Cost-effectiveness of bringing a nurse into an Italian genetic day clinic: a before and after study

BACKGROUND

Only a few studies explore the role of nurses in genetic counselling and genetic health care, and none of them is related to orphan diseases. In addition, few studies address the issue of finding variables that might affect the economy of a service or perform a cost-effectiveness analysis of a having genetic nurse at a unit.

METHODS

A multidisciplinary panel of experts working in the hospital was set up to identify sensitive indicators and remove confounding variables. This panel evaluated efficiency and effectiveness indicators and drafted a questionnaire to estimate patient perception of the quality of the service. Data were captured from different sources, including the hospital patient database and a web-accessible platform for data collection. More than 600 clinical evaluations of 400 patients were considered, and economic parameters were studied by applying Porter's Time-Driven Activity-Based Costing methodology to evaluate costs and outcomes. Additionally, an anonymous, semi-structured, paper-and-pencil interview questionnaire was given to patients at their periodic follow-ups.

RESULTS

The results showed an increase in the quality of patient management, more accurate data capturing, and higher quality ambulatory care. In fact, approximately 70% of the respondents reported positive changes. In addition, a parallel economic analysis explored indicators influencing economic impact, and outcomes showed positive results with the quality of outcomes improving more compared to the increase in costs.

CONCLUSIONS

The variety of evaluated issues highlighted that having a nurse in a genetic service and at day clinic activities resulted in better access, better scheduling, more satisfaction, and proved to be a cost-effective solution for patients affected by rare diseases.

Surgical management of ostomy complications: a MISSTO-WSES mapping review

BACKGROUND

The creation of an ileostomy or colostomy is a common surgical event, both in elective and in emergency context. The main aim of stoma creation is to prevent postoperative complications, such as the anastomotic leak. However, stoma-related complications can also occur and their morbidity is not negligible, with a rate from 20 to 70%. Most stomal complications are managed conservatively, but, when this approach is not resolutive, surgical treatment becomes necessary. The aim of this mapping review is to get a comprehensive overview on the incidence, the risk factors, and the management of the main early and late ostomy complications: stoma necrosis, mucocutaneous separation, stoma retraction, stoma prolapse, parastomal hernia, stoma stenosis, and stoma bleeding.

MATERIAL AND METHODS

A complete literature research in principal databases (PUBMED, EMBASE, SCOPUS and COCHRANE) was performed by Multidisciplinary Italian Study group for STOmas (MISSTO) for each topic, with no language restriction and limited to the years 2011-2021. An international expert panel, from MISSTO and World Society of Emergency Surgery (WSES), subsequently reviewed the different issues, endorsed the project, and approved the final manuscript.

CONCLUSION

Stoma-related complications are common and require a step-up management, from conservative stoma care to surgical stoma revision. A study of literature evidence in clinical practice for stoma creation and an improved management of stoma-related complications could significantly increase the quality of life of patients with ostomy. Solid evidence from the literature about the correct management is lacking, and an international consensus is needed to draw up new guidelines on this subject.

Arthrobacter sp. Inoculation Improves Cactus Pear Growth, Quality of Fruits, and Nutraceutical Properties of Cladodes

A study was undertaken to determine the effects of a strain of Arthrobacter sp., a Plant Growth-Promoting Bacteria (PGPB), on plant phenology and qualitative composition of Opuntia ficus-indica (L.) Mill. fruits and cladodes. The strain was inoculated in soil, and its effects on cactus pear plants were detected and compared to nontreated plants. Compared to the latter, the treatment with bacteria promoted an earlier plant sprouting (2 months before the control) and fruitification, ameliorating fruit quality (i.e., improved fresh and dry weight: + 24% and + 26%, respectively, increased total solid content by 30% and polyphenols concentrations by 22%). The quality and quantity of monosaccharides of cladodes were also increased by Arthrobacter sp. with a positive effect on their nutraceutical value. In summer, the mean values of xylose, arabinose, and mannose were significantly higher in treated compared to not treated plants (+ 3.54; + 7.04; + 4.76 mg/kg d.w. respectively). A similar trend was observed in autumn, when the cladodes of inoculated plants had higher contents, i.e., 33% xylose, 65% arabinose, and 40% mannose, respect to the controls. In conclusion, Arthrobacter sp. plays a role in the improvement of nutritional and nutraceutical properties of cactus pear plants due to its capabilities to promote plant growth. Therefore, these results open new perspectives in PGPB application in the agro-farming system as alternative strategy to improve cactus pear growth, yield, and cladodes quality, being the latter the main by-product to be utilized for additional industrial uses.

The impact of the pandemic on functional outcomes for joint replacement patients: An observational study

Elective surgeries, as joint replacement, were resumed after the first COVID-19 pandemic wave in 2020 and a phase of coexistence with the virus began. Surgery was organized in a new way that incorporated procedures aimed at reducing the risk of spreading the virus. The aim of this study is to describe the early functional results for patients undergoing hip and knee replacements at the time healthcare services were being reopened and to compare them with the same outcomes recorded in the prepandemic period. This is a controlled retrospective study. All patients consecutively admitted during 2020 and who underwent hip and knee replacement were enrolled in the study. Patient records from January to March 2020 constituted the prepandemic control group, while patient records from May to December 2020 constituted the study group. Functional recovery was described through the patient's ability to walk using antebrachial devices and to climb up and down 3 steps. The day after surgery on which these activities were first performed was also recorded. The prepandemic group consisted of 183 patients and the pandemic group of 280 patients. The mean age of patients was 66 years (±13.1), female was 44.9% and hip replacement was 66.5%. The number of patients who climbed stairs and the timing thereof was comparable for the 2 groups (68.5% vs 72.2%, respectively; P = .403). There was no significant difference in the incidence of patients able to walk with antebrachial device and incidence of pressure ulcers and major complications. Multivariate analysis confirmed that the incidence of stair climbing was not associated with the prepandemic or pandemic inclusion. During the reopening of orthopedic surgery activity, the reorganization and treatment pathway did not affect the functional outcome achieved by patients underwent joint replacement. Constant monitoring of the functional outcomes will be required so as to further increase the number of joint replacement surgeries.

