclude that egr-1 induction by anisomycin is mediated by p38/SAPK2 and probably by MSK1. Phosphorylated CREB and ATF1 then bind to the CRE of the egr-1 promoter and cause a stress-dependent transcriptional activation of this gene.

[Orthopaedic one day surgery: anaesthesiologic techniques used and intra- and postoperative complications]. / One day surgery otropedico: tecniche anestesiologiche utilizzate e complicanze intra- e postoperatorie.

OBJECTIVE: Optimize patient management in one day surgery (ODS) by an observative study regarding one day orthopaedic surgery, assessing kind and quantity of intra- and postoperative complications, need for prolonged postoperative assistance postponing discharge, recovery in other hospitals, patients satisfaction index. METHODS: From september 1999 until december 2000 we distributed a questionnaire 1286 consecutive patients. The patients were ASA I (80,7%), ASA II (17%) and ASA III (2,3%). We evaluated intra- and postoperative complications considering type of surgery and anaesthesiologic technique; need and reason for medical consulting; if consulting took place in other institutes. Patients judgement regarding medical and nursing assistance during in hospital stay was assessed. RESULTS: Main surgical procedures: arthroscopy (44,6%), internal fixation removal (21,3%), neurolysis (9,5%), cysts/tumours/nodules removal (7,5%), foot surgery (8,0%). Used anaesthesiologic techniques: neural block (65,6%), plexus block (15,1%), general (12,5%), spinal (4,8%) and local anaesthesia (1,9%). An intraoperative complication (convulsion) was reported twice. Postoperative complications: pain (3,6%) most frequent in foot surgery (5,2%), nausea (0,2%), fever (0,7%), haematoma (0,5%). 5 delayed discharges (beyond 24h) were reported, for surgical reasons. In 5 cases another institute was visited. There were no deads. CONCLUSIONS: The percentage of not planned recoveries (0,1%) is an indication of frequency of major complications. Satisfaction index of patients was high (96%). Kind of surgical procedure and anaesthesiologic technique, considering the minimal intra- and postoperative complications, are adjusted to the ODS regime. Reinforcing analgesic protocols in foot surgery though are necessary. According to our opinion the peripheral block is preferable in orthopaedic ODS.