How will technology change people's home care in the next 20 years? A strategic foresight study.

The rapid expansion of home health care has raised many unresolved issues and will have far-reaching consequences that can only be overcome with a holistic approach to help build and use collective intelligence in a structured, systemic way to anticipate developments. In this frame, the set of issues covered by the human factors research field will significantly impact the safety, quality, and effectiveness of home health care. However, only with a gaze of strategic foresight will we be capable of exploring, anticipating, and shaping the future. A group of researchers from the Italian Society of Ergonomics and Human Factors (SIE) has developed a road map to help all the stakeholders involved in this process.

A Strategic Foresight study was conducted to define a preferred scenario of home care in the next 20 years. A hybrid survey method called Human-Centred Foresight was applied. The results achieved in the study show a possible scenario of home care that can define medium- and long-term goals from today until 2041.

Relationships between hepatic melanogenesis and respiratory conditions in the newt, Triturus carnifex.

The Kupffer cells (melanomacrophages) in the livers of lower vertebrates contain varying quantities of melanin according to the season. Specimens of Triturus carnifex raised for 2 months at 6 degrees C and then transferred to water at 22 degrees C show a rapid increase in the hepatic accumulation of the pigment. The Kupffer cells make up more than one fourth of the liver mass in chlorbutol-anesthetized animals isolated for 6-7 hr in hypoxic water at 18 degrees C (to bring the oxygen content in a 620-mL respiratory chamber from 1.1 ppm to 0.0). Thus, hepatic melanin is synthesized when the newt's oxygen supply is inadequate to meet its metabolic needs; melanogenesis, however, requires the presence of oxygen and does not occur in anesthetized specimens immersed in a totally anoxic fluid such as paraffin oil. The intraperitoneal injection prior to hypoxic treatment of 1 mg/g of body weight of kojic acid (inhibitor of the enzyme tyrosinase which catalyzes melanin synthesis) blocks melanogenesis and doubles oxygen consumption. The combination of hypoxia and tyrosinase inhibition causes permanent damage to essential functions of the nervous system, while hypoxic treatment alone has no irreversible consequences. The genic expression of tyrosinase in hypoxia appears to be a physiological response aimed at prolonging survival time in anaerobiosis by lowering the metabolic level; melanin would be an inert subproduct of this function.

Relationships between spleen and respiration in the newt.

Specimens of newt, Triturus cristatus carnifex (Laurenti), anesthetized by submersion in 0.2% chlorbutol in tap water for 15 min, and then placed out of water in a damp terrarium, show hypertrophy of the spleen that in 2 hr gradually increases from 0.31 +/- 0.12%with respect to body weight to 1.56 +/- 0.26% (means and standard deviation calculated for groups of six animals). Other anesthetics either do not produce hypnosis (Veronal), do not have a prolonged enough effect (ethyl ether, chloroform), or induce vasodilatation, which prevents hypertrophy (MS-222, urethane). The spleen hypertrophy, seen histologically to be due exclusively to blood congestion, is not caused by either a pharmacological effect of the chlorbutol or by the hypnotic state, as it does not appear in submerged anesthetized animals, unless the water is constantly stirred by a magnetic agitator, and can be reversed depending on the ventilation of the animal's skin. The spleen hoards blood when oxygenation is good (in air or stirred water) and releases this supply in the bloodstream when oxygenation is insufficient (in still water). The hypoxic "diffusion boundary layer," which, in still water, forms around the immobile newts, hampers respiratory exchange and stimulates the spleen contraction. This mechanism and its relationship to oxygenation has been demonstrated statistically in unanesthetized newts as well, in both air and water, despite the interference of two contrasting factors--lung respiration and spontaneous motor activity--absent in anesthesized animals. Congestion and decongestion of the spleen are the physiological mechanisms compensating for variations in the level of oxygenation, an alternative to the "capillary recruitment" described by Poczopko and Burggren and Moalli in may amphibians that appears to be absent in newts. The newt spleen, known to play a lesser role in erythropoiesis and destruction of aged erythrocytes than that traditionally assigned to it is thus of primary importance in respiration.

Sites and trend of erythropoiesis in anemic, normal, and splenectomized newts.

