Role of emotions in the clinical decision-making process of the hospital nurse: A multicentre qualitative study

While for a long-time emotional reaction and moral distress, have been primarily investigated for the possible outcomes of the nursing decision-making process rather than in terms of their role as antecedents of the final decision taken. The primary study's aim is to explore how inpatient nurses' decision-making takes place in different care settings, with a special focus on the role played by emotions during decision-making. The secondary aim is to explore the subjective experience of hospital nurses in relation to successful and unsuccessful decision-making situations. Multicentre qualitative study, consisting of three phases with different designs: participatory study, grounded theory study, and phenomenological study. Participants will be nurses and may be doctors with various levels of professional experience working in hospital, outpatient, or ward settings. Participants will be recruited through different sampling (purposive and convenience). Data will be collected through focus groups and in-depth interviews with nurses working in different hospital care settings. The researchers expect to find themes that will contribute to a better understanding of the role of emotions in decision-making. The results of this study have the potential of providing important implications to support nurses in the recognition and management of their emotions during the decision-making process.

Mindfulness-Based Interventions During Pregnancy and Long-Term Effects on Postpartum Depression and Maternal Mental Health: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Objectives: Preventing postpartum depression (PPD) is a public health goal. The scientific literature has demonstrated the short-term efficacy of Mindfulness-Based Interventions (MBIs) delivered during pregnancy on PPD. Nevertheless, the long-term outcomes of MBIs are still unclear. Design: Systematic review and meta-analysis of randomized controlled trials (RCTs). Four databases were searched to identify RCTs focused on describing the efficacy of MBIs on PPD and published in English up to February 2022. Settings/Location: The study was conducted globally. Subjects: Pregnant women who received MBIs. Interventions: MBIs were delivered during pregnancy in the included RCTs. Outcome Measures: Data collection and analysis effect size were combined using a random-effects model. The reporting in this study was consistent with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Results: Six studies were included. The overall effect size significantly reduced PPD symptoms severity in the MBI group versus the control group in the first 3 months after childbirth (standardized mean difference = -0.26; 95% confidence interval = -0.51 to -0.01; I2 = 30.65%). The effects of MBIs were significant in women who started MBIs with a low risk of developing PPD. Conclusions: MBIs delivered during pregnancy have long-term benefits for PPD. Implications for Practice: Further studies focused on testing MBIs starting during pregnancy and lasting over the postpartum and modulating the intensity of delivering MBIs based on the risk for developing PPD are needed to inform the practice with solid evidence.

Non-Pharmacological Management of Urge Urinary Incontinence in Women between 40 and 65 Years Old: A Systematic Review

BACKGROUND

Urinary incontinence (UI) has been identified as a World Health Organization health priority. In particular, urge UI (UUI) refers to urine leakage associated with a sudden and compelling desire to void urine. It affects quality of life more than other kinds of UI, but it is not always treated adequately. For these reasons, this study aimed to evaluate the effectiveness of conservative treatment practices to counteract UUI in women aged 40-65 years old.

METHODS

This systematic review was conducted following the Joanna Briggs Institute (JBI) methodology. According to the protocol registered in PROSPERO, a systematic search was carried out in the CINAHL, Embase, PubMed, PsycInfo, Scopus and Web of Science databases up to October 2022, to find primary studies meeting the inclusion criteria.

RESULTS

Fourteen studies were included. The scientific literature reported different strategies dealing with the problem of UUI, some purely physical, others physical and psycho-educational and others exclusively psychological.

CONCLUSION

Conservative treatments are useful to aid the reduction in UUI episodes in middle-aged women. However, none of them can be considered more effective than others due to the impossibility of conducting meta-analytical analyses. Further studies comparing the effectiveness of conservative treatments for UUI are needed.

Gamification as an Educational Approach for Oncological Patients: A Systematic Scoping Review

BACKGROUND

Education plays a pivotal role in the care of oncological patients, reducing health costs, hospital readmission, and disease relapses. Education can be supportive in achieving multiple outcomes, improving symptom control and quality of life. A new approach is emerging in patient education: gamification. Gamification was defined as the "use of game elements in non-game contexts", including the application of games in serious contexts. The aim of this review is to explore the use of gamification in the oncology setting.

METHODS

A systematic scoping review was conducted in the MEDLINE, CINAHL, PsychINFO, Embase, Scopus, and Cochrane Library databases using the JBI guidelines.

RESULTS

The 13 included reports were critically appraised by two reviewers independently. It seems that gamification could be effective both in prevention and cancer treatments. Gamification also seems to improve chemotherapy-induced nausea and vomiting management, quality of life, and reduced anxiety levels in different cancer groups. Moreover, gamification seems effective in improving self-care in cancer patients, regardless of gender, age, and ethnicity.

CONCLUSIONS

Gamification improves patient engagement and biopsychosocial outcomes and could represent a valid approach to cancer patient education; however, it is not a substitute for healthcare professionals, who remain the leaders in the education process.

Functional Magnetic Resonance Imaging to Monitor Disease Progression: a prospective study in Patients with Primary Membranoproliferative Glomerulonephritis

INTRODUCTION

Primary membranoproliferative glomerulonephritis (MPGN) is a rare kidney disease with poor prognosis and no specific therapies. The disease heterogeneity and the difficulty of performing repeated kidney biopsies poses big challenges. This study investigates the correlation between non-contrast enhanced magnetic resonance imaging (MRI) and histologic and clinical findings in patients with primary MPGN.

METHODS

Patients with primary MPGN underwent baseline and 1-year kidney MRI in addition to biopsy and laboratory testing as part of a prospective MRI subproject of a clinical trial (ClinicalTrials.gov identifier NCT03723512). Diffusion-weighted and phase-contrast MRI were used to investigate kidney diffusivity and perfusion. Peritubular interstitial volume and fibrosis were quantified on kidney biopsies.

RESULTS

Seven patients with primary MPGN (18[17-21] years, 43% females) were included. Kidney biopsies showed variable degree of global and segmental glomerular sclerosis ([5-30]% and [10-60]%), mild interstitial fibrosis (<10%), and increased peritubular interstitial volume ([19-40]%). MRI and laboratory parameters changed very differently from patient to patient over 1 year. Peritubular interstitial volume and glomerular sclerosis negatively associated with renal blood flow (RBF)(rho = -0.81 and -0.77), and positively with renal vascular resistance (RVR)(rho = 0.65 and 0.73). Urinary albumin to creatinine ratio (uACR) negatively associated with RBF and filtration fraction (FF)(rho = -0.86 and -0.6), while positively with RVR (rho = 0.88). uACR decrease was associated with kidney diffusivity increase (rho = -0.5). Measured glomerular filtration rate (GFR) positively associated with kidney diffusivity, RBF, and FF (rho = 0.87, 0.85 and 0.59), while negatively with RVR (rho = -0.89); GFR increase was associated with kidney diffusivity, RBF, and FF increase (rho = 0.77, 0.7, and 0.7) and RVR decrease (rho = -0.7).

DISCUSSION/CONCLUSION

The strong correlation found between MRI and histologic and clinical findings, despite the rather limited number of patients, highlights MRI potential to monitor disease progression in patients with rare kidney disease.

[The Educational Aspect in Promoting a Low-Sodium Diet, Physical Activity and Therapy Adherence among Patients with Autosomal Dominant Polycystic Disease: A Literature Review]

Background. Polycystic kidney disease (ADPKD) is the most common monogenic cause of End Stage Renal Disease (ESRD), and, thus, of kidney transplantation and dialysis. Educational interventions aimed to improve adherence to therapy, physical performance, and adequate food intake in patients can slow down disease progression by developing self-care skills, which are useful to promote their autonomy while aligning their life plans and required treatments. The aim of this review is to analyze the adherence of patients with polycystic kidney to pharmacological therapy, low-sodium diet, and physical activity, as evidenced in the clinical literature to guide structured educational interventions. Methods. We conducted a literature review from 01/09/2021 to 30/12/2022 through the combination of free keywords and MeSH terms on the databases: PubMed, CINAHL and Cochrane. Results. Findings in medical literature show that physical activity can improve blood pressure control and a low-sodium diet can slow down the progression towards ESRD. Furthermore, although patients may adhere to the complex drug therapy, unresolved educational demands concern choices and behaviors of daily life that, involving the sphere of feelings and emotions, can evolve into manifestations of anxiety and stress. Conclusion. Among ADPKD patients a personalized educational support, considering disease stage and psychological factors, may enable them to acquire knowledge, skills, and behaviors that can improve clinical outcomes.

