How to reduce erroneous Emergency Department admissions for the frail elderly.

Background: Readmission after a first hospitalization is a common occurrence. It may be due to incomplete treatment, poor care for underlying problems or reflect bad coordination with health services at the time of discharge. The aim of this study was to identify the factors and classify the pathologies that expose elderly patients to erroneous access to the Emergency/Urgency Department (EUD). Study design: Retrospective observational study. Materials and methods: From January 2016 to December 2019 we studied patients who had at least one readmission to the EUD in the six months following discharge. All EUD accesses of the same patient that occurred for the problem treated during the previous hospitalization were identified. Data was provided by the University Hospital of Siena. Patients were stratified by age, gender, and municipality of residence. We used an ICD-9-CM coding system to describe health problems. Statistical analysis was carried out with Stata software. Results: We studied 1,230 patients (46.6% females) the mean age was 78.2 ± 14.3. Most of them, 721 (58.6%) were ≥80 years old, 334 (27.1%) were 65-79, 138 (11.2%) were 41-64, and only 37 (3.0%) were ≤40. Patients who lived in Municipality of Siena had a lower probability to return than to those living in other municipalities (OR 0.76; 95%CI: 0.62-0.93; p<0,05). The main causes of readmission for ≥65 years old were "symptoms, signs and ill-defined conditions" (18.3%), "respiratory diseases" (15.0%), "injury and poisoning" (14.1%), "cardiovascular diseases" (11.8%), "classification of factors influencing health status and contact with health services" (9.8%), "genitourinary diseases" (6.6%) and "digestive diseases (5.7%). Conclusions: We observed that patients residing a greater distance from the hospital facilitates the risk of readmission. The factors that were exposed could be used to identify frequent users and initiate measures to reduce their access.

Comparison of two molecular methods used for subtyping of Legionella pneumophila 1 strains isolated from a hospital water supply.

The results of the pulsed-field gel electrophoresis and the sequence-based typing (using the loci flaA, pilE, asd, mip, mompS and proA) were compared for subtyping of Legionella pneumophila 1 strains isolated from a hospital water supply. Molecular typing was carried out on 61 isolates (38% of the positive samples) selected on space and temporal criteria in order to follow the evolution of the water-system colonization. For all the 61 isolates, the sequence of the amplified mip gene fragment identified Legionella pneumophila strain Wadsworth. Genotype testing by PFGE analysis showed three different patterns, correspondent to three SBT types according to the allelic profiles. Both PFGE and SBT indicated the circulation and the persistence in the hospital potable water-system of three types randomly distributed in space and time. The two molecular methods adopted showed a 100% concordance, although a low degree of genetic heterogeneity characterized the isolates. The electrophoretic patterns were sufficiently unambiguous to consider PFGE a highly discriminatory typing method, but the SBT technique besides accurately characterizing isolates, was able to identify Legionella strains through analysis of the mip gene. A typing method with this level of discriminatory power has great potential for assisting in epidemiological studies.

Laparoscopic cholecystectomy in children with chronic hemolytic anemia. Is the outcome related to the timing of the procedure?

BACKGROUND: The aim of this study was to evaluate whether the outcome in children with chronic hemolytic anemia (CHA) and cholelithiasis undergoing laparoscopic cholecystectomy (LC) is related to the operation timing. METHODS: From June 1995 to December 2004, 46 children with CHA were referred to our division of surgery for cholelithiasis. All 46 children were asymptomatic at the time of the first visit, and an elective LC was proposed to all of them before the onset of symptoms. The operation was accepted in the period of study by 24 children and refused by 22. The patients were divided into three groups (group A, asymptomatic; group B, symptomatic; and group C, emergency admitted) depending on clinical presentation and operation timing, and the respective outcomes were compared. RESULTS: Elective LC in asymptomatic children (group A) is safe with no major complications reported. In children who refused surgery (groups B and C), we observed four sickle cell crises, four acute cholecystitis, and two choledocholithiasis, and all these complications were related to waiting. Two sickle cell crises occurred in symptomatic children waiting for surgery during biliary colic. The risk of emergency admission in children with cholelithiasis and CHA awaiting surgery was found to be high: 28% of the children admitted in emergency after a mean of 32 months (range, 22-36). Morbidity rate and postoperative stay increased when children with hemoglobinopathies underwent emergency LC. CONCLUSIONS: Elective LC should be the gold standard in children with CHA and asymptomatic cholelithiasis in order to prevent the potential complications of cholecystitis and choledocholithiasis, which lead to major risks, discomfort, and longer hospital stay.

