Alberto Dal Molin

The late complications of totally implantable central venous access ports: The results from an Italian multicenter prospective observation study☆

PURPOSE The principal aim of this study is to analyze the incidence of late complications in oncologic patients with totally implanted central venous access ports. METHODS A prospective multicenter observational study was conducted in 26 Italian oncologic outpatient clinics. 1076 cancer patients with Totally Implanted Central Venous Access Ports (TIAP) were observed. 515 devices were observed in patients under treatment and 561 in patients who went to the outpatient clinic only for flushing. RESULTS Late complications observed in patients under treatment were: 3 pocket infections (0.09/1000 days of port observation), 1 cutaneous infection (0.03/1000 days of port observation), 8 occlusions (0.24/1000 days of port observation) and 12 others. In patients using the device only for flushing we observed 4 cases of device related bacteremia (0.04/1000 days of port observation), 1 pocket infection (0.01/1000 days of port observation), 1 cutaneous infection (0.01/1000 days of port observation), 3 occlusions (0.03/1000 days of port observation) and 7 other complications. CONCLUSIONS The low incidence of complications suggests that TIAP is safe and reliable for long term intermittent venous access. Our results support the use of TIAP in the oncology patients.

Flushing the central venous catheter: is heparin necessary?

Purpose The aim of this systematic review was to assess the efficacy of heparin flushing in the lock of central venous catheters. Methods We searched MEDLINE and CINAHL databases. Eligible studies were randomized controlled trials evaluating the use of heparin versus normal saline or other solution in the flushing of central catheter among adult patients. No language restrictions were applied. Two reviewers independently screened titles and abstracts in order to identify relevant publications. The same two reviewers retrieved and evaluated full texts. Parameter estimates regarding catheter occlusion were pooled using network meta-analysis with Bayesian hierarchical modeling. Results We identified 462 references. Eight studies were included. There was no evidence that heparin was more effective than normal saline in reducing occlusions. It was unclear whether urokinase and lepirudin were more effective than heparin in reducing occlusions. Vitamin C solution does not appear to prolong catheter patency. Conclusions There is no evidence of a different effectiveness between heparin flushing and normal saline or other solutions in reducing catheter occlusions. Due to the little and inconclusive evidence available in this field, further studies might be necessary.

Normal saline versus heparin solution to lock totally implanted venous access devices: Results from a multicenter randomized trial

PURPOSE Our aim was to determine the non-inferiority of normal saline flushing compared to heparin flushing in maintaining the patency of totally implanted venous access devices (TIVADs). METHOD Four hundred and thirty patients were recruited from 14 Italian centres. Patients were randomized to heparin group or to normal saline group. The primary outcome of the study was TIVAD occlusion. RESULTS After randomisation, 203 patients were assigned to normal saline group and 212 to heparin group. Median follow up time was 204 days in normal saline group and 294 in the heparin group. We observed 24 withdrawal occlusions (5.78%): 10 in the heparin group and 14 in the normal saline group. One total occlusion was observed in the normal saline group. Taking as reference the arm treated with heparin, the absolute risk difference was 2.67 with the 90% CI including the non - inferiority margin of 4%. No significant difference between hazards of occlusion was found. CONCLUSIONS This study failed to demonstrate that normal saline flushing is not inferior to heparin flushing, even if a significant difference between the two treatments was not found. The use of heparin is controversial and other prospective trials are necessary in this field. TRIAL REGISTRATION EudraCT number: 2009-013620-22.

Evidence-based criteria for the choice and the clinical use of the most appropriate lock solutions for central venous catheters (excluding dialysis catheters): a GAVeCeLT consensus