The impact of first wave of COVID-19 on the nursing-sensitive and rehabilitation outcomes of patients undergoing hip fracture surgery: a single centre retrospective cohort study

BACKGROUND

During the COVID-19 pandemic, the care of hip fracture patients remains a clinical priority. To date, there is limited empirical knowledge about the impact of pandemic on the care of patients surgically treated for hip fracture, affected or not by COVID-19.

OBJECTIVE

To investigate the effects of the COVID-19 pandemic on the nursing-sensitive and rehabilitation outcomes of frail patients undergoing hip fracture surgery.

METHODS

A retrospective cohort study was conducted in an Italian Orthopaedic Research Institute. All patients aged ≥ 65 years admitted with fragility hip fractures between 1st March and 30th June in 2019 (group PP: pre-pandemic) and in the same period in 2020 (group P: pandemic), were compared. In the P group, COVID-19 positive patients were excluded due to the presence of a specific treatment pathway. Data on patient demographics and baseline characteristics, and peri-operative care factors were obtained from the Institute's computer-based patient-record system. The primary outcome was the incidence of any stage hospital-acquired pressure ulcers (PUs). The secondary outcome was time to first static verticalization and to first ambulation.

RESULTS

Three-hundred and sixty patients were included in the study, which comprised 108 patients in PP group and 252 patients in P group. Overall PUs incidence was significantly higher in the P-group (21.8%) than in the PP-group (10.2%) (p = 0.009). Specifically, the incidence of sacral PUs was significantly lower in P-group (38.1%) vs PP-group (91%) (p = 0.004); on the contrary, the incidence of PUs localized to the heels or other body sites were significantly higher in P-group (30.9% and 30.9%, respectively) vs PP-group (0% and 9%, respectively) (p = 0.004). No significant between groups differences were found for all the secondary outcomes.

CONCLUSION

In the pandemic period, nursing and rehabilitation care provided to patients with fragility hip fracture maintained high standards comparable to the pre-pandemic period. The increase in PUs incidence in the pandemic period was probably due to the older age of the patients admitted to hospital. The qualitative evaluation of the care administered and the emotional impact of the pandemic on the patients are very interesting topic which would deserve further investigation.

Factors associated with pressure ulcer onset after knee replacement

OBJECTIVE

The aim of this study was to find the rate of pressure ulcers (PUs) in patients with knee replacements and identify predictive factors. The ability of the Braden scale to predict the onset of PUs was also investigated.

METHOD

A retrospective prognostic cohort study was carried out involving all consecutive patients undergoing knee replacement surgery. The data were collected from patient records. The variables collected were grouped into two categories: those connected to the patient's own characteristics; and those linked to the care methods used.

RESULTS

The total number of patients included in the study was 565. Of these, 2.3% had developed a PU: 0.5% at the heel and 1.8% at the sacrum. Multivariate analysis showed that the variables actually correlated to the outcome were age (p=0.074; odds ratio (OR)=1.08), body mass index (BMI, p=0.037; OR=1.13) and Braden scale (p=0.029; OR=0.72). A combination of these three parameters showed better predictivity of PUs (area under the curve (AUC) 84%).

CONCLUSION

Age, BMI and preoperative Braden score were shown to be independent predictive factors of the onset of PUs in patients with knee replacements. The combined use of all three variables increased the ability to identify the patients at most risk of developing a PU.

DECLARATION OF INTEREST

The study was financed by the Professional Nurse Register of Bologna as winner of a competition for research projects in the province of Bologna. The authors declare no conflicts of interest.

Surgical management of urinary diversion and stomas in adults: multidisciplinary Italian panel guidelines

BACKGROUND

Urinary stomas represent a worldwide medical and social problem. Data from literature about stoma management are extensive, but inhomogeneous. No guidelines exist about this topic. So, clear and comprehensive clinical guidelines based on evidence-based data and best practice are needed. This article aims to elaborate guidelines for practice management of urinary stomas in adults.

METHODS

Experts guided review of the literature was performed in PubMed, National Guideline Clearing-house and other databases (updated March 31, 2018). The research included guidelines, systematic reviews, meta-analysis, randomized clinical trials, cohort studies and case reports. Five main topics were identified: "stoma preparation", "stoma creation", "stoma complications", "stoma care" and "stoma reversal". The systematic review was performed for each topic and studies were evaluated according to the GRADE system, AGREE II tool. Recommendations were elaborated in the form of statements with an established grade of recommendation for each statement. For low level of scientific evidence statements a consensus conference composed by expert members of the major Italian scientific societies in the field of stoma management and care was performed.

RESULTS

After discussing, correcting, validating, or eliminating the statements by the experts, the final version of the guidelines with definitive recommendations was elaborated and prepared for publication. This manuscript is focused on statements about surgical management of urinary stomas. These guidelines include recommendations for adult patients only, articles published in English or Italian and with complete text available.

CONCLUSIONS

These guidelines represent the first Italian guidelines about urinary stoma multidisciplinary management with the aim to assist urologists and stoma specialized nurses during the urinary stoma management and care.

Post-hospital care pathway for individuals with hip fracture: what is the optimal setting and rehabilitation intensity? An observational study

PURPOSE

Health systems are using ever-increasing resources on treating hip fractures. Optimal post-hospital care needs to be defined to design an effective care pathway. The aim of the present study was to describe the post-hospital care pathway of individuals with hip fracture and to assess its association with the degree of recovery of independence achieved four months after surgery.