Parastomal hernia: an overview

Parastomal hernia (PH) is one of the most frequent ostomy complications, and the reported incidence in the literature is highly variable. As highlighted by the Association of Stoma Care Nurses UK, this complication develops mainly in children and older men over 70, but many predisposing factors are related to the individual patient and surgery. There is no standardised system for assessing PH. The main assessment techniques include objective examination, ultrasound scan and computed tomography. Prevention is based on various interventions by surgeons and stoma care nurses (SCNs). The SCN's primary interventions include accurate patient evaluation, pre-operative ostomy siting, education about body weight management and advice on appropriate exercises. The treatment of PH can be conservative or surgical, and the choice is based on the patient's clinical condition. Ostomy can significantly impact on a patient's quality of life (QoL), and the presence of PH can further aggravate the situation. This overview of PH considers the incidence, aetiology, prevention, treatment and impact on QoL.

Diffusion magnetic resonance imaging for kidney cyst volume quantification and non-cystic tissue characterisation in ADPKD

OBJECTIVES

Beyond total kidney and cyst volume (TCV), non-cystic tissue plays an important role in autosomal dominant polycystic kidney disease (ADPKD) progression. This study aims at presenting and preliminarily validating a diffusion MRI (DWI)-based TCV quantification method and providing evidence of DWI potential in characterising non-cystic tissue microstructure.

METHODS

T2-weighted MRI and DWI scans (b = 0, 15, 50, 100, 200, 350, 500, 700, 1000; 3 directions) were acquired from 35 ADPKD patients with CKD stage 1 to 3a and 15 healthy volunteers on a 1.5 T scanner. ADPKD classification was performed using the Mayo model. DWI scans were processed by mono- and segmented bi-exponential models. TCV was quantified on T2-weighted MRI by the reference semi-automatic method and automatically computed by thresholding the pure diffusivity (D) histogram. The agreement between reference and DWI-based TCV values and the differences in DWI-based parameters between healthy and ADPKD tissue components were assessed.

RESULTS

There was strong correlation between DWI-based and reference TCV (rho = 0.994, p < 0.001). Non-cystic ADPKD tissue had significantly higher D, and lower pseudo-diffusion and flowing fraction than healthy tissue (p < 0.001). Moreover, apparent diffusion coefficient and D values significantly differed by Mayo imaging class, both in the whole kidney (Wilcoxon p = 0.007 and p = 0.004) and non-cystic tissue (p = 0.024 and p = 0.007).

CONCLUSIONS

DWI shows potential in ADPKD to quantify TCV and characterise non-cystic kidney tissue microstructure, indicating the presence of microcysts and peritubular interstitial fibrosis. DWI could complement existing biomarkers for non-invasively staging, monitoring, and predicting ADPKD progression and evaluating the impact of novel therapies, possibly targeting damaged non-cystic tissue besides cyst expansion.

CLINICAL RELEVANCE STATEMENT

This study shows diffusion-weighted MRI (DWI) potential to quantify total cyst volume and characterise non-cystic kidney tissue microstructure in ADPKD. DWI could complement existing biomarkers for non-invasively staging, monitoring, and predicting ADPKD progression and evaluating the impact of novel therapies, possibly targeting damaged non-cystic tissue besides cyst expansion.

KEY POINTS

• Diffusion magnetic resonance imaging shows potential to quantify total cyst volume in ADPKD. • Diffusion magnetic resonance imaging might allow to non-invasively characterise non-cystic kidney tissue microstructure. • Diffusion magnetic resonance imaging-based biomarkers significantly differ by Mayo imaging class, suggesting their possible prognostic value.

The influence of patient and caregiver depression on patient self-care and caregiver contribution to self-care in ostomy: A dyadic analysis

AIMS AND OBJECTIVES

To explore the association between patient and caregiver depression and patient self-care and caregiver contribution to self-care in the context of ostomy care.

BACKGROUND

Self-care is essential for ostomy patients and their caregivers. The ostomy self-care process can be considered a dyadic phenomenon in which the patient and the caregiver interact together and work as a team. The presence of depressive symptoms may limit the patient's ability to perform self-care and caregivers' abilities to engage in caregiving tasks. Research into the dyadic influence of depression on self-care behaviours from the perspective of ostomates and their caregivers is still in its infancy.

DESIGN

Secondary analysis of a multicentre, cross-sectional study. The STROBE checklist was used to report the present study.

METHODS

Patient-caregiver dyads were recruited from eight ostomy outpatient clinics from February 2017 to May 2018. Depression was assessed with the nine-item Patient Health Questionnaire in both patients and caregivers. Patient self-care was evaluated with the Ostomy Self-Care Index, and caregiver contribution to self-care was assessed with the Caregiver Contribution to Ostomy Self-Care Index. Both instruments measure the dimensions of maintenance, monitoring and management. The actor-partner interdependence model was performed for the dyadic analysis.

RESULTS

In total, 252 patient-caregiver dyads (patients: 69.8% male, mean age 70.05; caregivers: 80.6% female, mean age 58.7) were enrolled. Patient depression was positively associated with caregiver contribution to self-care maintenance. Caregiver depression was negatively associated with self-care management.

RELEVANCE TO CLINICAL PRACTICE

These findings add a better understanding of the reciprocal influence of dyadic depression on patient and caregiver contributions to self-care in ostomy contexts was found. Patient and caregiver depression influence patient self-care and caregiver contribution to self-care. Therefore, clinicians should assess and treat depression in both members of the dyad to improve self-care.

Prevalence of Sarcopenia in Older Patients in Rehabilitation Wards

The multidisciplinary assessment of hospitalized patients via validated scales and tools has become crucial in the early identification of sarcopenia. The objective of this study was to determine the prevalence of sarcopenia and its related factors in patients aged ≥65 years admitted to the neurological rehabilitation departments of cognitive motor disorders and functional motor rehabilitation at the IRCCS Hospital San Raffaele in Milan. Using the algorithm reported by the European Working Group on Sarcopenia in Older People (EWGSOP2), the prevalence of sarcopenia in patients was investigated from 2019-2020. Definite sarcopenia was detected in 161 of 336 recruited patients (47.9%). Age was significantly higher in sarcopenic patients than in those without sarcopenia (median 81 vs. 79 years, p < 0.001) and height, weight, and body mass index were lower (p < 0.001 for all). The malnutrition screening test (MUST) was higher but still negative in most sarcopenic patients (47.8% vs. 20.6%, p < 0.001). Patients with sarcopenia had significantly reduced life autonomy (by Barthel index, median 55 vs. 60 points, p < 0.001) and increased mental impairment (tested by MMSE and MOCA, p < 0.005 for both). In conclusion, sarcopenic patients were more cognitively impaired and less autonomous in their daily life, but the majority presented with a negative malnutrition screening test.

Training Ethical Competence in a World Growing Old: A Multimethod Ethical Round in Hospital and Residential Care Settings

Ethical challenges are traditionally described in a negative light, even though moral conflict can express the individual ability to perceive when something is not working and promote change. The true question, therefore, is not to how to silence moral conflict but how to educate it. Although the need for ethical support of health- and social-care professionals in elderly care is clearly perceived, there is no universal method for providing effective interventions. The authors hypothesize that adequate training sessions can help care professionals enhance this skill, once clear goals and specific educational techniques are set. This research tests the hypothesis on twenty care professionals working in acute and residential care settings for the elderly, building on the ethics round method. Mixed methods drawn from literature and the experience of educators were adapted to meet different educational goals. Moral issues can hardly be removed from a context characterized by increasing demand and decreasing resources, but they can be recognized and addressed with common efforts, a critical attitude, and a growth mindset. Enhancing these skills in qualified workers can help them accept the reality of work, release pressure, and identify common team goals. Introducing these skills before graduation can help future workers avoid unreal expectations and reduce frustration and early job quit rates.

Is Gastrointestinal Bleeding a Problem for COVID-19 Intensive Care Unit Patients?

The objective of this study was to describe the COVID-19 intensive care unit population and analyze the characteristics and outcomes of gastrointestinal bleeding patients. An observational prospective study design was used following the STROBE checklist. All patients admitted between February and April 2020 to the intensive care unit were included. Main outcome measures were first bleeding event timing, sociodemographic and clinical data before admission, and gastrointestinal symptoms. A total of 116 COVID-19 patients were included; 16 (13.8%) developed gastrointestinal bleeding, 15 were males (93.7%), and the median age was 65.64 ± 7.33 years. All 16 patients were mechanically ventilated, one (6.3%) already had gastrointestinal symptoms, 13 (81.3%) had at least one concomitant disease, and six (37.5%) died. Bleeding episodes occurred on a mean of 16.9 ± 9.5 days after admission. Nine cases (56.3%) had effects on their hemodynamics, hemoglobin levels, or transfusion requirements; six (37.5%) required diagnostic imaging; and two (12.5%) underwent endoscopy procedures. The Mann-Whitney test showed statistically significant differences between the two groups of patients concerning comorbidities. Gastrointestinal bleeding can occur in critically ill patients with COVID-19. Having a solid tumor or chronic liver disease seems to increase that risk. Nurses caring for COVID-19 patients are urged to individualize patients at higher risk in order to improve safety.