[Radiofrequency-assisted hepatic resection--first experience]. / Resezione epatica assistita dalla radiofrequenza. Prime esperienze.

AIMS: Intra-operative blood loss during liver, resection remains a major concern due to its association with higher postoperative complications and shorter long-term survival. The aim of this study was to assess the feasibility and safety of a novel concept for liver resection using a Radio-Frequency energy assisted technique. METHODS: From January 2001 to January 2002, 27 patients were operated on using Radio-Frequency energy assisted liver resection. Radio-Frequency energy was applied along the resection edge to create a 'zone of desiccation' prior to resection with a scalpel. RESULTS: Median resection time was 47.5 minutes (range 30-110). The median blood loss during resection was 30 mls (range 15-992) and mean pre-operative and post-operative haemaglobin values were 13.5 g/dL (SD+1.7) and 11.6 g/dL (SD+1.4) respectively. No blood transfusion was registered, nor was any mortality observed. There was one post-operative complication: a sub-phrenic abscess. Median post-operative stay was 8 days (range 5-86). CONCLUSION: Liver resection assisted by RF energy is feasible, easy and safe. This novel technique offers a new method for 'transfusion-free' resection without the need for sutures, ties, staples, tissue glue or admission to Intensive Care Unit.

[Intraperitoneal neoplastic dissemination of incidental gallbladder carcinoma after laparoscopic surgery]. / La disseminazione neoplastica intraperitoneale da carcinoma incidentale della colecisti dopo chirurgia laparoscopica.

BACKGROUND: Several laboratory and clinical studies have raised the concern that laparoscopic procedures might worsen the prognosis of patient with malignant disease due to premature intraperitoneal cancer cell dissemination. The aim of the study was to examine the risk of the dissemination in patients with unsuspected gallbladder cancer diagnosed after laparoscopic cholecystectomy (LC). METHODS: A retrospective clinicopathologic study was performed on 5 patients with unsuspected gallbladder cancer without preoperatively diagnosis among 1280 patients that underwent LC in the period 1993-2002. The possible neoplastic dissemination was compared to that reported in 8 patients affected from unsuspected gallbladder cancer diagnosed after open cholecystectomy. RESULTS: Two patients with unsuspected gallbladder cancer (T1a-T2) presented a port-site recurrence after respectively six and four months. There was not statistically significant difference between types of cholecystectomy (LC or OC). Survival rate did not change according to whether the operation was carried out using LC or OC. CONCLUSION: After an accurate checking of the factors indicated to explain the early neoplastic dissemination frequently observed in the patients undergone LC and an analysis of their own experience the Authors conclude that LC does not worsen the prognosis of unsuspected gallbladder cancer.

[Immunological and clinical evaluation about mixed sistemic allogenic chimerism by transplantation]. / Considerazioni immunologiche e cliniche sul chimerismo sistemico allogenico misto da trapianto.

A critical revision of the data in the literature regarding mixed allogeneic systemic chimerism by transplantation permits to perceive the aspects of undoubted interest in the immunological and clinical field. The usefulness of the cellular exchange, with the aim of the acceptance of the transplantation, that is carried out between recipient and the transplanted organ and which constitutes a completely peculiar immunological situation, comparable to the immunotolerance of the fetal period even though with same not totally identificable is pointed out.

Efficacy of ropivacaine compared with ropivacaine plus sufentanil for postoperative analgesia after major knee surgery.