MATERIALS AND METHODS

A prognostic multicentric cohort study was conducted. All patients aged 65 years and over who were admitted with a diagnosis of fragility hip fracture were enrolled. After the hospital discharge, the patients were followed either at an inpatient rehabilitation facility with an intensive or extensive regimen, a nursing home, a long-term care facility or at home. Among the various care pathways, the intensity of rehabilitation differed according to its duration, frequency of sessions, and activities proposed. Primary outcome was the patient's degree of independence achieved four months after surgery, as measured with Activities of Daily Living scale. Several covariates were collected to test the correlation between the different post-hospital care pathways and the recovery of independence.

RESULTS

A total of 923 patients completed the follow-up. A post- hospital rehabilitation pathway was indicated for 88.2% of the patients. The extensive rehabilitation pathway, indicated for 36.7% of the patients, was the most common. The intensive rehabilitation pathway gave better results in terms of independence at four-month follow up, leading to a median ADL score of 1.4 (95% CI 1.0-2.0). The other care pathways did not show significant difference between each other.

CONCLUSIONS

High-intensity rehabilitation was associated to better results in terms of recovering of Activities of Daily Living.IMPLICATIONS FOR REHABILITATIONPost-hospital care pathways that include an intensive rehabilitation treatment should be improved/supported to make them available to a larger number of hip fracture patients.Patient selection criteria for post-hospital rehabilitation pathways should be standardized to optimize available healthcare resources.A cost-effectiveness analysis should be performed to analyze the economic sustainability of each post-hospital care pathway.

Italian Guidelines for the Nursing Management of Enteral and Urinary Stomas in Adults: An Executive Summary

PURPOSE

This article is an executive summary of Italian guidelines for nursing management of enteral and urinary ostomies in adults.

METHODS

Scoping review and generation of evidence and consensus-based clinical guidelines.

SEARCH STRATEGY

The Multidisciplinary Italian Study group for STOmas (MISSTO) was founded in 2018. This group created guidelines for management of enteral and urinary ostomies in adults based on a scoping review of the literature. The research included previous guidelines, systematic reviews, meta-analyses, randomized clinical trials, cohort studies, and case reports. Five main topics were identified: "stoma preparation," "stoma creation," "stoma complications," "stoma care," and "stoma reversal" (for enteral stomas)." All the studies were evaluated according to the GRADE system and AGREE II tool. Recommendations were elaborated in the form of statements, with an established grade of recommendation for each statement. For low levels of scientific evidence statements, a consensus conference composed of expert members of the major Italian scientific societies in the field of stoma management and care discussed, corrected, validated, or eliminated the statements. A final version of the guidelines with definitive recommendations was elaborated and prepared for publication.

FINDINGS/CONCLUSIONS

This document represents the first Italian guidelines on enteral and urinary stoma management to assist nurses caring for persons with an enteral or urinary ostomy.

Cross-Cultural Validation of the Italian Version of the Bt-DUX: A Subjective Measure of Health-Related Quality of Life in Patients Who Underwent Surgery for Lower Extremity Malignant Bone Tumour

The purpose of this study was to translate the English bone tumour DUX (Bt-DUX-Eng) questionnaire for lower extremity bone tumour patients, a disease-specific quality of life (QoL) instrument, into Italian and then examine the validity of the Italian version of Bt-DUX (Bt-DUX-It). The adaptation and translation process included forward translation, back-translation, and a review of the back-translation by an expert committee. The Bt-DUX-It was validated in a sample of adolescents treated for lower extremity osteosarcoma in Italy. Assessments included the Bt-DUX, the Toronto Extremity Salvage Score (TESS), and the European Organization for Research and Treatment Core Quality of Life Questionnaire of Cancer Patients (EORTC QLQ-C30). Fifty-one patients with a median age of 20 years (range: 15-25) completed the questionnaires. The mean Bt-DUX score was 70 (range: 16.30-100). The internal consistency of the overall score and that of the Bt-DUX-It was good: Cronbach's α was 0.95. Spearman's correlation coefficient between the Bt-DUX (total and domain scores) and EORTC QLQ C30 and TESS were overall moderate to good, reaching a p-value <0.01 in all cases. The Bt-DUX-It version is a useful tool for measuring QoL in patients with bone tumour and has similar internal consistency, construct validity, and discrimination as those of the Dutch and English versions.

Predictive factors for category II pressure ulcers in older patients with hip fractures: a prospective study

OBJECTIVE

To identify the incidence of category II or higher hospital-acquired pressure ulcers (HAPU) and significantly associated factors in older patients with hip fractures. PUs are a frequent complication in hip fracture patients, negatively impacting patients' quality of life, the health-care system and society.

METHOD

A prospective cohort study was conducted. A consecutive sample of patients with pertrochanteric, femoral neck or subtrochanteric fractures requiring surgical treatment, were included. A stepwise, multiple regression was performed to identify factors associated with PU development.

RESULTS

A total of 761 patients aged ≥65 years were sampled. The incidence of category II or higher PUs was 12%. The study identified five factors that were significantly, independently associated with category II or higher PU development, including a higher preoperative Braden score (Hazard Ratio [HR]: 0.884; 95% confidence interval [CI]: 0.806-0.969), surgical procedure with osteosynthesis (HR 1.876; 95%CI: 1.183-2.975), a higher percentage of days with the presence of foam valve before surgery (HR: 1.010; 95%CI: 1.010-1.023) and a urinary catheter (HR: 1.013; 95%CI: 1.006-1.019) and diaper (HR: 1.007; 95% CI 1.001-1.013) in the postoperative period.

CONCLUSION

Attention should be given by clinical staff to avoiding the use of foam valves, to limiting the use of diapers and to early removal of urinary catheters.