Newts, Triturus cristatus carnifex (Laurenti), were anesthetized by submersion in 2% chlorbutol in tap water for 15 min, splenectomized and then rendered totally anemic two months later by treatment with acetylphenylhydrazine (APH) diluted in their tanks (25 mg/liter for 36 h, changing the solution every 12 h). In the 14 weeks following hemolysis, erythron restoration occurred with the same intermittence as it did in whole animals rendered anemic by APH treatment: Beginning the second week the red blood cell count progressively increases for about one month, followed by a period of stasis which lasts about three weeks, then by a new increase, and then by a final period of stasis. Histological examination shows that erythropoietic activity occurs partly in the circulating blood and partly in erythroblasts nestled in the crypts between the muscular trabeculae of the ventricle as well as in the atrial walls. These cells, which are not part of the freely circulating elements in the blood stream, become very abundant in both whole and splenectomized anemic newts but are also present in normal animals. Newts, thus, have three sites for erythropoiesis: the spleen, the blood stream, and the heart. The other components compensate for the elimination of the spleen without determining any lack of, or delay in, erythropoietic response.

Microcythemia from anemic hypoxia and normal erythropoiesis in the newt.

Specimens of the newt, Triturus cristatus carnifex (Laurenti), rendered totally anemic, restore erythron by cyclic waves of erythropoietic activity that alternate with intervals of stasis. Hemolysis is obtained by administering 25 mg/liter of acetylphenylhydrazine in the breeding water for 36 h. The first cycle of erythropoietic activity produces microcytes, which have completely differentiated by 8 weeks after treatment. However, if the animals are raised in a hyperbaric chamber at a pressure of 1.5 atmospheres, in order to compensate for hypoxia, normocytes are produced. In both cases the hematocrit and hematic concentration of hemoglobin reach analogous values, so microcythemia appears to be the only effect of hypoxia. The hemoglobin, hematocrit values, and normocyte counts in hyperbaric animals are about one-half those of the controls newts. These data, together with those on the life span of red blood cells (RBC) and time span between two successive erythropoietic cycles (2 months and 1 month, respectively), indicate that the newts normally keep only two sets (one new, one old) of RBC in circulation, whose approximate parameters can be defined as RBC count: 60,000/mm3, hematocrit: 17%, and hemoglobin: 5.4 g/100 ml.

Periodic changes in the organs involved in the erythropoiesis of anemic newts.

In Triturus cristatus carnifex (Laurenti) newts rendered totally anemic by treatment with acetylphenylhydrazine (APH) diluted in their tank water (25 mg/liter for 48 hours, with four changes) the recovery of erythron occurs through periodic cycles of mitotic activity in the erythropoietic tissue. These cycles determine a marked increase in blood erythrocyte concentration at regular intervals of about 1 month. The consequence of this trend is the alternation of ferritin and hemosiderin accumulation phases during periods of stasis with iron mobilization phases during periods of erythropoietic activity, which is particularly evident in the Kupffer cells of the liver. Iron mobilization and erythropoietic activity are strictly related to the periodic hypertrophy of some Bowman's capsule cells in the renal corpuscle, which were previously denominated "lactate sensitive cells" (LSC). The histochemistry, location, and behavior of LSC indicate that they are probably the site of erythropoietin production in the newt.

Intermittent erythropoiesis in anemic newts.

A group of 88 newts, Triturus cristatus carnifex (Laurenti), was rendered totally anemic by administering acetylphenylhydrazine (APH) in the breeding water for 48 h at a concentration of 25 mg/liter. The course of erythron restoration was followed for 5 months, sacrificing four specimens per week and analyzing the blood and spleen hemopoietic tissue. The return to the normal values of the red blood cell count occurred through marked increases in concentration at fairly regular intervals, which is best explained by a discontinuous, rhythmic erythropoiesis. This fact is strictly correlated with the intermittent mitotic activity observed in the spleen and with the periodic appearance of large quantities of immature elements in the blood smears. The APH-induced synchronization of newt erythropoietic activity revealed the approximate length of each erythropoietic cycle to be 4 to 5 weeks and the erythropoietic life span to be 50 to 60 days.

Rapid bleach for melanin.

Complete bleaching of melanin in strongly pigmented specimens embedded in paraffin or polystyrene, and sectioned and mounted on slides, is possible in 1-3 hr at 37 C in a solution of 20 ml of benzyl alcohol, 10 ml of acetone, 5 ml of 10% hydrogen peroxide and 4 drops of a 25% ammonia solution. The bleached tissues are well preserved and tolerate further histochemical treatments. All the stains and reactions tested give results identical to or better than those obtained after 24-48 hr oxidation in 10% hydrogen peroxide.

[Changes in erythrocyte count of newts during periods of sexual activity]. / Variazioni nelle conte degli eritrociti del tritone in rapporto al periodo dell'attivita' sessuale.