This study compared the analgesic efficacy of an epidural infusion of ropivacaine and ropivacaine with sufentanil following major knee surgery. In a double-blind clinical trial, 115 adult patients received either epidural ropivacaine (R group, 2 mg.ml(-1)), or ropivacaine (2 mg.ml(-1)) with sufentanil (RS group, 1 microg.ml(-1)), using a patient-controlled epidural analgesia technique. Pain scores (visual analogue scale, VAS, and the simple descriptive scale, SDS), side-effects, motor block and treatment quality were recorded at 6, 12 and 24 h after the insertion of the epidural catheter. In the RS group, analgesic efficacy was significantly greater than in the R group between 12 and 24 h following insertion of the epidural catheter (VAS: 92.9% vs. 72.9%, p = 0.009). There was no significant difference during the other periods. Pruritus, nausea and vomiting were significantly more frequent in the RS group. Good postoperative analgesia was obtained with an epidural infusion of ropivacaine (2 mg.ml(-1)). When this local anaesthetic was administered with sufentanil, there was an improvement in the analgesic effect but a significant increase in the number of patients who reported adverse effects. The differences were more pronounced 12 h after the beginning of the analgesic schedule. This study failed to demonstrate any worthwhile clinical benefit from the addition of sufentanil.

Pituitary adenylate cyclase-activating polypeptide hormone (PACAP) at very low dosages improves memory in the rat.

To ascertain whether very low dosages of pituitary adenylate cyclase-activating polypeptide (PACAP) influence learning in mammals, immediately after the acquisition trial of a passive avoidance response (PAR) paradigm, PACAP-38 was administered intracerebroventricularly at increasing dosages (0, 0.02, 0.2, 2, 20, and 200 ng in 10 microl saline) to different groups of rats. The mnemonic effects were measured by means of retention testing 48 and 96 h later. At intermediate PACAP-38 concentrations there was a significant mnemonic improvement of the PAR. The maximal effect was observed after the 0.2-ng PACAP-38 administration (longer step-through latencies). There was a lesser effect at the subsequent higher concentration, 2 ng. Higher dosages had no effects. It is concluded that PACAP-38 acts as an enhancer of mammalian mnemonic processes even at very low dosages. The positive effect follows an inverted U-shaped dose-response curve. The results may be of interest for the therapy of some neuropathological conditions.

Long-lasting hippocampal potentiation and contextual memory consolidation.

In order to ascertain whether there are hippocampal electrophysiological modifications specifically related to memory, exploratory activity and emotional stress, extracellular electrical activity was recorded in hippocampal slices prepared from the brains of male adult rats. Several groups of animals were employed: (i) rats which had freely explored the experimental apparatus (8 min exposure); (ii) rats which had been subjected, in the same apparatus, to a fear conditioning paradigm training entailing the administration of aversive electrical footshocks (8 min exposure); (iii) rats to which the same number of aversive shocks had been administered in the same apparatus, but temporally compressed so as to make difficult the association between painful stimuli and the apparatus (30 s exposure); (iv) naïve rats never placed in the apparatus. Half of the rats from each treatment group were used for retrieval testing and the other half for hippocampal excitability testing. The conditioned freezing response was exhibited for no less than 4 weeks. Hippocampal excitability was measured by means of input-output curves (IOC) and paired-pulse facilitation curves (PPF). Retrieval testing or brain slices preparation were performed at increasing delays after the training sessions: immediately afterwards or after 1, 7 or 28 days. Only the rats subjected to the fear conditioning training exhibited freezing when placed again in the apparatus (retrieval testing). It was found that IOCs, with respect to naïve rats, increased in the conditioned animals up to the 7-day delay. In free exploration animals the IOCs increased only immediately after the training session. In all other rats no modification of the curves was observed. IOC increases do not appear to imply presynaptic transmitter release modifications, because they were not accompanied by PPF modifications. In conclusion, a clear-cut correlation was found between the increase in excitability of the Schaffer collateral-CA1 dendrite synapses and freezing response consolidation.