The Effects of Early Mobilization on Acquired Weakness in Intensive Care Units: A Literature Review

BACKGROUND

Intensive care unit (ICU)-acquired weakness (ICUAW) is defined as a clinical syndrome of neuromuscular weakness, and a consequence of critical illness, unrelated to any other etiology. It is associated with difficult weaning from the ventilator, prolonged ICU stay, increased mortality, and other important long-term outcomes. Early mobilization is defined as any active exercise in which patients use their muscle strength actively or passively within the first 2 to 5 days of critical illness. Early mobilization can be safely initiated from the first day of admission to the ICU during mechanical ventilation.

OBJECTIVES

The purpose of this review is to describe the effects of early mobilization on complications from ICUAW.

METHOD

This was a literature review. Inclusion criteria were as follows: observational studies and randomized controlled trials conducted with adult patients (aged ≥18 years) admitted to the ICU were included. Studies selected were published in the last 11 years (2010-2021).

RESULTS

Ten articles were included. Early mobilization reduces muscle atrophy, ventilation, length of hospital stay, and ventilator-associated pneumonia and improves patients' responses to inflammation and hyperglycemia.

DISCUSSION

Early mobilization appears to have a significant impact on the prevention of ICUAW and appears to be safe and feasible. The results of this review could be useful for improving the provision of efficient and effective tailored care for ICU patients.

Non-pharmacologic interventions for improving cancer-related fatigue (CRF): A systematic review of systematic reviews and pooled meta-analysis

INTRODUCTION

Literature encloses numerous systematic reviews (SRs) on nonpharmacologic interventions for improving cancer-related fatigue (CRF). The effect of these interventions remains controversial, and the available SRs have not been synthesized yet. We conducted a systematic synthesis of SRs and meta-analysis to determine the effect of nonpharmacologic interventions on CRF in adults.

MATERIAL AND METHODS

We systematically searched 4 databases. The effect sizes (standard mean difference) were quantitatively pooled using a random-effects model. Chi-squared (Q) and I-square statistics (I²) tested the heterogeneity.

RESULTS

We selected 28 SRs, including 35 eligible meta-analyses. The pooled effect size (standard mean difference, 95% CI) was -0.67 (-1.16, -0.18). The subgroup analysis by types of interventions showed a significant effect in all the investigated approaches (complementary integrative medicine, physical exercise, self-management/e-health interventions).

CONCLUSIONS

There is evidence that nonpharmacologic interventions are associated with CRF reduction. Future research should focus on testing these interventions on specific population clusters and trajectories.

PROSPERO REGISTRATION

CRD42020194258.

How Do Nursing Students Perceive Moral Distress? An Interpretative Phenomenological Study

Background: Research shows that the longer nurses care for terminally ill patients, the greater they experience moral distress. The same applies to nursing students. This study aims to analyze episodes of moral distress experienced by nursing students during end-of-life care of onco-hematologic patients in hospital settings. Methods: This study was conducted in the interpretative paradigm using a hermeneutic phenomenological approach and data were analyzed following the principles of the Interpretative Phenomenological Analysis. Results: Seventeen participants were included in the study. The research team identified eight themes: causes of moral distress; factors that worsen or influence the experience of moral distress; feelings and emotions in morally distressing events; morally distressing events and consultation; strategies to cope with moral distress; recovering from morally distressing events; end-of-life accompaniment; internship clinical training, and nursing curriculum. Conclusions: Moral distress is often related to poor communication or lack of communication between health care professionals and patients or relatives and to the inability to satisfy patients’ last needs and wants. Further studies are necessary to examine the quantitative dimension of moral distress in nursing students. Students frequently experience moral distress in the onco-hematological setting.

Self-care and type 1 diabetes mellitus: systematic review of sex-related differences

INTRODUCTION

Self-care is associated with clinical outcomes of adults with T1DM. Some evidence highlighted significant sex-related differences in self-care behaviors in this population. However, the literature on this topic has not been synthesized before. This study aimed to summarize, critically review, and interpret evidence regarding sex-related differences in adults' self-care behaviors with type 1 diabetes mellitus (T1DM).

EVIDENCE ACQUISITION

A systematic search of articles in the following databases was performed: PubMed, Scopus, Embase, and CINAHL. Articles published from 2009 to 2019 were reviewed. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and flowchart were used to support the systematic review and study reporting. Two reviewers independently screened and extracted data from the included articles.

EVIDENCE SYNTHESIS

From the 596 identified records, only 15 articles were included because pertinent to this review. Both females and males with T1DM must improve their ability to respond to signs and symptoms when they occur. Females are more likely to perform adequate blood glucose monitoring and adequate diet than males. In contrast, males are more likely to show more adequate levels of physical activity.

CONCLUSIONS

Clinicians should pay greater attention to supporting females with T1DM to enhance their behaviors for maintaining an adequate health status and glycemic control. Likely, greater attention is required to sustain males to monitor changes in their signs and symptoms. Self-care management should be improved in both sexes.

A comprehensive assessment of frailty status on surgical, functional and oncologic outcomes in patients treated with partial nephrectomy-A large, retrospective, single-center study

BACKGROUND

Partial nephrectomy (PN) is a challenging procedure, which can be associated with severe complications. In consequence, the search for accurate and independent indicators of unfavorable surgical outcomes appears warranted. We aimed at evaluating the impact of frailty status on surgical, functional and oncologic outcomes in patients undergoing PN for renal cell carcinoma (RCC).

METHODS

A retrospective, single-center study including 1,282 patients treated with PN for clinically localized cT₁ RCC was performed. The modified Frailty Index (mFI) was used to assess preoperative frailty. Multivariable logistic, Poisson and linear regression analyses(MVA) tested the effect of frailty on complications, acute kidney injury(AKI), renal function decline after PN. Cumulative incidence and competing-risk analyses investigated survival outcomes.

RESULTS

Of 1,282 patients, 220 (17%) were frail. Overall, 982 (76%) vs. 123 (9.6%) vs. 171 (13%) patients underwent open vs. laparoscopic vs. robot-assisted PN. Median follow-up was 66 (IQR: 35-107) months. At MVA, frailty status predicted increased risk of complications [Odds ratio (OR): 1.46, 95%CI 1.17-1.84; P < 0.001]. Moreover, frail patients were at higher risk of postoperative AKI (OR: 1.95, 95%CI 1.13-3.35; P = 0.01). In frail patients, renal function permanently decreased over time (P = 0.01) without any renal function plateau or improvement during the follow-up, which were instead observed in the nonfrail cohort. At competing-risks analyses, frailty status predicted higher risk of other-cause mortality [Hazard ratio (HR): 1.67, 95%CI 1.05-2.66; P = 0.02], but not of cancer-specific mortality (P = 0.3).

CONCLUSIONS

Frailty status predicts higher risk of adverse surgical outcomes after PN. Moreover, greater renal function decline was observed in frail patients, compared with nonfrail patients. Finally, the risk of OCM significantly overcomes the risk of dying due to RCC in frail patients.

Effects of Octreotide-Long-Acting Release Added-on Tolvaptan in Patients with Autosomal Dominant Polycystic Kidney Disease: Pilot, Randomized, Placebo-Controlled, Cross-Over Trial

BACKGROUND

Tolvaptan and octreotide-long-acting release (LAR) have renoprotective effects in autosomal dominant polycystic kidney disease (ADPKD) that are partially mediated by amelioration of compensatory glomerular hyperfiltration. We compared the effects of tolvaptan and octreotide-LAR combination therapy versus those of tolvaptan monotherapy in patients with ADPKD.

METHODS

This pilot, randomized, placebo-controlled, cross-over trial primarily compared the effects of 1- and 4-week treatments with octreotide-LAR (two 20-mg i.m. injections) or placebo (two i.m. 0.9% saline solution injections) added-on tolvaptan (up to 90 and 30 mg/d) on GFR (iohexol plasma clearance) in 19 consenting patients with ADPKD referred to a clinical research center in Italy. Analyses were intention-to-treat. The local ethical committee approved the study.