Background The most appropriate lock solution for central venous access devices is still to be defined. GAVeCeLT – the Italian group for venous access devices – has developed a consensus on the evidence-based criteria for the choice and the clinical use of the most appropriate lock solution for central venous catheters (excluding dialysis catheters). Method After the constitution of a panel of experts, a systematic collection and review of the literature has been performed, focusing on clinical studies dealing with lock solutions used for prevention of occlusion (heparin, citrate, urokinase, recombinant tissue plasminogen activator [r-TPA], normal saline) or for prevention of infection (citrate, ethanol, taurolidine, ethylene-diamine-tetra-acetic acid [EDTA], vancomycin, linezolid and other antibiotics), in both adults and in pediatric patients. Studies on central lines used for dialysis or pheresis, on peripheral venous lines and on arterial lines were excluded from this analysis. Studies on lock solutions used for treatment of obstruction or infection were not considered. The consensus has been carried out according to the Delphi method. Results The panel has concluded that: (a) there is no evidence supporting the heparin lock; (b) the prevention of occlusion is based on the proper flushing and locking technique with normal saline; (c) the most appropriate lock solution for infection prevention should include citrate and/or taurolidine, which have both anti-bacterial and anti-biofilm activity, with negligible undesired effects if compared to antibiotics; (d) the patient populations most likely to benefit from citrate/taurolidine lock are yet to be defined. Conclusions The actual value of heparinization for non-dialysis catheters should be reconsidered. Also, the use of lock with substances with anti-bacterial and anti-biofilm activity (such as citrate or taurolidine) should be taken into consideration in selected populations of patients.

Screening tools for identification of elder abuse: a systematic review

AIMS AND OBJECTIVES To review the efficacy and accuracy of tools administered to older people, intended to detect and measure elder abuse. BACKGROUND The mistreatment of older people represents a widespread problem, with exponential growth risk, especially considering the progressive ageing of the world population. It could have serious consequences for the victims health if not recognised early, denounced and stopped. Abuse is often undetected by service providers because there is a lack of awareness surrounding the magnitude of the problem. Education and formal training in the signs of abuse are also generally poorly developed, as are reporting procedures which would lead to further investigation. DESIGN Systematic review. METHODS Comprehensive database searches of MEDLINE, Cochrane, EMBASE and Scopus were undertaken. Screening of 695 articles resulted in 11 included. Appraisal and analysis using PRISMA Statement and STROBE checklist were undertaken. RESULTS Eleven screening tools have been presented: H-S/EAST, VASS, EASI, CASE, BASE, E-IOA, EAI, EPAS, CPEABS, OAPAM and OAFEM, all aimed at healthcare professional or, in some cases, expected to be specifically used by nurses. CONCLUSIONS The fundamental function of any assessment instrument is to guide through a standardised screening process and to ensure that signs of abuse are not missed. Several tools have been tested; some have demonstrated a moderate to good internal consistency and some have been validated to allow an early identification. None have been evaluated against measurable violence or health outcomes. RELEVANCE TO CLINICAL PRACTICE Nurses and all healthcare providers should screen patients routinely. However, we are not able to recommend a single tool as the selection and implementation has to be appropriate to the setting. Furthermore, the study population and the possibility of using multiple tools in combination should be taken into consideration, to assess all the aspects of violence.

Communication with the public in the health-care system: a descriptive study of the use of social media in Local Health Authorities and public hospitals in Italy

INTRODUCTION In 2010 the Italian Ministry of Health set out recommendations for the use of social technology and Web 2.0, inviting organisations within the Italian national health service (Servizio Sanitario Nazionale, SSN) to equip themselves with instruments. OBJECTIVES 1. to ascertain how many local health authorities (Aziende Sanitarie Locali, ASL) and public hospitals have a presence on the most widely used social media websites in Italy: Facebook, Twitter and YouTube; 2. to find out how well the Facebook, Twitter and YouTube pages of ASLs and public hospitals are known among the general population; 3. to find out how ASLs and public hospitals engage with the general public on social media sites. MATERIALS AND METHODS The websites of all ASLs and public hospitals across the country were visited to look for the icons of the social media sites under examination. The data considered were publicly available upon access. RESULTS A total of 245 websites were analysed. 7.34% ASLs and hospitals had social media accounts. 8 organisations had an account on all three of the social media sites considered in the study. CONCLUSIONS The results show a low presence of ASLs and hospitals on social media. Other studies are needed in this field.

Bed rest for preventing complications after transfemoral cardiac catheterisation: a protocol of systematic review and network meta-analysis.