Role of the perirhinal cortex in rats' conditioned taste aversion response memorization.

The role of the perirhinal cortex (PC) in conditioned taste aversion (CTA) learning was investigated in Long Evans rats. CTA was induced by the intraperitoneal administration of LiCl 60 min after saccharin-sweetened water drinking. The PC was reversibly inactivated by the stereotaxic administration of tetrodotoxin (TTX) 60 min before saccharin drinking, immediately after saccharin drinking (Experiment 1), 6 or 24 hr after LiCl administration (Experiment 2), and 60 min before CTA retrieval testing (Experiment 3). Only pre-saccharin drinking PC inactivation disrupted CTA. Thus, PC integrity is necessary only during the earliest phases of CTA mnemonic processing, that is, taste information acquisition and early gustatory memory elaboration. The results are discussed in relation to PC connectivity and PC temporal involvement in the memorization process of other aversive responses.

Effects of coupled perirhinal cortex and medial septal area, fimbria-fornix, entorhinal cortex tetrodotoxin inactivations on passive avoidance consolidation in the rat.

In order to ascertain the rat perirhinal cortex (PC) function during early consolidation of a passive avoidance response (PAR), and to ascertain whether there are some functional interactions with the medial septal area (MSA), the fimbria-fornix complex (FF) and the entorhinal cortex (EC), PC-MSA, PC-FF, and PC-EC coupled inactivations were performed immediately after the PAR acquisition session. Anesthetized male adult Wistar rats aged 60 days were treated with stereotaxical bilateral injections of TTX (5 ng in 0.5 microl saline) in the appropriate sites. Retrieval testing was performed 48 h later. It was shown that all three coupled inactivations were followed by significant PAR disruption. It may be concluded that PC is somehow active even during the first mnemonic phase following the acquisition session, thus better defining PC mnemonic involvement chronology. These results may be taken as indicating that during initial consolidation the engram is concurrently processed in more than one septal and parahippocampal site, each of which by itself is not absolutely necessary for the final engram formation.

Pre and intra-operative methods of staging gastric cancer.

The aim of this paper was to examine the indications and limits of pre- and intra-operative instrumental diagnosis of gastric cancer. In order to achieve this effectively, the authors emphasized the importance of proper staging methods and obtained a detailed description of tumor diffusion. The most important diagnostic instruments considered were magnetic resonance, endosonography, intra-operative echography, pre- and intra-operative immunoscintography and a cytological examination of peritoneal lavage fluid. The authors concluded that pre- and intra-operative staging of gastric cancer is important for two major reasons: it results in the most accurate definition possible of disease evolution, enabling a proper therapeutic program; and it involves a combination of three complementary metasurgical treatments.

Auditory thalamus, dorsal hippocampus, basolateral amygdala, and perirhinal cortex role in the consolidation of conditioned freezing to context and to acoustic conditioned stimulus in the rat.

On the basis of previous experimental evidence, it is known that the auditory thalamus (AT), the dorsal hippocampus (DH), the basolateral amygdala (BLA), and the perirhinal cortex (PC) are involved in the mnemonic processing of conditioned freezing. In particular, BLA and PC appear to be involved both in conditioned stimulus (CS) and context conditioned freezing. Through AT, the auditory CS is sent to other sites, whereas DH is involved in context conditioning. Nevertheless, the existing evidence does not make it possible to assess AT, DH, BLA, and PC involvement during the consolidation phase of conditioned freezing. To address this question, fully reversible tetrodotoxin (TTX) inactivation was performed on adult male Wistar rats having undergone CS and context fear training. Anesthetized animals were injected stereotaxically with TTX (either 5 or 10 ng in 0.5 or 1.0 microliter of saline, according to site dimensions) at increasing post-acquisition delays. Context and CS freezing durations were measured during retention testing, always performed 48 and 72 hr after TTX administration. The results showed that AT inactivation does not disrupt consolidation of either contextual or auditory fear memories. In contrast, inactivation of the other three structures disrupted consolidation. For the DH, this disruption was specific to contextual cues and only occurred when inactivation was performed early (up to 1.5 hr) after training. The BLA and PC were shown to be involved in the consolidation of both contextual and auditory fear. Their involvement persisted for longer periods of time (2d for BLA and 8 d for PC). These findings provide information to build a temporal profile for the post-training processing of fear memories in structures known to be important for this form of learning. The results are discussed in relation to previous studies on conditioned freezing and other aversive conditioned response neural correlates.