RESULTS

At 4 weeks, GFR significantly decreased by a median (interquartile range) of 3 (-1 to 5) ml/min per 1.73 m2 with tolvaptan and placebo (P=0.01) and by 7 (3-14) ml/min per 1.73 m2 with tolvaptan and octreotide-LAR (P=0.03). GFR changes during the two treatment periods differed by 2 (-5 to 14) ml/min per 1.73 m2 (P=0.28). At 1 week, GFR significantly decreased by 3 (0-7) ml/min per 1.73 m2 with tolvaptan and placebo (P=0.006) and by 10 (-6 to 16) ml/min per 1.73 m2 with tolvaptan and octreotide-LAR add-on therapy (P<0.001). GFR changes during the two treatment periods significantly differed by 3 (0-12) ml/min per 1.73 m2 (P=0.012). Total kidney volume nonsignificantly changed by 4 (-48 to 23) ml with tolvaptan and placebo (P=0.74), whereas it decreased significantly by 41 (25-77) ml with tolvaptan and octreotide-LAR (P=0.001). Changes during the two treatment periods differed by 36 (0-65) ml (P=0.01). Octreotide-LAR also attenuated (P=0.02) the aquaretic effect of tolvaptan. Treatments were well tolerated.

CONCLUSIONS

In patients with ADPKD, octreotide-LAR added-on tolvaptan reduced GFR more effectively than octreotide-LAR and placebo. Octreotide-LAR also reduced total and cystic kidney volumes and attenuated the acquaretic effect of tolvaptan.

CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER

Tolvaptan-Octreotide LAR Combination in ADPKD (TOOL), NCT03541447.

Moral Distress of Intensive Care Nurses: A Phenomenological Qualitative Study Two Years after the First Wave of the COVID-19 Pandemic

BACKGROUND

The COVID-19 pandemic has imposed great pressure on healthcare facilities, exposing healthcare professionals to various challenges that may result in the onset of moral distress, a condition of psychological distress caused by the inability to act as it would be most morally appropriate. The purpose of this research was to investigate the experience lived by nurses who worked in an intensive care unit during the COVID-19 pandemic.

METHODS

This is a phenomenological study using interpretative phenomenological analysis. Sixteen nurses who worked in the COVID-19 Intensive Care Unit of Northern Italian Hospitals from January to April 2022 were selected through purposive sampling. Data on experiences, thoughts, and symptoms were collected through semi-structured interviews with in-person and remote modalities.

RESULTS

Five themes and fourteen subthemes emerged from the study. The themes are: (1) pride, isolation, and fear; (2) teamwork and organisation; (3) moral/ethical aspect; (4) true heroes; and (5) dignity.

CONCLUSIONS

This study highlights the impact of the COVID-19 pandemic on intensive care unit nurses. It has emerged that the risk of moral distress is high among healthcare workers in the front line of the fight against the virus. This condition should be avoided and managed through early psychological interventions, sharing of experiences, and a good organization that supports decision-making and professional well-being.

Frontline Involvement in Population COVID-19 Vaccinations: Lived Experience of Nursing Students

(1) Background: The globally promoted vaccination campaign has been shown to be the solution for the COVID-19 pandemic, reducing transmission, hospitalisation and the need for intensive care. Although several studies have examined the experiences of healthcare workers during the pandemic, few studies have investigated healthcare student experiences. The aim of this study is to explore the lived experience of third-year nursing students during the COVID-19 vaccination campaign. (2) Methods: A phenomenological qualitative method was adopted. The researchers selected third-year students undertaking a bachelor’s nursing degree who took part in the COVID-19 vaccination campaign at a high-volume vaccination centre in the period from May to August 2021. (3) Results: Thirteen students were included in the study. Three themes and twelve subthemes emerged from the study. The themes were: a challenging experience; it is not as easy as it seems; a learning experience worth living; and teamwork and trust leading to professional development. (4) Conclusions: Participation in the vaccination campaign was a novelty for students in their degree program. Students emphasized the positive aspects of having the opportunity to participate in the vaccination campaign and help the entire community in the fight against COVID-19.

Low-density lipoprotein cholesterol reduction with evolocumab and its use in clinical practice: evidence from Swedish national register data

Background/Introduction

Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors reduce low density lipoprotein cholesterol (LDL-C) levels by around 50% to 60%, and the risk of cardiovascular events in patients with atherosclerotic cardiovascular disease (ASCVD) in randomized clinical trials. Data on LDL-C reduction with PCSK9 inhibitors and its use in clinical practice is lacking.

Purpose

Assess LDL-C reduction with the PCSK9 inhibitor evolocumab and its use in clinical practice in Sweden.

Methods

Population-based, retrospective, longitudinal, observational study of patients initiating evolocumab treatment between July 2015 and May 2020. Patients undergoing lipoprotein apheresis were excluded. Patient level data was obtained from national diagnosis and pharmaceutical registers (covering 100% of the Swedish population), and electronic health records (covering 60% of the Swedish population). The use of evolocumab was assessed based on persistence with and adherence to treatment. Patients were defined as being persistent if they were still taking evolocumab 12 months after treatment initiation. Medication gaps were allowed until a last gap of ≥56 days. Patients were defined as being adherent if the proportion of days covered (PDC) by the drug was ≥80% during that same period. Mean LDL-C reduction was estimated 3 months after evolocumab treatment initiation, using a Generalized Least Squares regression model.

Results

Overall, 2341 patients were included in the analysis, with a median follow-up of 376 days. Median age was 65 years, 43% were women, 79% had a history of ASCVD and, among them, 94% had had a coronary event and 24% had diabetes. 44% of the patients had LDL-C available. Median LDL-C was 4.1 mmol/L and 64% of the patients were receiving oral lipid-lowering treatment (LLT). After 12 months of treatment, 76% of the patients were persistent with evolocumab. In these patients, median PDC over 12 months was 93%, with 86% of these patients being adherent (PDC ≥80%). In the overall population (n=724), the estimated mean LDL-C reduction with evolocumab at 3 months was 48% (2.1 mmol/L, from 4.4 mmol/L at baseline). In patients who were adherent to evolocumab during the first 6 months (n=567), LDL-C reduction was 53% (2.2 mmol/L, from 4.3 mmol/L at baseline) (see figure). In patients who were adherent to both evolocumab and oral LLT (PDC ≥80% over a period of 3 months before and after evolocumab initiation) (n=186), LDL-C reduction was 59% (2.1 mmol/L, from 3.6 mmol/L at baseline). The estimated mean LDL-C reduction remained stable over a 6-month period.

Conclusions

Persistence with and adherence to evolocumab treatment were high over 12 months. LDL-C reduction with evolocumab in clinical practice was similar to that observed in randomized clinical trials and remained stable over 6 months. At evolocumab treatment initiation, many patients had high LDL-C levels and underused oral LLT, potentially due to statin intolerance.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Amgen

Pharmacotherapy for Obstructive Sleep Apnoea and Coupled Life: A Descriptive Phenomenological Study of a Complex Interaction

BACKGROUND

Obstructive Sleep Apnoea (OSA) is a common chronic sleep-related breathing disorder. Drug therapy is a recent approach to treating OSA, and no data is available regarding its effects on a couple's life. The aim of this study was to investigate the impact on couples' lives of a novel drug treatment for OSA.

METHODS

Participants of a trial on new drug therapy (reboxetine plus oxybutynin) for OSA were interviewed. The study was conducted using a descriptive phenomenological approach by Sundler et al. Results: Ten patients and six of their partners were recruited through a purposive sampling between February and April 2021. The results indicate that drug treatment of OSA had a favourable impact on the couples' lives. Pharmacotherapy improved self-reported sleep quality, as the absence of CPAP allows people to sleep closer to the bed partner and because the patient does not have to sleep in a forced position. Moreover, the couples developed teamwork from the beginning which appeared to be crucial during the trial, especially when some difficulties and adverse events occurred.

CONCLUSIONS

This study presents the presence of a positive closed loop that could be considered a predictor of adherence to drug therapy.

Moral Distress Scores of Nurses Working in Intensive Care Units for Adults Using Corley's Scale: A Systematic Review

BACKGROUND

No systematic review in the literature has analyzed the intensity and frequency of moral distress among ICU nurses. No study seems to have mapped the leading personal and professional characteristics associated with high levels of moral distress. This systematic review aimed to describe the intensity and frequency of moral distress experienced by nurses in ICUs, as assessed by Corley's instruments on moral distress (the Moral Distress Scale and the Moral Distress Scale-Revised). Additionally, this systematic review aimed to summarize the correlates of moral distress.