A multilayer polyurethane foam dressing for pressure ulcer prevention in older hip fracture patients: an economic evaluation

OBJECTIVE

Hospital-acquired pressure ulcers (PU) have a substantial negative impact on patients and continue to impose a cost burden on hospital providers. Since the incidence of fragility fracture is growing, driven by the increase in the older population, it is expected that the overall incidence of associated complications will also increase accordingly. The aim of this economic evaluation was to determine whether the use of a multilayer, silicone-adhesive polyurethane foam dressing (ALLEVYN LIFE, Smith & Nephew, UK) alongside standard prevention (SP) for the prevention of PUs in older patients with hip fractures is a cost-effective strategy, compared with SP alone.

METHOD

A decision-analytic model was constructed to determine the incremental cost and effectiveness of the foam dressing strategy from the perspectives of the Italian and US hospital systems. We also performed one-way and probabilistic sensitivity analyses.

RESULTS

The foam dressing intervention was found to be cost saving and more effective than SP in both Italy and the US. Switching to foam dressing and standard prevention would result in an expected cost saving of €733 per patient in Italy and $840 per patient in the US, reducing the per-patient cost of treating PUs by 37-69% and 36-68%, respectively. The one-way and probabilistic sensitivity analyses demonstrate that the strategy remains dominant over a range of values of the input variables.

CONCLUSION

The foam dressing intervention is likely to be a cost-effective strategy compared with standard prevention alone.

One-year mortality after hip fracture surgery and prognostic factors: a prospective cohort study

Older adult patients with hip fractures are 3-4 times more likely to die within one-year after surgery than general population. The study aimed to identify independent predictive factors associated with one-year mortality after hip fracture surgery. A prospective prognostic cohort study was performed. All patients aged ≥65 years, consecutively admitted in three Italian hospitals with a diagnosis of fragility hip fracture were included. Patients with periprosthetic or pathological fractures were excluded. Multivariate analysis was used to determine variables that significantly increased the risk of one-year mortality and Receiver operating characteristic (ROC) curve analysis to assess their predictive capacity on the outcome.1083 patients fulfilled the inclusion criteria and the one-year follow-up was reached in 728 patients. The 16.6% of patients died within one-year after surgery. At the multivariate analysis, advancing age (OR = 1.094, 95% CI = 1.057-1.132), higher baseline Charlson Index (OR = 1.257, 95% CI = 1.114-1.418) and Activities of Daily Living scores (OR = 1.259, 95% CI = 1.143-1.388), presence of hospital-acquired pressure ulcers (PUs) (OR = 1.579, 95% CI = 1.002-2.489) and lack recovery of ambulation (OR = 1.736, 95% CI = 1.115-2.703), were found to be independent predictive factors of one-year mortality after surgery. The area under the ROC curve of the model was 0.780 (CI95% 0.737-0.824) for one-year mortality in elderly hip fractures patients. Early ambulation and careful long-term follow-up, with attention to frailty in elderly people, should be promoted.

Postoperative function recovery in patients with endoprosthetic knee replacement for bone tumour: an observational study

Background

The objective of this study is to describe the rehabilitative pathway of patients undergoing endoprosthetic knee replacement surgery, build reference values ​​of the functional results achieved, and identify possible prognostic factors.

Methods

Prospective observational study. All patients undergoing resection and knee replacement surgery using a modular prosthesis following bone tumor resection were consecutively recruited over the last 2 years. The patients were followed for a period of 1 year, the result values ​​were collected at 3, 6 and 12 months.

Results

In total, 30 patients were enrolled. The median age was 19 years with 33% of patients being female. Median values recorded for knee flexion, quadriceps strength, Toronto Extremity Salvage Score, Time Up and Go and Six Minutes Walking Test showed an improvement of 16, 25, 18, 48 and 38% from 3 to 12 months, respectively. The level and width of the resection were correlated with the mobility of the knee and the strength of the quadriceps.

Conclusion

Patients undergoing knee replacement for bone tumors were able to achieve satisfactory functional outcomes from the first postoperative year. A specific assessment of outcomes can be conducted to facilitate the management of patient expectations. A very wide resection and interventions of the proximal tibia are risk factors for a poorer functional outcome.

Effects of treated industrial wastewaters and temperatures on growth and enzymatic activities of duckweed (Lemna minor L.)

The efficacy of the removal of contaminants from wastewater depends on physico-chemical properties of pollutants and the efficiency of treatment plant. Sometimes, low amounts of toxic compounds can be still present in the treated sewage. In this work we considered the effects of contaminant residues in treated wastewaters and of temperatures on Lemna minor L. Treated effluent waters were collected, analyzed and used as duckweed growth medium. In order to better understand the effects of micropollutants and seasonal variation, the plants were grown under ambient conditions for seven days in summer and winter. Relative growth rate, pigments and phenolic compounds concentrations were determined, as well as the activities of catalase (CAT), ascorbate peroxidase (APX), guaiacol peroxidase (G-POD) and polyphenol oxidase (PPO). The pollutant concentrations varied in the two seasons, depending on the industrial and municipal activities and efficiency of treatments. Treated waters contained heavy metals, nitrogenous and phosphorus compounds, surfactants and hydrocarbons. Compared to the control, duckweed growth of treated plants decreased by 25% in summer, while in the winter due to the lower temperatures and the presence of pollutants was completely impeded. The amounts of photosynthetic pigments of treated plants were not significantly affected in the summer, while they were higher than the control in the winter when the effluent had a high nitrogen amount. High CAT activity was registered in both seasons. Treated plants had significantly lower APX activity in the summer (53%) and winter (59%) respect to the controls. The observed inhibition of the peroxidase activities in the exposed plants, confirms the controversy existing in the literature about the variability of enzymatic response in stress condition.