Memorization of contextual and CS conditioned fear response (freezing) in a one-trial acquisition paradigm.

In fear-conditioned Wistar rats freezing was induced by the delivery of a series of footshocks paired to tones (CS) in a specific conditioning chamber (context). CS and contextual fear were acquired in the same single conditioning session without preexposition to the conditioning chamber (day 1). Different groups of animals were conditioned employing three increasing US (footshock) intensities (0.25, 0.5, 0.75 mA). During the retention sessions context and CS conditioned freezing (fear response) were measured using a paradigm that fulfilled the following conditions: i) CS freezing retention was measured in a context different from the conditioning one; ii) CS and context freezing were measured at increased delays after the training session (days 3 and 4, 14 and 15, 28 and 29). The results show that there are significant differences between CS and context freezing retention, which are clearly related to delay after the initial session and to US intensity. In particular: 1) conditioned freezing to a discrete tone is better retained than conditioned freezing to context (irrespective of US intensity); 2) context freezing is directly related to US intensity much more than to tone freezing; 3) context freezing is easier to extinguish than tone freezing. The results are discussed in relation to previous ones and to their relevance to freezing genesis neural correlates.

Effects of combined medial septal area, fimbria-fornix and entorhinal cortex tetrodotoxin inactivations on passive avoidance response consolidation in the rat.

On the basis of previous experimental evidence, it has been concluded that the entorhinal cortex (EC), the fimbria-fornix (FF) complex and medial septal area (MSA) do not take part in the consolidation phase of passive avoidance response (PAR) memorization. On the other hand, a mnemonic role during consolidation of at least two of these structures has been argued, based on several considerations. In order to ascertain whether the EC and FF are still involved in PAR memorization during consolidation, the coupled fully reversible functional tetrodotoxin (TTX) inactivation of MSA, FF and EC was performed in rats having undergone a PAR training. In Experiment 1 MSA, FF and EC were inactivated pair-wise (FF and EC always bilaterally). Permanently cannulated animals were injected stereotaxically with TTX (5 ng in 0.5 microliter saline) or saline (0.5 microliter) immediately following PAR acquisition. It was shown that combined FF-EC inactivation induced PAR retention impairment, whereas FF-MSA and EC-MSA inactivation was not followed by amnesic effects. Having obtained a positive result, in Experiment 2 the combined FF-EC inactivation was performed at different post-acquisition delays (0.25 h, 1.5 h, 6 h), so as to assess the duration of their involvement in PAR consolidation. It was shown that only the coupled inactivation performed at the shortest post-acquisition delay was followed by amnesic effects. Thus EC and FF play a definite role during early consolidation. The results are discussed in relation to EC, FF, MSA, and hippocampal involvement in PAR memorization, as reported in previous studies, and to their connectivity.

Neural topography and chronology of memory consolidation: a review of functional inactivation findings.

Findings on the role of subcortical and cortical structures in mnemonic processes, obtained by means of the reversible functional inactivation technique, are reviewed. The main advantage of this method (subcortical or cortical administration of local anesthetics or tetrodotoxin) is that it provides information not only on "where" but also "when" and for "how long" these processes take place, thus adding to the topographical dimension the chronological one. The review covers several types of memory (e.g., passive avoidance and spatial memory) studies examining the neural substrates of memory consolidation on the basis of the functional inactivation of the nucleus of the solitary tract, parabrachial nuclei, substantia nigra, hippocampus (dorsal and ventral), nucleus basalis magnocellularis, amygdala, medial septal area, striatum, olfactory bulb, and neocortex. The data are discussed in relation to earlier research and with respect to the anatomical and functional connectivity of the examined centers.