METHODS

A systematic search and review were performed using the following databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), the National Library of Medicine (MEDLINE/PubMed), and Psychological Abstracts Information Services (PsycINFO). The review methodology followed PRISMA guidelines. The quality assessment of the included studies was conducted using the Newcastle-Ottawa Scale.

RESULTS

Findings showed a moderate level of moral distress among nurses working in ICUs. The findings of this systematic review confirm that there are a lot of triggers of moral distress related to patient-level factors, unit/team-level factors, or system-level causes. Beyond the triggers of moral distress, this systematic review showed some correlates of moral distress: those nurses working in ICUs with less work experience and those who are younger, female, and intend to leave their jobs have higher levels of moral distress. This systematic review's findings show a positive correlation between professional autonomy, empowerment, and moral distress scores. Additionally, nurses who feel supported by head nurses report lower moral distress scores.

CONCLUSIONS

This review could help better identify which professionals are at a higher risk of experiencing moral distress, allowing the early detection of those at risk of moral distress, and giving the organization some tools to implement preventive strategies.

Gastrointestinal Bleeding in COVID-19 Patients: A Rapid Review

The incidence of COVID-19 gastrointestinal manifestations has been reported to range from 3% to 61%. There are limited data on the incidence rates and risk factors associated with gastrointestinal bleeding (GIB) in patients with COVID-19. A rapid review has been designed to investigate whether there is a relationship between COVID-19 and GIB in adult patients. PubMed, CINAHL, EMBASE, Cochrane Library, and Scopus databases have been analyzed. A total of 129 studies were found; 29 full texts were analyzed, and of these, 20 were found to be relevant to the topic. The key findings of the included studies present an overall GIB rate in COVID-19 patients ranging from 1.1% to 13%. The bleeding involves mucosal damage of the duodenum, stomach, colon, and rectum. The management of gastrointestinal bleeding could be conservative. The use of fecal diversion systems for the management of diarrhea in COVID-19 patients should be minimized and closely evaluated for the risk of rectal mucosal damages and erosions. It is recommended to provide an accurate nutritional assessment; an early setting up of enteral nutrition, if not contraindicated, can help protect the gut mucosa of patients and restore normal intestinal flora. Larger cohort studies are needed to increase the information about this topic.

Risk factors and pooled incidence of intestinal stoma complications: systematic review and Meta-analysis

OBJECTIVE

The present systematic review aimed to identify, critically assess and summarize which risk factors might determine the onset of ostomy complications, describing a pooled incidence and stratified incidences by each identified risk factor.

METHODS

A systematic literature review with a meta-analysis of observational studies was performed by following the PRISMA statement and flow chart. The quality assessment of the included articles was performed through the Newcastle-Ottawa Scale (NOS).

RESULTS

Sixteen articles published between 1990 and 2018 focused on the risk factors related to intestinal stomal complications, and the performed analysis led to identifying influenceable and non-influenceable risk factors. The median of the NOS evaluation was 6 (IQR = 5.75-6). Among 10,520 included patients, the pooled incidence of stomal complications was 35%, ranging from 9% to 63%, regardless of the nature of the complications. Analysis of the sub-groups highlighted obesity and ostomy surgery performed via laparoscopy or emergency conditions have significant incidences, respectively, of 66% and 68%.

CONCLUSIONS

The pooled incidence of stomal complications requires greater attention for its relevant epidemiology. From the clinical point of view, patients with obesity and chronic conditions require more attention to prevent complications, possibly employing accurate educational interventions to enhance proper stoma management.

[The FRASNET study: identification of clinical and social factors of renal failure in an elderly population]

Background. Chronic renal failure is an epidemic in elderly patients. Older population have an increased prevalence of frailty and sarcopenia, associated with a wide range of adverse health outcomes such as falls, hospitalization, disability. Aim. Describe the sociodemographic and clinical variables of an elderly Lombard population and identify predictors of renal insufficiency. Materials and methods. Cross-sectional observational study conducted in hospitals, in recreational centers for the elderly, in the Universities of the Third Age of the provinces of Milan and Monza-Brianza conducted through a convenience sampling of 1250 subjects over the age of 65. Results. The study identified living alone, annual individual income < € 10,000, polypharmacy, sarcopenia and frailty as predictors of chronic kidney failure. The sample has a mean eGFR of 71.74 mL/min/1.73m2 (SD ± 16.56). Older people living alone are more likely to develop CRI (P = 0.031, confidence interval, CI [1.031-1.905]) as well as having an income < € 10,000 (P = 0.002, CI [0.392-0.923]). Taking more than 11 drugs a day increases the probability of having chronic renal failure by 16 times (P = 0.012, CI [1.155-3.16]). Sarcopenia and frailty increase the likelihood of having chronic renal failure (CRI) (P = 0.001, CI [1.198-2.095]). Conclusions. Identifying predictors of chronic kidney failure is a key step in introducing preventive measures and providing better care to the elderly population.

Nurse's bedside screening of dysphagia: an umbrella review

INTRODUCTION

Dysphagia often results in serious, poor health outcomes. Nurses have an important role in assessing dysphagia. Therefore, they need reliable and effective screening tools to detect dysphagia. The purpose of this umbrella review is to locate the most valid, reliable, and usable bedside screening tools that allow nurses to identify dysphagia in institutionalized patients.

METHODS

Umbrella Review as suggested by the Joanna Briggs Institute. Inclusion criteria were: systematic reviews of randomized controlled trials or cross-sectional studies. We excluded: pediatric and psychiatric patients. We searched on PubMed, CINAHL, Scopus, Cochrane Library, the Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, and the Joanna Briggs Institute Evidence-Based Practice Database.

RESULTS

Six reviews were included. Four tools were reported in all the reviews: 3 oz swallowing water test, Mann Assessment of Swallowing Ability, Toronto Bedside Swallowing Screening Test, Gugging Swallowing Screen. They have shown fair to good sensitivity and specificity. The reviews analysed did not allow for a comparative analysis between instruments, which may be hindering the selection of the optimal instrument for clinical practice.

CONCLUSIONS

Almost all reviews have considered stroke patients. The next steps will be to determine if there is a tool applicable in multiple settings with different patients and if this intervention is cost-effective.

The impact of the italian law mandating an automatic external defibrillation in all sports venues on sudden cardiac arrest survival

Funding Acknowledgements

Type of funding sources: None.

Introduction

The chances of surviving a sport-related cardiac arrest depend strictly on resuscitation efforts. Since 2015, all Italian recreational and competitive sport venues must be equipped with automated external defibrillators (AEDs), and trained staff must be present during competitions. The aim of the study was to evaluate the incidence and survival rates of cardiac arrests in sport Venues in the Lombardia region of Italy before and after 2015.

Methods

We collected retrospectively data regarding all sudden cardiac arrests of presumed cardiac origin that involved both athletes and non-athletes (coaches, referees, spectators, etc.) and which occurred in sports venues of the Lombardia region in the period 2015-2019 versus those that occurred in the period 2011-2014, when automatic external defibrillators were not mandatory yet. All cases have been gathered thanks to the database built by the regional territorial emergency service (AREU) of the Lombardia region and consulting the news reported by the local and national press.

Results

Between 2015 and 2019, the incidence of cardiac arrest of presumed cardiac origin which affected athletes in sports venues of the Lombardia region was 0.19 per 100,000 inhabitants/year, versus 0.28 per 100,000 inhabitants/year in the period 2011-2014 (p&lt;0.005). The average age of the victims was 49.9 years in 2015-2019 and 52 years in 2011-2014 (p=0.96). After the enactment of the "compulsory AED law", the proportion of cardiac arrests treated with onsite AEDs increased from 15% to 42.1% (p&lt;0.001) and the return of spontaneous circulation (successful resuscitation) increased from 67% to 80% (p&lt;0.05). The association between mandatory presence of AEDs in sports venues and resuscitation success in terms of ROSC was found significant (p&lt;0.05).

Conclusions

Cardiac arrest in sports venues is a rare event and involves mainly male athletes older than 30 years old. A nationwide law mandating the presence of AEDs in all sport venues significantly increased the proportion of individuals suffering cardiac arrest who received defibrillation before the emergency medical system arrival and favorably influenced survival rates.

Tackling the Italian emergency 2019-nCoV: nurses' knowledge, attitudes and behaviors

Background and aim:

The aim was to understand the knowledge, attitudes, and behaviors of Health Care workers regarding the Novel Coronavirus 2019 cases at the start of the diffusion of the disease in Italy.

Methods:

Cross-sectional survey of nurses working in Italian hospitals.