Effectiveness of using a new polyurethane foam multi-layer dressing in the sacral area to prevent the onset of pressure ulcer in the elderly with hip fractures: A pragmatic randomised controlled trial

Hip fractures in the elderly are a serious problem for the health service due to the high rate of complications. One of these complications is pressure ulcers that, according to the literature, occur in 8.8% to 55% of patients and mainly arise in the sacral area. The present randomised controlled trial tests whether applying a new innovative multi‐layer polyurethane foam dressing (ALLEVYN LIFE™), reduces the onset of pressure ulcers in the sacral area. From March to December 2016, 359 fragility hip fracture patients were randomly divided into 2 groups: 182 in the control group and 177 in the experimental group. Pressure ulcers occurred overall in 36 patients (10%): 8 patients (4.5%) in the experimental group compared to 28 (15.4%) in the control group: P = 0.001, relative risk 0.29 (95% CI 0.14‐0.61) with NNT of 9 (95% CI 6‐21). In the experimental group the onset of pressure ulcers occurred on average on the 6th day compared to the 4th day in the control group (HR 4.4). Using polyurethane foam is effective at reducing the rate of pressure ulcers in the sacrum in elderly patients with hip fracture. The adhesiveness of this device also enables costs to be kept down.

[Not Available]

. Efficacy of splint with heel off-loaded in children with lower limbs plaster cast. Randomised open label trial.

INTRODUCTION

Plasters cast are medical devices widely used in paediatric orthopaedics; however, few studies have addressed the occurrence and prevention of device-related complications.

AIM

To evaluate whether positioning a custom made splint with heel off-loaded, would relieve pain, reduce care interventions, the materials to maintain heel unloading position and, at the same time, improve comfort and reduce pressure sores in children with lower limb plaster.

METHODS

Children enrolled in the study were randomised to splint, provided with a custom made splint positioned underneath the lower limb plaster after surgery; in the second group (control) the plaster position was maintained with cushions.

RESULTS

A total of 57 children were enrolled from November 2014 to August 2015, 29 in the treatment group (50.8%) and 28 in the control group (49.2%). Pain median levels were 4 (splint) vs. 5 (control) p=ns; mean number of care intervention was 2.1 (splint) vs. 5.2 (control) p<0.0005; materials used were 1.3 (splint) vs. 2.8 (control) p<0.0005; perceived comfort was 8.9 (splint) vs. 7.6 (control) p<0.001. A difference in the total number of pressure sores was observed with 1 case in the splint group vs. 5 cases in the control group RR 0.21 (IC 95% -1.88-2.29; P 0.079).

CONCLUSIONS

The use of splint is effective in reducing care intervention the use of other materials and in improving comfort, but not in relieving pain.

Rotationplasty in adult cancer patients: what is the rehab strategy and what results can be expected? A case study

BACKGROUND AND AIM

Rotationplasty is an important and demanding challenge for physiotherapists. The aim of this paper is to describe the functional outcome achieved by a patient undergoing rotationplasty in adult age following osteosarcoma. Case description and Methods: The patient was followed throughout the rehabilitation course and the results achieved were recorded at 6, 9 and 12 months after surgery. Findings and outcomes: The results progressively improved in terms of function, functional performance and quality of life. The MSTS and TESS scales showed an improvement respectively of 20 and 23 percentage points, reaching levels of 80% and 87%. The quality of life perceived by the patient increased in the three assessments, the mental health score at one-year follow-up is higher than that expected for the population.

CONCLUSIONS

Rotationplasty, even in adult age, produces good results and in the treatment of tumours in adults this operation should be taken into consideration. Clinical relevance Rotationplasty in adult age following osteosarcoma combined with a rehabilitation program enabled a patient to reach a successful outcome in terms of functional performance and quality of life.

Evaluation of the impact of support for nursing research on scientific productivity in seven Italian hospitals: A multiple interrupted time series study

BACKGROUND

Nursing research is not well-developed in Italy, and knowledge of the methodologies for conducting research is lacking. In several hospitals, including those in which this study was conducted, a research center has been established to support and educate nurses on how to conduct clinical research.

AIMS AND OBJECTIVES

In this observational study, we sought to assess whether establishing a support center for nursing research has resulted in an increase in scientific production in terms of the numbers of protocols approved (primary outcome), articles published and nurse authors involved in the publications (secondary outcomes).

DESIGN

Multiple interrupted time series.

METHODS

Data from 2002 to 2012 were collected in seven hospitals. Research centers have been established at various times in only four of these hospitals.

RESULTS

A statistically significant increase in the primary outcome (the number of protocols approved by the Research Ethics Committee in which the principal investigator was a nurse) was observed in two hospitals approximately 2years after establishing a research center. The number of nursing research articles published in scientific journals with an impact factor increased but was not statistically significant. Finally, the number of nurse authors increased significantly in two hospitals with support units. Definitive conclusions could not be reached for the other two experimental hospitals because notably few post-intervention data were available. In the control hospitals, the scientific production outcomes did not change.

CONCLUSIONS

This study shows that establishing a support center for nursing research inside hospitals can facilitate the production of research.

Sodium hypochlorite in antisepsis of children’s and new-born babies’ skin prior to insertion of peripheral venous catheter

Antisepsis of the skin of children to whom a peripheral venous catheter (PVC) is to be attached is an important factor in reducing catheter related infections. No data are available on the effectiveness of sodium hypochlorite. Explorative study of children and new-born babies treated in hospital to ascertain bacterial contamination levels of PVC tips as surrogate infection indicator. In a sample of 51 children and 52 new-born babies, catheter tips were found contaminated for 7.8% of the children and 3.8% of the new-born babies. The positive results of this pilot study suggest that serious consideration should be given to assessing Amukine Med 0.05% for use with PVCs. 

[Where and how to retreive clinical practice guidelines]

Indications on how to retrieve clinical practice guidelines are offered, presenting the main agencies that produce guidelines and the trip database. A google search with the key word nursing guidelines, after a selection of agencies with multiprofessional groups, with an explicit process of bibliographic search and a grading of recommendations produced the selection of 4 agencies.

