La responsiveness dei sistemi sanitari: un’analisi empirica sull’assistenza ospedaliera nel Servizio Sanitario Regionale dell’Emilia Romagna

The release of the World Health Report 2000 has brought to the fore the concept of responsiveness as an indicator of health system performance. Responsiveness relates to a system’s ability to respond to the legitimate expectations of potential users about non-health enhancing aspects of care (Valentine et al. 2003). A few studies have investigated how standard socio-demographic characteristics (such as income or education) have an influence on the evaluation of responsiveness by health care users (Puentes Rosas et al. 2006, Sirven et al. 2012, Rice et al. 2012). However, we are not aware of any study investigating the relationship between the frequency with which patients use health services and their evaluation of responsiveness. This paper narrows this gap by using data regarding a sample of patients hospitalized in 9 hospitals of Emilia Romagna, a Region of Italy. The data have been collected by the Agency for Health Care and Social Services of Emilia Romagna between January 2010 and December 2012. We investigate a representative sample of about 2500 in-patients, who have been asked to evaluate 29 different aspect of quality of care which refer to 6 domains of health system responsiveness (communication, social support, privacy, dignity, waiting times and quality of facilities). We make use of this structure of the data by adopting a panel data regression model. The adoption of a panel model helps in controlling for individual heterogeneity, which otherwise could bias our results. Given that responsiveness is evaluated on an ordinal and categorical scale (going from “very dissatisfied” to “very satisfied”) we estimate a panel ordered logit model. Our results suggest that if patients have already been hospitalized in the same ward over the last 5 years they evaluate responsiveness more positively compared to patients who have never been hospitalized before. However, this effect is statistically significant only if patients have been hospitalized in the last 6 months. More generally, the use of a proper methodology to investigate responsiveness at hospital level can allow a better identification of area of intervention for investments in staff training; moreover, it can allow to modify hospital characteristics which have a negative impact on patients’ reporting of responsiveness

Effects on Clinical Outcomes of a 5-Year Surgical Safety Checklist Implementation Experience: A Large-scale Population-Based Difference-in-Differences Study

The adoption of a surgical checklist is strongly recommended worldwide as an effective practice to improve patient safety; however, several studies have reported mixed results and a number of issues are still unresolved. The main objective of this study was to explore the impact of the first 5-year period of a surgical checklist-based intervention in a large regional health care system in Italy (4 500 000 inhabitants). We conducted a retrospective longitudinal study on 1 166 424 patients who underwent surgery in 48 public hospitals between 2006 and 2014. The adherence to the checklist was measured between 2011 and 2013 through a computerized database. The effects of the intervention were explored through multivariable logistic regression and difference-in-differences (DID) approaches, based on current administrative data sources. In-hospital and 30-days mortality, 30-days readmissions and length-of-stay (LOS) \u2a7e8 days were the observed outcomes. Adherence to the checklist showed marked variations across hospitals (0%-93.3%). A pre/post analysis detected statistically significant differences between surgical interventions performed in hospitals with higher adherence to the checklist (\u2a7e75% of the surgeries) and those performed in other hospitals, as for the 30-days readmissions rate (odds ratio [OR]: 0.96; 95% confidence interval [CI]: 0.94-0.98) and LOS \u2a7e 8 days rate (OR: 0.88; 95% CI: 0.87-0.89). These findings were confirmed after risk adjustment and DID analysis. No association was observed with mortality outcomes. On the whole, our study attained mixed results. Although a protective effect of the surgical checklist use could not be proved over the first 5 years of this regional implementation experience, our research offers some methodological insights for practical use in the evaluation process of large-scale implementation projects

Platelet preparations in neuronal cell differentiation

Concentrated Growth Factors (CGF) is a platelet rich preparation that has the important feature of a tight fibrin network and containing a large number of growth factors possessing great regenerative potentialities [1]. The regeneration of nervous system is one of the mail goal of regenerative medicine. The aim of this study is to test the in vitro CGF effects on both differentiated and undifferentiated SH-SY5Y cells, derived from human neuroblastoma. To induce differentiation, SH-SY5Y cells have been treated with Retinoic Acid (RA) 10µM, in both basal and complete medium and in the presence and absence of CGF. After 72 hours, different parameters have been investigated: the morphological characteristics of the cells, the cell proliferation, the cellular vitality using the MTT test, the CGF and/or RA differentiation property and the immunocytochemical analysis of neuronal specific markers (NeuN, Sinaptophisine, β-III-tubulin, Nestin). Moreover the NGF (Nerve Growth Factor) and BDNF (Brain Derived Growth Factor) release have been assayed by ELISA test. Our results obtained suggest that treatment with CGF, also used alone, positively affects cell differentiation and neuronal phenotype regulating the expression of the neuronal markers and improving the outgrowth of neurites. Taken together these results seems to be promised into new approaches for neuronal regeneration using platelet preparations