A peculiar pattern of temporal involvement of rat perirhinal cortex in memory processing.

By means of the fully reversible tetrodotoxin inactivation technique, perirhinal cortex (PC) mnemonic function was investigated in rats trained to a passive avoidance response (PAR). It was shown that PC functional integrity is necessary during PAR acquisition, during late and very late consolidation (from 24 hr up to 192 hr after the training session), and during retrieval. An unexpected finding was that the PC was not involved in the early consolidation period. Thus the PC may play a relatively simple relay or connective role during acquisition, but its very late and very long consolidative involvement may indicate a peculiar function in consolidation and possibly in the storage of the PAR engram. The results are discussed in terms of the mnemonic characteristics of other neural sites (amygdala, hippocampus, and entorhinal cortex) involved in the same learning process.

[The use of synthetic prosthesis in the treatment of hernia]. / L'impiego di protesi sintetiche nel trattamento dei laparoceli.

The authors report their experience on synthetic prosthesis used in 36 patients with abdominal hernias. Thirty six cases of incisional hernias have been analyzed by Institute of General Surgery of Messina University from 1992 to 1998. Among the 33 cases with median parietal defect, in 7 cases concerning great incisional hernias group a PTEF-e prosthesis, which was positioned in an intraperitoneal site, was employed. In 21 cases of medium size incisional hernias they used a polypropylene prosthesis, which was positioned in an intraparietal or preperitoneal site. In 5 cases of small size incisional hernias, polypropylene prosthesis was placed in a superfascial site. In the 3 cases of medium size lateral laparocele++, polypropylene prosthesis was positioned in a intraparietal site. There was no operative mortality. Among postoperative complications, 4 seromas, 1 parietal and 1 subcutaneous haematoma and 2 haematomas in retroperitoneal site appeared. Clinical-instrumental controls, which have continued until two or three years after the operation were performed which pointed out a recurrence in just one case where the prosthesis was positioned in a superfascial site. To conclude, we consider that nowadays the use of synthetic prosthesis lets us face and solve problems concerning surgical treatment of incisional hernias with confidence.

Temporal characterization of subcortical nuclei in mnemonic processes: results of tetrodotoxin reversible inactivation studies in the rat.

By means of permanent lesion techniques it has been possible to ascertain whether a given subcortical neural structure is involved in memory processing. These results, however, are useful only to build a topography of memory, i.e. to provide information only on the "where" such processes take place. Memory being, per se, a temporal process, organized in at least three putative phases (acquisition, consolidation, retrieval) it is of paramount importance to know not only the "where", but also the "when", and, possibly, the "how long" of a given site involvement. The fully reversible inactivation technique has been employed to assess the chronological involvement of subcortical sites. By means of the stereotaxic administration of tetrodotoxin (TTX) it has been possible to inactivate known volumes of nervous tissue for given periods of time. In this way, it has been possible to measure the amnesic effects (disruption of the performance of a passive avoidance response, PAR) after inactivation of discrete neural sites. The data so far obtained by these means are presented and discussed. The comparison of results is justified by the constancy of the experimental subjects (young adult male rats of the same age), the surgical interventions, and the conditioning paradigm (passive avoidance responding in the light-dark box). The parabrachial nuclei, substantia nigra, ventral hippocampus, dorsal hippocampus, nucleus basalis magnocellularis, amygdala, globus pallidus, nucleus caudate-putamen (anterior, median, posterior), medial septal area and nucleus accumbens have been investigated. From these studies, data have been acquired on all three phases of memorization. The most detailed findings concern consolidation. In particular, it was shown that the functional integrity duration necessary to avoid amnesic damages varies greatly from site to site, from at least 15 min to no less than 48 hours. The results confirm and amplify previous experimental work, by defining the chronology of mnemonic involvement of many neural sites. The results are discussed in terms of comparison between sites and connectivity between the investigated sites and other sites or neuronal systems.