Use of sodium hypochlorite for skin antisepsis before inserting a peripheral venous catheter: a pilot study

Although it can be prevented, catheter-related bacteremia is common and dangerous. The antiseptics most widely used during insertion of peripheral venous catheters (PVCs) include povidone iodine, alcohol, and chlorhexidine. Another widely used antiseptic is a solution of 0.057 g sodium hypochlorite. This pilot study explored the contamination rate of the PVC tip inserted after skin decontamination with sodium hypochlorite. Culture analysis of the tips of the PVCs inserted into the 42 participants showed 7 (16.7%) colonized catheters. The results of this pilot study suggest taking into serious consideration the assessment of this antiseptic in randomized experimental studies.

[The measurement of pain in patients with dementia: a review of the most appropriate tools]

Pain is one of the most frequent symptom in elderly people with dementia and despite of this, it is still under-acknowledged and under-treated. The best approach to pain assessment is to evaluate it with the most appropriate scale. While in the elderly suffering mild-moderate cognitive impairment, it's possible to use self-report scales, in the elderly with severe cognitive impairment the use of observational scales is recommended. The objective of this review is to analyze the various types of pain assessment tools used in patients with cognitive impairment. Literature review was carried out through consultation of the most important bio-medical databases: Medline (PubMed), KT+, Trip Database, Cinahl, Cochrane Library, Embase. The keywords used were: "pain measurement", "pain assessment", "dementia", "validation study", "aged". All keywords were linked using AND and OR boolean operators. Altogether 5 self-report scales and 17 observational scales were retrieved, 7 of which available in Italian validated versions. The review analyzes potential and limitations of each assessment tool, in order to assist the clinician to make the most appropriate choice when using it in health care contexts.

[The assessment of the impact of education and support to nursing research on nurses' scientific production in an Emilia Romagna Hospital]

INTRODUCTION

In Italy research conducted by non medical professions is scarce also for the lack of knowledge on methods. At Rizzoli hospital in Bologna in 2006 a Centre for research to educate and support health professionals was implemented.

AIM

To assess the impact of the research centre on number of research articles and protocols produced by nurses.

METHODS

Interrupted time series. In the five years before and after the implementation of the centre data on the number of protocols approved by Ethical Committee with a nurse as principal investigator and on the number of articles published on impacted journals with a nurse as first author were collected. The number of nurses authors of the publications was also collected.

RESULTS

For all the variables an increasing trend, starting from 2006 was observed, with statistically significant differences from 2008 for the number of research protocols presented (p=0.037), the number of nurses authors of scientific articles (p=0.027). Although the number of publications on impacted journals increased from 2006, differences were not statistically significant after 2008.

CONCLUSIONS

An hospital based Centre for education and support to research for health professionals may facilitate the scientific and research production.

Characterization of the response of in vitro cultured Myrtus communis L. plants to high concentrations of NaCl

Effect of salt stress was examined in in vitro shoot cultures of Myrtus communis L. a species of the Mediterranean maquis. To determine the effects of high salt concentrations on myrtle plantlets and contribute toward understanding the mechanisms adopted from this species to counteract soil salinity, in vitro rooted shoots were transferred to a liquid culture medium containing 0, 125 or 250 mM NaCl for 30 days. After 15 and 30 days of in vitro culture, shoot and root growth, chlorosis and necrosis extension, chlorophylls, carotenoids, proline, arginine, cysteine and total sugars content, as well as guaiacol peroxidase (G-POD, EC 1.11.1.7) and ascorbate peroxidase (APX, EC 1.11.1.11) activities were determined. In treated plants shoot and root growth, as well as chlorophyll content, significantly decreased, while carotenoids content was not affected by the NaCl treatment. Among osmolytes, proline did not significantly increase, arginine and cysteine decreased, while total sugars were found to be higher in the treated plants than in the control. Enhancement of G-POD and APX activities was positively related to increasing salt concentrations in the culture media, regardless of the exposure time. Salt-treated plants did not show significant changes in lipid peroxidation or DNA fragmentation after 30 days salt treatment, regardless of the NaCl concentrations applied. The results represent a contribution towards understanding the mechanisms adopted by this species to high salinity.

[Skin antisepsis with 0.05% sodium hypochlorite before the insertion of a peripheral venous catheter in adults, children and newborns]

INTRODUCTION

Antisepsis of the skin of adults, children and newborns before the insertion of a peripheral venous catheter (PVC) reduces the risk of catheter related infections (CRI). Data on the effectiveness of electrolytic sodium hypochlorite are missing.

METHODS

An explorative study was conducted on children, adults and newborns admitted to hospital and with skin antisepsis with sodium hypoclorite 0.057g with active chlorine 0.055g in 100ml (Amukine Med®) to assess the level of contamination of PVC tips, as surrogate sign of infection. Quantitative methods were used and the catheter tip was considered colonized if >1000 CFU (colony forming Units)/catheter segment.

RESULTS

In the sample of 42 adults, 51 children and 52 newborns, 16.7%, 7.8% and 3.8% of catheter tips were contaminated respectively. No catheter related phlebites were observed.

CONCLUSIONS

Skin antisepsis with Amukine Med® seems effective in preventing CRIs but further comparative studies are needed with the antiseptics recommended by guidelines.

[Effectiveness of the transparent sterile dressing vs standard to fix the peripheral venous catheter (PVC) on the incidence of phlebitis. A randomized controlled trial]

Effectiveness of the transparent sterile dressing vs standard to fix the peripheral venous catheter (PVC), on the incidence of phlebitis. A randomized controlled trial.

INTRODUCTION

The type of dressing could contribute to the incidence of phlebitis, infiltration and accidental removals but the results of the studies are contrasting and samples are limited.