Newts (Triturus cristatus carnifex) raised for the first six months of the year at temperatures not less than 10 degrees C did not undergo hibernation with a drop in the number of their erythrocytes. On the contrary, during their wintertime period of sexual activity and parallel development of secondary sex characters, the red blood cells reached a much higher concentration than was previously assumed to be normal.

[Effects of low temperatures on the concentration of erythrocytes in newts during winter]. / Effetti della bassa temperatura sulla concentrazione degli eritrociti del tritone nel periodo invernale.

In winter time, specimens of Triturus cristatus carnifex kept at temperature of 5 degrees C show a decrease in the concentration of circulating erythrocytes and marked hypertrophy of the spleen, in comparison to animals raised at 15 degrees C. Thanks to their capacity to accumulate a large number of erythrocytes in the spleen, newts can switch from their condition of a seasonal hyperactivity, maintained by a high concentration of circulating erythrocytes, to hibernation. This is the reason why red blood cell counts made an freshly collects animals during the winter are extremely heterogeneous.

J10 lactate-induced polycythemia in newts.

Specimens of Triturus cristatus carnifex (Laurenti) raised for about 3 weeks in a 3 gm/liter solution of sodium lactate present a slight alkalosis and a mean increase of about 35% in the red blood cell count in comparison to control animals raised in identically oxygenated water; analogous treatment with an equal molar concentration of sodium pyruvate produces only alkalosis. Since lactate alone determines an increase in the number of erythrocytes as does hypoxia, and hypoxia always induces an increase in plasma lactate levels, it can be deduced that erythropoietin (ESF) production is stimulated by an increase in plasma lactate and not directly by a lack of oxygen. The hypothesis that ESF in newts is produced by the "lactate-sensitive cells" of the renal corpuscles, which hypertrophy after experimental anaemia or treatment with lactic acid salts, is indirectly confirmed.

[Experimental polycythemia induced by lactate in Tritons]. / Policitemia sperimentale da lattato nel Tritone.

Specimens of Triturus cristatus carnifex (Laurenti) raised for 4 weeks in a 7 g/l solution of sodium lactate present a mean increase of about 32% in the red blood cell count in comparison to control newts raised in identically oxygenated water. Since lactate alone determines an increase in the number of erythrocytes as does hypoxia and hypoxia always induces an increase in plasma lactate levels, it can be deduced that erythropoietin (ESF) production is stimulated by an increase in plasma lactate and not directly by a lack of oxygen. The hypothesis that ESF in newts is produced by the "lactate sensitive cells" of the renal corpuscles, which hypertrophy after experimental anaemia or treatment with lactic acid salts, is indirectly confirmed.

Lactate sensitive cells in newt kidneys.

Specimens of Triturus cristatus carnifex (Laurenti), raised in 3.2 g/l solution of sodium lactate, presented hypertrophy of "lactate sensitive cells" (LSC) clustered at the vascular pole of each renal corpuscle. As seen under both the light and electron microscopes, these are specialized cells of the Bowman's capsule located at the junction between its visceral and parietal layers. The structure formed by the cells, heretofore unknown, is topographically associated with the juxtaglomerular apparatus. As lactate stimulates erythropoiesis even in normal oxygenated specimens and hypoxia induces hypertrophy of LSC in newts, it is hypothesized that the LSC are the site of erythropoietin (ESF) synthesis. A scheme of ESF biogenesis in newts, integrating the above principles, concludes the paper.

Polystyrene embedding: a new method for light and electron microscopy.

Polystyrene embedments of histological specimens can be obtained with a solution of 1:14 polystyrene-toluene, 5% benzyl alcohol and 1% dibutyl phthalate, allowing the solvent to evaporate in polyethylene containers for 2-3 days at 58 C. The resulting blocks are easily cut into truncated pyramids, each containing a piece of tissue, which are then glued to a Plexiglas support. Drying is completed at 80 C for 20 hr. The pyramids can then be sectioned to produce thick sections with a steel knife or to produce semi- or ultrathin sections with a glass knife. A 10% paraldehyde solution is used to mount the light microscopy sections on a slide heated on a hot plate to 80 C; these can be treated with the same techniques used with paraffin sections. The results are of high quality. Semithin sections of tissues fixed for electron microscopy can be stained directly after mounting, or by a wider range of stains once the polystyrene has been removed by organic solvents. In electron microscopy, the ultrathin sections obtained with the usual techniques are highly electron beam-resistant and given acceptable results.