BackgroundTransfemoral cardiac catheterisation is an invasive medical procedure used for therapeutic or diagnostic purposes. Postoperative bed rest can prevent a number of complications such as bleeding and haematoma formation and can result in side effects such as back pain and urinary discomfort. Currently, there is no consensus regarding the optimal length of bed rest. Our objective is to assess the effects of post-catheterisation length of bed rest on bleeding and haematoma, other vascular complications, patient symptoms and patient discomfort, among patients who underwent transfemoral cardiac catheterisation.MethodsWe wrote this protocol in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols statement. We defined the search query by using the PICO framework (Population: Patients undergoing cardiac catheterisation; Intervention: early mobilisation; Comparison: late mobilisation; Outcomes: early and late complications). We will search six biomedical databases and five online registries to obtain both published and unpublished studies. We will include randomised controlled trials and quasi-randomised controlled trials, and their quality will be independently appraised with the Cochrane Effective Practice and Organisation of Care criteria for quality assessment. We will carry out a pairwise meta-analysis and network meta-analysis to estimate the overall intervention effects from both direct and indirect comparisons.DiscussionThis review may have considerable implications for practice and help to achieve an effective and efficient management of patients who underwent cardiac catheterisation. This review will be grounded in an expanded search of 11 resources and will employ innovative statistical methods such as network meta-analysis.Systematic review registrationPROSPERO registration number: CRD42014014222.

Hospital Discharge: Results From an Italian Multicenter Prospective Study Using Blaylock Risk Assessment Screening Score

PURPOSE To analyze the predictive validity and reliability of the Blaylock Risk Assessment Screening Score (BRASS) Index in a large group of patients. METHODS Prospective multicenter observational study was conducted in six Italian hospitals. Data were collected in three phases. FINDINGS Seven hundred eleven patients were recruited. The mean length of hospitalization for low-risk patients was significantly shorter than those in the medium and high-risk groups. Patients with a BRASS Index lower than 10, unlike those with a higher BRASS Index, were mainly discharged home. CONCLUSIONS Our results indicate that the BRASS Index is useful to identify patients at risk for prolonged hospitalization. CLINICAL RELEVANCE The use of a validated BRASS instrument can be useful to screen the patients, improving individual discharge planning.

The Impact of the Primary Nursing Model on Cultural Improvement: A Mixed-Method Study

Evaluating the implementation of care models such as Primary Nursing requires assessment of both short-term and long-term outcomes. In a hospital in Piemonte, Italy, a mixed-method time-series study was conducted to assess if and how the organizational culture of nurses changed in relation to the implementation of a new organizational model of care. Instruments used included the Condition of Work Effectiveness Questionnaire (CWEQ II) and an investigator-developed questionnaire to evaluate perceptions of dimensions consistent with Primary Nursing. Results showed a significant culture change over time related to the implementation of Primary Nursing, mainly in terms of nurses’ understanding of their professional role specifications. In addition, the results supported a relationship between being involved in the project implementation and the procedural and cultural approach adopted.

Impact of a Clinical Therapeutic Intervention on Pain Assessment, Management, and Nursing Practices in an Intensive Care Unit: A before-and-after Study

Background: Accurate pain assessment and management constitute a major challenge for medical and nursing staff in intensive care units (ICUs). A distinct recollection of pain is reported by high proportions of ICU patients. Purpose: A clinical therapeutic intervention directed at improving pain assessment and management in critically ill patients who are unable to communicate was implemented at an Italian ICU. Methods: In this before‐and‐after study, data were collected before (T0) and after (T1) the adoption of a protocol involving pain assessment with an ad hoc behavioral pain scale and the administration of analgesics, rather than sedatives, to patients with intermediate to high pain scores. Results: The main outcome measure was pain recollection a year after discharge; secondary outcome measures were the use and doses of sedatives and analgesics. A significantly (p = .037) smaller proportion of patients treated after protocol adoption recollected feeling severe pain compared with patients treated before the protocol was introduced. This group also received significantly (p < .001) fewer sedatives and significantly (p = .0028) more anti‐inflammatory drugs and analgesics on an “as needed” basis. The administration of strong analgesics was similar in the two groups. The intervention was implemented in 70.5% of patients with intermediate to high pain scores. Conclusions: Appropriately trained ICU nurses have the potential to help adopt pain relief and prevention measures during nursing care and to contribute to the successful management of sedation and analgesia. Further studies of larger patient samples are needed to monitor the stability of results over time and to explore the efficacy of the approach in other populations, such as pediatric and neonatal ICU patients.