Results:

Most of the sample showed good knowledge and behaviors about the new virus and good attitudes. Logistic regression analysis demonstrated that predictive variables of knowledge, attitude, and behavior were: educational background, work experience years and age of nurses.

Conclusions:

This study is the first one in a time of a full health emergency. It would be appropriate to develop further studies to better analyze the skills implemented to tackle Novel Coronavirus 2019 disease. Novel Coronavirus 2019 pandemic has put on health personnel a considerable workload. Despite this, the Italian nursing staff has been showing excellent knowledge, attitude, and good behavior in the management of this pandemic. (www.actabiomedica.it)

Consensus-Based Technical Recommendations for Clinical Translation of Renal Phase Contrast MRI

BACKGROUND

Phase-contrast (PC) MRI is a feasible and valid noninvasive technique to measure renal artery blood flow, showing potential to support diagnosis and monitoring of renal diseases. However, the variability in measured renal blood flow values across studies is large, most likely due to differences in PC-MRI acquisition and processing. Standardized acquisition and processing protocols are therefore needed to minimize this variability and maximize the potential of renal PC-MRI as a clinically useful tool.

PURPOSE

To build technical recommendations for the acquisition, processing, and analysis of renal 2D PC-MRI data in human subjects to promote standardization of renal blood flow measurements and facilitate the comparability of results across scanners and in multicenter clinical studies.

STUDY TYPE

Systematic consensus process using a modified Delphi method.

POPULATION

Not applicable.

SEQUENCE FIELD/STRENGTH

Renal fast gradient echo-based 2D PC-MRI.

ASSESSMENT

An international panel of 27 experts from Europe, the USA, Australia, and Japan with 6 (interquartile range 4-10) years of experience in 2D PC-MRI formulated consensus statements on renal 2D PC-MRI in two rounds of surveys. Starting from a recently published systematic review article, literature-based and data-driven statements regarding patient preparation, hardware, acquisition protocol, analysis steps, and data reporting were formulated.

STATISTICAL TESTS

Consensus was defined as ≥75% unanimity in response, and a clear preference was defined as 60-74% agreement among the experts.

RESULTS

Among 60 statements, 57 (95%) achieved consensus after the second-round survey, while the remaining three showed a clear preference. Consensus statements resulted in specific recommendations for subject preparation, 2D renal PC-MRI data acquisition, processing, and reporting.

DATA CONCLUSION

These recommendations might promote a widespread adoption of renal PC-MRI, and may help foster the set-up of multicenter studies aimed at defining reference values and building larger and more definitive evidence, and will facilitate clinical translation of PC-MRI.

LEVEL OF EVIDENCE

1 TECHNICAL EFFICACY STAGE: 1.

COVID-19 and the Environment: Pandemics, Climate, and Ecosystems, and the Environmental Challenge in Dialysis

The recent COVID-19 pandemic has had a significant impact on the population worldwide. Patients with chronic kidney disease treated with kidney replacement therapy were no exception because they were considered highly vulnerable due to multiple comorbidities. The consequences of the physical, biological, and ecological system on the environment as a result of human activity represent a huge global health care danger. The purpose of this article is to identify strategies that improve environmental sustainability, improve prevention of COVID-19 infection in dialysis centers, and improve the environmental impact of hemodialysis centers.

Characteristics of registered clinical trials assessing strategies of medication errors prevention. An unusual cross sectional analysis

BACKGROUND

ClinicalTrials.gov is the oldest and largest of these registries. Through this, the researchers can explore and monitor the clinical research landscape. In the last decades, the number of Medline-indexed publications on adverse events and medication errors have increased exponentially. The aims were to define the prevalence of clinical trials that have as outcome the medication errors and to describe the characteristics of these trials, including their distribution across countries, and publication rate.

METHODS

A cross-sectional analysis of all clinical trials reporting as primary outcome medication errors identified through ClincialTrials.gov.

RESULTS

Among 5.881 trials, only 1,68% focused on intervention to improve medication safety process and prevent medication errors. 25,3% of clinical trials included had their primary outcome changed (p= ,005). Recording study results in ClinicalTrials.gov was associated with trials that had their primary outcome changed (OR: ,060; 95% C.I.: ,007 - ,541). Only few interventional trials were totally compliant with the ICMJE policy. For all trials completed in our sample, in mean 7,44 months (median: 12 months) elapsed between study completion and the first publication in Medline showing the trial's identification number.

CONCLUSIONS

This study demonstrates several strengths of using ClinicalTrials.gov to track intervention to improve medication safety process. It is unknown how many trials are designed to focus on medication errors. However, 1,68% of trials focused on intervention to improve medication safety process.

Further evidence of validity of the Nursing Decision Making Instrument: an Italian validation study

BACKGROUND AND AIM

This study aimed to provide the Italian version of the Nursing Decision Making Instrument (NDMI) and establish its content and face validity, construct validity, and reliability among Italian nurses.

METHODS

A three phases validation, methodological and cross-sectional study was realized. Phase one referred to the cultural-linguistic translation of the NDMI into Italian (i.e., I- NDMI). Phase two aimed to obtain a good level of content and face validity (cut-off <0.70). Phase three involved a cross-section data collection amongst Italian nurses in assessing the construct validity and reliability of the I-NDMI.

RESULTS

I-NDMI showed adequate content validity. Confirmatory factor analysis models supported the four-factorial structure of the I-NDMI (i.e., Intuition; Prevision; Assessment; Planning) in explaining data obtained from nurses. Moreover, the scale and each domain showed adequate internal consistency.

CONCLUSIONS

This study constituted an advancement in the psychometric testing of the NDMI. Future research should identify specific decision-making processes and their determinants to allow theoretically grounded interventions to improve decision-making among nurses.

Burnout and post-traumatic stress disorder in frontline nurses during the COVID-19 pandemic: a systematic literature review and meta-analysis of studies published in 2020

This study aimed to systematically synthesize evidence regarding burnout and post-traumatic stress disorder (PTSD) among nurses engaged in the frontline during the COVID-19 pandemic, highlighting their risk and protective factors. The specific literature on nurses' mental health outcomes still remains not synthesized. A systematic review was performed (PROSPERO: CRD42021227939), searching literature published in 2020 on Pubmed, Scopus, CINAHL, and PsycInfo. We quantitatively pooled means of included studies measuring burnout and PTSD with the same tools. Twenty-five studies were included in this review. Seven (3766 nurses) were included in the meta-analysis for estimating means of depersonalization and emotional exhaustion assessed using the Maslach Burnout Inventory, respectively: 7,40 (95%CI=6,00-8,80) and 22,82 (95%CI=19,24-26,41). Likely, 12 studies were used to estimate two pooled means for PTSD, one for six studies adopting the Impact of Event Scale-Revised (1551 nurses), and six adopting the PTSD Scale for DSM-5 (8547 nurses). The main risk and protective factors of both outcomes were female sex and younger age, work-related variables, and physical and mental factors, such as concerns, skin lesions from wearing personal protective equipment. This systematic review portrayed the situation described in literature during 2020 on nurses' burnout and PTSD during the COVID-19 pandemic. Although the outcomes' levels described in the included studies are diverse, the broad situation appears alarming, and supportive multi-level strategies, considering individual and system-level, should be planned to decrease the described worsening scenario within the clinical settings avoid middle and long-term negative consequences.

Levels of Moral Distress among Health Care Professionals Working in Hospital and Community Settings: A Cross Sectional Study

Moral distress is a concern for all healthcare professionals working in all care settings. Based on our knowledge, no studies explore the differences in levels of moral distress in hospital and community settings. This study aims to examine the level of moral distress among healthcare professional working in community or hospital settings and compare it by demographic and workplace characteristics. This is a cross-sectional study. All the professionals working in the hospitals or community settings involved received personal e-mail invitations to participate in the study. The Moral Distress Thermometer was used to measure moral distress among healthcare professionals. Before data collection, ethical approval was obtained from each setting where the participants were enrolled. The sample of this study is made up of 397 healthcare professionals: 53.65% of the sample works in hospital setting while 46.35% of the sample works in community setting. Moral distress was present in all professional groups. Findings have shown that nurses experienced level of moral distress higher than other healthcare professionals (mean: 4.91). There was a significant differences between moral distress among different professional categories (H(6) = 14.407; p < 0.05). The ETA Coefficient test showed significant variation between healthcare professionals working in community and in hospital settings. Specifically, healthcare professionals who work in hospital experienced a higher level of moral distress than those who work in community settings (means 4.92 vs. means 3.80). The results of this study confirm that it is imperative to develop educational programs to reduce moral distress even in those settings where the level perceived is low, in order to mitigate the moral residue and the crescendo effect.