AIM

To compare the effectiveness of a transparent polyurethane sterile dressing on the rate of phlebitis associated to peripheral venous catheter (PVC) vs a non sterile sticking plaster in use in current practice (standard dressing).

DESIGN

Randomized controlled trial. Participants. 1061 PVCs (703 patients, adults and children) at a research orthopedic hospital in the north of Italy; 540 PVCs allocated to receive the sterile and 521 the standard dressing.

RESULTS

96 PVCs were excluded for phlebitis, 48 (9.6%) in the sterile and 48 (10.1%) in the standard dressing group, RR 0.96 (95%CI 0.697 - 1.335). Accidental removal of the PVCs was more frequent with the sterile dressing (9.6% vs 6.3%) but the number of catheters removed without complications was larger in the standard dressing group (48.9% vs 54.9% P=0.0503). Eighty-five PVCs were replaced for detachment of the dressing (50, 9.2% sterile and 35, 6.7% standard dressing). The cheapest transparent sterile dressing costs 32 cents while the standard 9 cents.

CONCLUSIONS

A sticking non sterile plasters is not influential on the rate of phlebitis and ensures an good fix of the PVC compared the transparent sterile dressing to of polyurethane film.

Stress responses of duckweed (Lemna minor L.) and water velvet (Azolla filiculoides Lam.) to anionic surfactant sodium-dodecyl-sulphate (SDS)

Surfactants are used for several purposes and recently they have attracted the attention for their ability to modify the behavior of other preexistent or co-disposed contaminants, although their use or discharge in wastewaters can represent a real or potential risk for the environment. Lemna minor L. and Azolla filiculoides Lam. are floating aquatic macrophytes, very effective in accumulating several pollutants including sodium dodecyl sulphate (SDS). In this work we evaluated the effects of SDS on these species by determining the stress ethylene production via laser-based trace gas detection, and the activities of enzymes involved in stress response, such as guaiacol peroxidase (G-POD), phenylalanine ammonia-lyase (PAL) and polyphenol-oxidase (PPO). Phenolics content was also determined. The macrophytes were treated with different concentrations of SDS for one week. SDS affected duckweed enzymatic activities and phenol content. While in the fern phenolics amount, PAL, G-POD and PPO activities were not affected by SDS except for 100 ppm SDS, the only concentration that was taken up and not completely degraded. Stress ethylene production was induced only in the fern treated with 50 and 100 ppm SDS.

Living with rotationplasty--quality of life in rotationplasty patients from childhood to adulthood

BACKGROUND

Knowledge about the long-term sequelae of rotationplasty, in adults treated surgically in childhood for Osteosarcoma in the lower limb, mainly concerns function and performance; the aim of this study is to explore the experience and the Quality of Life (QoL) of the patients who underwent Rotationplasty from 1986 to 2006 in Italy.

METHODS

Quantitative test: Administration SF-36 questionnaire to 20 subjects aged ≥16 years. Qualitative test: Semi-structured interview recorded in 10 of these subjects.

RESULTS

Greater well-being was found in the Mental Component Summary (MCS) scale of subjects aged over 24 years, with a score mean of 54.2 (±4.8), compared with that of those aged up to 24 years, with a mean score of 48.0 (±6.6), P = 0.04. Relational and emotional difficulty in adolescence, which had been partially overcome in adulthood, was revealed.

CONCLUSIONS

The assessment of QoL by the SF-36 questionnaire was effective, and a correspondence was found between what emerged from the quantitative study and the contents of the interview. Knowing the strengths and weaknesses that were highlighted is indispensable for parents and operators when choosing among the various surgical options and to facilitate coming to terms with the injury and the "scars".

Telangiectatic osteosarcoma of the extremity: Neoadjuvant chemotherapy in 24 cases

Between April 1990 and December 1994, we treated 24 patients with telangiectatic osteosarcoma (TO) of the extremities with neoadjuvant chemotherapy using 2 protocols. Surgery consisted of limb salvage in 21 patients and amputation or rotation plasty in 3. The histologic response to chemotherapy was good (90% or more tumor necrosis) in 23 patients, of whom 12 had total necrosis. With a mean follow-up of 74 (60-96) months, 20 patients remained continuously free of disease and 4 relapsed with lung metastases. There were no local recurrences. Comparing these results to the ones achieved in 269 contemporary patients with conventional osteosarcoma of the extremities using the same protocols for chemotherapy, we found a significantly better histologic response to chemotherapy (96% vs 68% of good histologic response; p = 0.004) and disease-free survival (83% vs 55%; p = 0.01) in the TO group. We conclude that TO, once considered a lethal tumor, seems to be even more sensitive to chemotherapy than conventional osteosarcoma, and that most of these patients may be cured without amputation.

Nonmetastatic osteosarcoma of the extremity with pathologic fracture at presentationLocal and systemic control by amputation or limb salvage after preoperative chemotherapy

To determine whether a pathologic fracture in osteosarcoma of long bones has prognostic importance, and limb salvage can be safely performed in such cases, we reviewed the surgical treatment and oncologic results in 46 patients with nonmetastatic osteosarcoma of the extremity and pathologic fracture at presentation who had been treated in our Institution with neoadjuvant chemotherapy, between 1983 and 1999. Neoadjuvant chemotherapy was given according to 6 consecutive protocols. Surgery consisted of limb salvage (34 patients), amputation (11 patients) and rotationplasty (1 patient). The average follow-up was 11 (3-20) years. 28 patients remained continuously disease-free, 17 patients relapsed and 1 died of chemotherapy-related toxicity. Despite the high rate of limb salvage, only 2 local failures occurred, 1 after amputation and 1 after limb salvage. The 5-year disease-free survival and overall survival rates were 59% and 65%, respectively, with no differences between amputated and resected patients. These results are similar to those obtained in 689 contemporary patients having an osteosarcoma without a pathologic fracture treated in our Institution, and using the same protocols for chemotherapy. We conclude that with neoadjuvant chemotherapy, osteosarcoma patients presenting with a pathologic fracture can be surgically treated like those with no fracture, and that limb salvage procedures do not increase the risk of local recurrence or death of these patients.