Peripheral Purinergic Modulation in Pediatric Orofacial Inflammatory Pain Affects Brainstem Nitroxidergic System: A Translational Research

Physiology of orofacial pain pathways embraces primary afferent neurons, pathologic changes in the trigeminal ganglion, brainstem nociceptive neurons, and higher brain function regulating orofacial nociception. The goal of this study was to investigate the nitroxidergic system alteration at brainstem level (spinal trigeminal nucleus), and the role of peripheral P2 purinergic receptors in an experimental mouse model of pediatric inflammatory orofacial pain, to increase knowledge and supply information concerning orofacial pain in children and adolescents, like pediatric dentists and pathologists, as well as oro-maxillo-facial surgeons, may be asked to participate in the treatment of these patients. The experimental animals were treated subcutaneously in the perioral region with pyridoxalphosphate-6-azophenyl-2′,4′-disulphonic acid (PPADS), a P2 receptor antagonist, 30 minutes before formalin injection. The pain-related behavior and the nitroxidergic system alterations in the spinal trigeminal nucleus using immunohistochemistry and western blotting analysis have been evaluated. The local administration of PPADS decreased the face-rubbing activity and the expression of both neuronal and inducible nitric oxide (NO) synthase isoforms in the spinal trigeminal nucleus. These results underline a relationship between orofacial inflammatory pain and nitroxidergic system in the spinal trigeminal nucleus and suggest a role of peripheral P2 receptors in trigeminal pain transmission influencing NO production at central level. In this way, orofacial pain physiology should be elucidated and applied to clinical practice in the futur

The anastomotic network around the anterior superior alveolar nerve: an anatomical and radiological study

Innervation of superior teeth is supplied by the posterior (PSAN), anterior (ASAN) and sometimes by middle superior alveolar nerve (MSAN). PSAN arises from the maxillary nerve and passes through the posterolateral maxillary wall towards the posterior teeth. ASAN arises from the anterior portion of the infraorbital nerve and courses within the infraorbital canal passing nearby the piriform aperture and premaxilla. When present, MSAN arises from the posterior portion of the infraorbital nerve and runs along the lateral maxillary wall. However, an additional nasopalatine or sublabial injection is frequently required to obtain a complete anesthesia of the maxillary teeth due to rich anastomotic network (1-2). With the aim to better describe the complexity of the superior alveolar nerve network, fifty-seven high-definition sinonasal cone-beam CT (CBCT) were analyzed. PSAN, ASAN and MSAN were detected by specific bony landmarks/canals and nervous anastomoses were accurately evaluated. In addition, medial anastomotic branches from the palatal and/or nasal nervous plexi were also considered. PSAN and ASAN were identified in 100% of cases whereas MSAN in 19.6% of cases. Anastomotic branch versus ASAN was identified in all cases from MSAN and in 60.3% from PSAN. Medial anastomotic branch was detected in 62.0% of cases from the nasal plexus and in 6.2% from the palatal plexus: the former passed through a bony defect in the floor of the piriform aperture or at the base of the nasal septum; the latter passed through a tiny canal in the interface between maxilla and premaxilla. These data confirm that maxillary teeth innervation, especially for incisor teeth, could be provided not only by alveolar nerves but also from palatal and nasal plexi via small branches running within maxillary bony canals. These results support the need of additional anesthetic injection to obtain adequate anesthesia of the maxillary teeth; moreover, the role of CBCT in the identification of the nervous pattern was underlined

In silico analysis and theratyping of an ultra-rare CFTR genotype (W57G/A234D) in primary human rectal and nasal epithelial cells

Mutation targeted therapy in cystic fibrosis (CF) is still not eligible for all CF subjects, especially for cases carrying rare variants such as the CFTR genotype W57G/A234D (c.169T>G/c.701C>A). We performed in silico analysis of the effects of these variants on protein stability, which we functionally characterized using colonoids and reprogrammed nasal epithelial cells. The effect of mutations on cystic fibrosis transmembrane conductance regulator (CFTR) protein was analyzed by western blotting, forskolin-induced swelling (FIS), and Ussing chamber analysis. We detected a residual CFTR function that increases following treatment with the CFTR modulators VX661±VX445±VX770, correlates among models, and is associated with increased CFTR protein levels following treatment with CFTR correctors. In vivo treatment with VX770 reduced sweat chloride concentration to non-CF levels, increased the number of CFTR-dependent sweat droplets, and induced a 6% absolute increase in predicted FEV1% after 27 weeks of treatment indicating the relevance of theratyping with patient-derived cells in CF