SACS Evolution: a peristomal health tool for the prevention of peristomal skin disorders

BACKGROUND

The ostomy patient's quality of life also depends on their peristomal health and thus first and foremost on keeping healthy peristomal skin. This is by no means an easy task, given that the incidence of peristomal skin disorders can be a factor in up to 80% of cases. Over the past 15 years, several tools have been developed to classify peristomal skin lesions to facilitate the management of the problem. These tools, however, meet the needs of healthcare professionals and those of patients. Hence the decision to work on an advanced version of the SACS^©, currently the most widely used tool, with the setting up of the SACS Evolution Consensus Group.

METHODS

By applying the simplified Delphi method, the SACS Evolution Consensus Group critically re-read what had been garnered from the literature in the light of their personal clinical experience, identified the key issues to be addressed, and processed and refined the relevant statements. This made it possible to achieve the challenging objective of creating a peristomal health tool to help prevent peristomal skin lesions.

RESULTS

SACS Evolution is, indeed, a promising tool for preventing peristomal lesions. It is structured on two different levels, one for the patient and one for the healthcare professional, each characterized by specific language and based on an innovative concept of healthy peristomal skin, which is essential for those who work on peristomal health.

CONCLUSIONS

The SACS Evolution Consensus Group thus aims to validate this peristomal health tool and has already started a validation process so that the tool can be used in clinical practice.

Systematic review of clinical evidence on postoperative delirium: literature search of original studies based on validated diagnostic scales

BACKGROUND

Postoperative delirium is a serious complication that can occur within the 5th postoperative day. In 2017, the European Society of Anesthesiologists delivered dedicated guidelines that reported the need for routine monitoring using validated scales.

OBJECTIVE

Aim of this systematic review is to identify clinical studies related to postoperative delirium that included postoperative monitoring with validated scales.

DESIGN

Systematic review METHODS: Searched keywords included the following terms: postoperative, postsurgical, post anesthesia, anesthesia recovery, delirium, and confusion. Two researchers independently screened retrieved studies using a data extraction form.

RESULTS

Literature search led to retrieve 6475 hits; of these, 260 studies (5.6% of the retrieved), published between 1987 and 2021, included in their methods a diagnostic workup with the use of a postoperative delirium validated scale and monitored patients for more than 24 h, therefore are qualified to be included in the present systematic review.

CONCLUSION

In conclusion, available clinical literature on postoperative delirium relies on a limited number of studies, that included a validated diagnostic workup based on validated scales, extracted from a large series of studies that used inconsistent diagnostic criteria. In order to extract indications based on reliable evidence-based criteria, these are the studies that should be selectively considered. The analysis of these studies can also serve to design future projects and to test clinical hypothesis with a more standardized methodological approach.

Thirst in patients admitted to intensive care units: an observational study

Background

Despite various studies reporting a high prevalence, reaching 71%, the sensation of thirst in intensive care unit (ICU) patients, its prevention, detection, and management, is not well known nor considered. Limited research has examined the causes of thirst in ICU patients, while it has been examined in other patient populations.

Aim

To determine the incidence and intensity of thirst in patients admitted to ICU and its association with airway devices (endotracheal tube, tracheostomy, oxygen mask), airway humidification, patients’ characteristics, and therapy (serum sodium concentration, hematocrit, fluid balance, possibility of oral hydration, and dosage of diuretics).

Methods

Patients were interviewed daily to report the presence of thirst and rate its intensity on a Numeric Rating Scale (NRS) from 0 (no thirst) –10 (intolerable thirst). Other data were obtained through direct evaluation or by consulting medical records. Patients admitted to three ICUs from May to August 2014 in a university hospital in Italy were included.

Results

A total of 220 Patients were enrolled. Thirst was found in 76.1% of patients’ observations, with a mean thirst score of 5.37. Thirst intensity was predicted by high doses of diuretics (> 100 mg/die), increasing serum sodium concentration, absence of oral hydration and the presence of xerostomia. Thirst was associated with the use of humidified Venturi mask.

Conclusions

Thirst is highly prevalent among patients in this population of intensive care patients. It would be desirable to evaluate this stressor at least daily, to eliminate or relieve this sensation.

The influence of drug therapy for obstructive sleep apnoea on couple life. Qualitative study grounded theory

Background

Obstructive sleep apnoea (OSA) is characterised by the collapse of the upper airway during sleep, which determine intermittent hypoxia and sleep fragmentation leading to snoring, impaired cognitive function, excessive daytime sleepiness, and cardiovascular impairments. These disorders have a significant impact on the quality of life and health of both patient and partner, determining stress and frustration also to the couple relationship, and to the workplace. Although the gold standard of treatment for OSA is the use of continuous positive airway pressure (CPAP), many patients find it uncomfortable both for them and for their partners (difficulty in partner intimacy, fear of disturbing their partner's sleep) with consequent low adherence to treatment in about 50% of OSA patients.

For these reasons, efforts to develop drug therapies for the treatment of OSA have been ongoing for at least 20 years. Recently, we conducted a randomized controlled trial (RCT) in Italy to test the combination of reboxetine (a noradrenergic agent) and oxybutynin (an antimuscarinic) for OSA treatment with promising results. The aim of this study is to understand how OSA drug therapy has influenced couples' life.

Methods

The study was conducted from February to March 2020 by the research nurse who participated during the trial. We interviewed 11 patients participating in the pharmacological RCT and 7 partners. The data analysis was conducted in order to collect the subjects' answers in categories, and to identify a core category as the central element for the explanation of the process.

Results

Interviews permitted to extrapolate 6 main categories and the relative subcategories for patients: 1) OSA: unconscious danger; 2) OSA and couple life (subcategories: sleepiness and nervousness, lack of sleep); 3) transitory situations; 4) drug therapy and couple (subcategories:change in intimacy and sleep quality); 5) motivation to help others (subcategories: therapy recommended for everyone; intention to continue); 6) partner awareness helps in adherence to therapy (subcategories: partner as caregiver, presence and proximity, partner support). While for partners, 7 main categories and the relative subcategories emerged: 1) apprehension and concern for the partner; 2) repercussions on daily life (subcategorie: discomfort); 3) OSA and the couple's lives; 4) drug therapy and couple; 5) support during therapy (subcategorie: before therapy, during therapy); 6) changes during drug therapy; 7) recommended therapy (subcategories: helping others, partner support). “The OSA is our problem” was the core category of the study that linked the categories together.

Conclusions

Drug therapy is well embraced by both patients and partners as it allows the couple to recover intimacy during sleep and in daily life. The results of this study provide useful information on the need to involve the partner in order to promote adherence to therapy.

Funding Acknowledgement

Type of funding sources: None.

Potential cardiovascular risk reduction with evolocumab in the real world: a simulation in patients with a history of myocardial infarction from the HEYMANS register

Background/Introduction

FOURIER included 22,351 patients with a history of myocardial infarction (MI) and a median low-density lipoprotein cholesterol (LDL-C) of 2.4 mmol/L. Reducing LDL-C with evolocumab reduced the risk of major cardiovascular (CV) events by 1.3%, in absolute terms, over 2.2 years. Whether similar benefits might be observed in real-world evidence from evolocumab use is unknown.

Purpose

Simulate CV risk and assess the potential CV risk reduction among a large European cohort of evolocumab users with a history of MI.

Methods

We used interim data from HEYMANS, a register of patients initiating evolocumab in routine clinical practice across 12 European countries, from August 2015 with follow-up through July 2020. Demographic and clinical characteristics, lipid-lowering therapy (LLT), and lipid values were collected from routine medical records (6 months prior to evolocumab initiation through 30 months post initiation). Patients with a history of MI were considered and two sub-cohorts were created: recent MI (MI ≤1 year before evolocumab initiation) and remote MI (MI &gt;1 year before evolocumab initiation). For each patient, we 1) simulated their CV risk using three different sources, correcting for age and LDL-C: i) the REACH equation, ii) FOURIER, iii) an observational study including FOURIER-like patients; 2) calculated their absolute LDL-C reduction on evolocumab; 3) simulated their relative risk reduction (RRR) by randomly sampling from the inverse probability distribution of the rate ratio per 1 mmol/L from the key secondary endpoint in the FOURIER landmark analysis; 4) calculated their absolute risk reduction (ARR) and number needed to treat (NNT) over 2 years (recent MI) or 10 years (remote MI).