[Cohort study of the incidence of heel pressure sores in patients with leg casts at the Rizzoli Orthopedic Hospital and of the associated risk factors]

INTRODUCTION

Pressure sores, especially at the heel, are a side effect of the cast.

AIM

To assess the incidence of late skin complications (heel pressure sores) of a cast and determine risk factors.

METHODS

All consecutive patients treated with a leg cast over a 16 months observation time were recruited. Risk factors were identified by the nurse that placed the cast and skin lesions classified with the NPUAP scale when the cast was removed.

RESULTS

In the 216 enrolled patients 17.6% (38) developed a pressure sore: 16/124 in orthopedic wards; 22/92 in oncology wards. The multivariate analysis identified the following risk factors: administration of cytotoxic drugs (p = 0.033; OR = 2.61; having a cancer did not increase the risk); skin redness before cast application (p = 0.001; OR = 4.44) and having reported symptoms after the application (p = 0.000; OR = 7.86). Pressure sores were mainly stage 1 and only 6/216 (2.4%) > or = stage II. The type of plaster cast, the material, the number of days it was worn and having had a surgery are not significant risk factors.

CONCLUSIONS

Pressure sores related to leg plaster casts are a frequent complication in at risk sub-groups. The acknowledgement and identification of specific risk factors may allow to identify and evaluate preventive interventions to improve the care of these patients.

Treatment of nonmetastatic Ewing's sarcoma family tumors of the spine and sacrum: the experience from a single institution

The objective of this study is to determine the best local treatment combined with neoadjuvant chemotherapy for ESFT of the spine and sacrum, for the best local treatment for Ewing sarcoma family tumors (ESFT) according to the primary site is still unclear. Nowadays surgery is used in local treatment of ESFT, but literature is scarce on the best local treatment in sites where surgery is problematic, such as the spine. This study evaluates the outcome and the rate of local recurrence of ESFT in the spine and sacrum when treated with neoadjuvant chemotherapy, and locally by radiotherapy alone or surgery, followed by reduced doses of radiotherapy. Forty-three patients with nonmetastatic ESFT located in the spine and sacrum were treated at our institution between 1983 and 2000 with neoadjuvant chemotherapy, and locally by radiotherapy alone in 26 cases, and surgery followed by radiotherapy at reduced doses in 17. The 5- and 10-year event-free survival (EFS) was 37 and 30%, and the 5- and 10-year overall survival was (OS) 42 and 32%. The prognosis was unrelated to gender and age, tumor volume, chemotherapy protocol, and local treatment. The outcome seemed worse for patients with primary tumors located in the sacrum than for patients with tumors located in the rest of the spine (5-year EFS = 23 vs. 46%). For these patients the results were significantly worse than for those we achieved with neoadjuvant treatment for ESFT located in other sites. However, no differences were observed between patients locally treated with radiotherapy alone and those treated by radiotherapy followed by surgery. We concluded that regardless of the type of local treatment even when associated with neoadjuvant therapy, ESFT in the spine and sacrum has a poor outcome and prognosis is significantly worse than that of primary ESFT in other sites.

High grade osteosarcoma of the extremities with lung metastases at presentation: treatment with neoadjuvant chemotherapy and simultaneous resection of primary and metastatic lesions

BACKGROUND AND METHODS

Between 1986 and 2001, 162 patients with extremity osteosarcoma and lung metastases at presentation, were treated by neoadjuvant chemotherapy, simultaneous resection of primary and, when feasible, secondary lesions followed by chemotherapy.

RESULTS

After neoadjuvant chemotherapy, metastases disappeared in 14 patients, 16 were judged unresectable by both our thoracic surgeons, 132 had primary tumors and lung metastases removed simultaneously. Removal of lung metastases was complete in 123 and incomplete in 9. Histologically lesions were benign in 32 patients. For the 100 patients simultaneously operated with histologically proven lung metastases, 5-year event-free survival (EFS) was 18.9%; 27.4% for the 91 who had a complete resection of pulmonary lesions and entered remission as opposed to none for 9 patients who had incomplete removal of lung nodules. Among these 91, 5-year EFS was significantly higher for patients with monolateral compared to bilateral lesions (27.1% vs. 7.9%, P < 0.02) and when only one to three metastatic nodules were present (40.0% vs. 13.3%, P < 0.0001).

CONCLUSIONS

These different results, demonstrate that our treatment had a reasonable survival outcome whereas other groups continue to have dismal prognosis. More efforts should be made to improve survival by identifying new active agents or novel approaches with cellular molecular targets.

Ewing’s sarcoma family tumours

Despite local treatment with systemic chemotherapy in Ewing’s sarcoma family tumours (ESFT), patients with detectable metastases at presentation have a markedly worse prognosis than those with apparently localised disease. We investigated the clinical, pathological and laboratory differences in 888 patients with ESFT, 702 with localised disease and 186 with overt metastases at presentation, seen at our institution between 1983 and 2006.

Multivariate analyses showed that location in the pelvis, a high level of serum lactic dehydrogenase, the presence of fever and a short interval between the onset of symptoms and diagnosis were indicative of metastatic disease. The rate of overt metastases at presentation was 10% without these four risk factors, 22.7% with one, 31.4% with two, and 50% for those with three or four factors. We concluded that in ESFT the site, the serum level of lactic dehydrogenase, fever, and the interval between the onset of symptoms and diagnosis are indicators of tumours having a particularly aggressive metastatic behaviour.