Exploring reliability in epidemiology and clinical research

Quality of measurement is a fundamental issue in medical research and clinical practice, of relevance for any inference or decision-making process. Reliability, as an estimate of the variability in the domain of repeated measurements, is an important component of the quality of measurements.Reliability indices are frequently used and presented in the medical literature and a considerable amount of methodological research has been conducted on this topic in the last decades. However, the debate is still open on some theoretical and operational aspects. Available knowledge concerning reliability, particularly for categorical data, is not easily accessible since it is often confined to specialized journals and almost disregarded by statistical textbooks. Therefore, a thorough understanding is difficult to achieve for a researcher potentially involved in reliability studies.My main objective was to pursue a conceptual and global understanding of the role of reliability in the domain of categorical data. In order to achieve this goal I reviewed and synthesized the literature according to some specific objectives: (a) to provide an overview on the founding concepts and methods in the measurement of reliability for categorical variables, also contrasting them with what has been done in the domain of continuous variables; (b) to present and discuss the main limitations of traditional indices, particularly the kappa statistic; (c) to briefly introduce some possible alternative methods and areas for future development; (d) to emphasize the implications of reliability for epidemiological and clinical research.Finally, in order to illustrate the application of some of the methods discussed, I used a real set of data, concerning 209 slides of lymphomas tissue samples, reviewed by a panel of four pathologists, according to a standard classification based on 10 categories

How the different material and shape of the blood collection tube influences the Concentrated Growth Factors production

Platelet concentrates, such as Concentrated Growth Factors (CGF), are autologous preparations obtained from the patient's own blood and rich in platelets, growth factors and cytokines involved in the key processes of tissue regeneration. These autologous concentrates differ in the way of preparation and also in the content of platelets, growth factors and leucocytes, as well as in the fibrin network architecture. So it is difficult to have a standardized product. The aim of the present study was to evaluate how the use of test tubes of different material, for blood collection, could influence the CGF production. Three different test tubes were used and the obtained CGFs were subjected to histomorphological and immunohistochemical analyses. Results showed that the tube material and shape influenced the CGF composition. In fact, according to the type of tube used, the obtained CGFs showed differences in morphology, in the fibrin network architecture and in blood cell localization and distribution

Vascular cell dysfunctions: a possible atheroprotective role of melatonin

Atherosclerosis is a chronic disease of the arterial wall and a leading cause of death and loss of productive life years worldwide. It is considered a chronic inflammatory vascular disease characterized of monocyte extravasation into the arterial wall (Libby et al., 2011). Researches into the disease have led to many compelling hypotheses about the pathophysiology of atherosclerotic lesion formation and of complications such as myocardial infarction and stroke (Ross, 1999). The last several decades have witnessed aburgeoning growth of understanding of the molecular pathways involved in atherogenesis, atherosclerotic lesion progression and the pathogenetic mechanisms involved. In this study was evaluated the role of cyclophilin A (CyPA) in early phase of atherosclerosis, the beneficial effects of melatonin in vascular remodelling due to its ability to modulate rolling of mononuclear cells and its acting on vascular smooth muscle cell proliferation and neointima formation. In particular, in this study APOE null mice at 6 and 15 weeks of age were used; they were treated with melatonin at dose of 0.1mg/kg/day and 10mg/kg/day. We evaluated both CyPA expression and its signaling pathways in atherosclerosis development. CyPA expression increased in mononuclear cells and, in turn, stimulated vascular cell adhesion and interleukin-6 increase in the endothelial cells and vascular smooth muscle cells in a time-dependent manner. Melatonin treatment at the dose of 10mg/ kg/day completely improved vascular injury inhibiting the increase of CyPA. In summary, these findings suggest that CyPA induces the early step of atherosclerosis and indicate that the antioxidant effects of melatonin are both on antioxidant enzymes and other proteins, such as CyPA. Moreover, CyPA will be considered the bridge between inflammation and atherosclerosis. Thus, melatonin use could be a safe strategy of improving the development and progression of atherosclerosis