Results

Our analysis included 90 recent MI and 489 remote MI patients initiating evolocumab in clinical practice per local reimbursement criteria, with up to 24 months follow-up. Median (inter-quartile range) age was 59 (53–67) and 61 (53–68) years in recent MI and remote MI patients, respectively. LDL-C before evolocumab was 3.8 (3.2–4.6) and 3.6 (3.0–4.5) mmol/L. Absolute LDL-C reduction on evolocumab was 2.2 (1.4–2.8) and 2.2 (1.6–2.8) mmol/L, meaning relative LDL-C reduction of 60% (44%-73%) and 62% (47%-72%), respectively. Predicted ARR with evolocumab was substantial, whether over 2 years (recent MI) or over 10 years (remote MI). See Table 1.

Conclusions

This cohort of evolocumab users in clinical practice had a higher baseline LDL-C and CV risk than patients enrolled in FOURIER. LDL-C reduction and RRR were very similar in recent MI and remote MI patients. However, patients with a recent MI had a higher short-term CV risk and therefore showed a larger ARR on evolocumab.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Amgen

Potential low-density lipoprotein cholesterol, cardiovascular risk and costs reduction with evolocumab: a simulation in patients with a recent myocardial infarction in Spain

Background/Introduction

FOURIER included 5,711 patients with a recent myocardial infarction (MI) and a median low-density lipoprotein cholesterol (LDL-C) of 90 mg/dL. Reducing LDL-C with evolocumab reduced the risk of major cardiovascular (CV) events by 2.1%, in absolute terms, over 2.3 years. Further research may be conducted to understand the potential benefits of evolocumab in the real world.

Purpose

Simulate the potential LDL-C, CV risk and costs reduction among a cohort of patients with a recent MI in Spain.

Methods

We considered data from a retrospective observational study using the BIG-PAC database, with anonymized electronic medical records from 1.9 million inhabitants from 7 regions in Spain. Eligible patients were adults, hospitalized for an MI (index date) between January 2015 and December 2017, treated with high-intensity lipid-lowering therapy, and with LDL-C available at baseline and at the end of follow-up (up to 18 months). For each patient, we 1) predicted their CV risk using the REACH equation; 2) simulated their LDL-C reduction based on FOURIER and assessed whether they had achieved the 2019 ESC/EAS LDL-C goals; 3) simulated their relative CV risk reduction (RRR) based on the key secondary endpoint in FOURIER and calculated their absolute CV risk reduction (ARR) over 2 years. Costs (direct and indirect), excluding medication, were computed based on achieved LDL-C categories, before and after evolocumab treatment. We conducted separate analyses for patients with LDL-C ≥100 mg/dL (current reimbursement recommendation in Spain) and LDL-C ≥70 mg/dL.

Results

LDL-C, CV risk and costs, before and after evolocumab treatment, are presented in Table 1. We included 1,941 patients with LDL-C ≥100 mg/dL and 3,725 patients with LDL-C ≥70 mg/dL. Median absolute LDL-C reduction was 73 mg/dL and 59 mg/dL for patients with LDL-C ≥100 mg/dL and LDL-C ≥70 mg/dL, respectively. 53% and 65% of the patients achieved LDL-C &lt;55 mg/dL, respectively. Median ARR was 3% and 2% over 2 years, respectively. Mean costs were reduced by 1,565 EUR and 1,296 EUR, respectively.

Conclusions

The sub-cohort of evolocumab users with LDL-C ≥70 mg/dL had similar baseline LDL-C and CV risk than patients enrolled in FOURIER, and therefore CV risk reduction was also consistent. Evolocumab reduced LDL-C, CV risk and costs in the two sub-cohorts analysed, but the clinical and economic benefit was larger in patients with LDL-C ≥100 mg/dL.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Amgen

A real-world analysis of characteristics and lipid-lowering therapy use in patients initiating treatment with evolocumab in Sweden

Background/Introduction

Proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors reduce low-density lipoprotein cholesterol (LDL-C) levels and the risk of cardiovascular events in patients with atherosclerotic cardiovascular disease (ASCVD) in clinical trials. In January 2019, evolocumab reimbursement recommendation in Sweden was broadened to include patients on maximally tolerated oral lipid-lowering therapy (LLT) and either ASCVD and LDL-C ≥2.5 mmol/L, or familial hypercholesterolemia (FH) with no ASCVD and LDL-C ≥3.0 mmol/L.

Purpose

Describe characteristics and LLT use in patients initiating treatment with evolocumab in the context of the 2019 reimbursement recommendation in Sweden.

Methods

Cross-sectional, population-based, retrospective, observational study of patients initiating treatment with evolocumab between January 2019 and June 2020. Data were obtained from national healthcare registers and electronic medical records, covering more than half of the Swedish population.

Results

Out of 1560 patients included, 41% had LDL-C available ≤3 months prior to treatment initiation with evolocumab. Among those with LDL-C available, 79% had ASCVD and 19% had definite, probable or possible FH with no ASCVD. Mean pre-treatment LDL-C levels were 3.7 and 5.0 mmol/L for patients with ASCVD, and FH with no ASCVD, respectively. Most of the patients, 84.6% and 80.0%, respectively, had been ever treated with both statins and ezetimibe. However, 28.0% and 38.3% of them, respectively, were not on oral LLT at the time of treatment initiation with evolocumab. Patient characteristics and LLT use are presented in Table 1.

Conclusions

Patients initiating treatment with evolocumab in Sweden had pre-treatment LDL-C levels far from treatment targets, despite being at very high risk for cardiovascular events. Most of the patients had been treated with both statins and ezetimibe in the past. However, almost a third of them were not using oral LLT at the time of treatment initiation with evolocumab. The conditions in the 2019 evolocumab reimbursement recommendation in Sweden were generally met.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Amgen

Experiences of healthcare providers from a working week during the first wave of the COVID-19 outbreak

Background and aim of the work:

The delivery of care to patients with COVID-19 enhanced many psychological issues among healthcare workers (HCWs), exacerbating the risk of burnout and compromising the efficacy and quality of services provided to patients. In this context, the peculiarities regarding professional roles in delivering care to patients with COVID-19 might reflect daily lived experiences that could impact psychological outcomes in specific professional groups. However, daily lived experiences considering different groups of HCWs have been poorly investigated, especially with a longitudinal qualitative study. Accordingly, our study aims firstly to longitudinally explore perceptions and experiences of HCWs about their daily working life during the initial COVID-19 outbreak, highlighting the specific lived experiences of physicians, nurses, radiology technicians, and healthcare assistants.

Methods:

A longitudinal qualitative content analysis was conducted to analyse the comments and quotations made on a daily diary lasting seven days by physicians, nurses, radiology technicians, and healthcare assistants during the first wave of the COVID-19 outbreak. According to Elo and Kyngäs recommendation, the data analysis process was developed in three main phases: preparation, organising, and reporting.

Results:

Four main generic categories emerged by data analysis: ‘Clinical practice in COVID-19 patients’; ‘The importance of relationship’; ‘Navigating by sight’; and ‘Good always pays off’. Several differences emerged from the sentences of the HCWs, which require further investigation.

Conclusions:

Understanding the profession-specific experiences of the involved HCWs in facing the challenges of the COVID-19 pandemic is key for boosting reflections, research, and actions to adequately support each professional group.

Keywords:

COVID-19 outbreak; Healthcare workers; Perceptions and experiences; Qualitative content analysis

One-week longitudinal daily description of moral distress, coping, and general health in healthcare workers during the first wave of the COVID-19 outbreak in Italy: A quantitative diary study

Background and aim of the work:

The fluctuation from day to day within a working week of moral distress, coping, and general health of frontline healthcare workers (HCWs) in facing the challenges of the COVID-19 pandemic has been poorly studied. This study described the weekly fluctuation from day to day of moral distress, coping, and general health in frontline HCWs who worked during the first epidemic wave (May-June 2020) of the COVID-19 pandemic in Italy.

Methods:

This study has an intensive longitudinal design, and a convenience sampling procedure was employed to enroll physicians, nurses, allied health professions, and healthcare assistants. Data collection was performed using diary encompassed four sections: a socio-demographic form (required only at the baseline data collection) and three scales to assess moral distress, coping, and general health.

Results:

Results confirmed poor perceived health and mild moral distress in frontline HCWs, especially in HCWs with offspring, during the initial phases of the COVID-19 pandemic and the stability of their daily perception over a working week regarding moral distress, general health, and avoidant coping strategy, while approach coping strategy reported a slight fluctuation over time.

Conclusions:

Accordingly, on the one hand, these results confirm that outcomes regarding mental health and moral distress are pretty stable and provide insights, on the other hand, regarding the possible organizational interventions to support approach coping strategy as it seems more susceptible to variation over time. (www.actabiomedica.it)