Anne Destrebecq

Physical Training and Noninvasive Ventilation in COPD Patients: A Meta-Analysis

BACKGROUND: Exercise training improves both exercise tolerance and quality of life in patients with COPD. The intensity of exercise training is crucial to achieve a true physiologic effect. However, in COPD patients, exertional dyspnea and leg fatigue mean that the patient cannot maintain intensity of training for enough time to yield a physiologic training effect. The use of noninvasive ventilation (NIV) support has been proposed as an alternative strategy to improve exercise tolerance and respiratory and cardiovascular performances. The first aim of our meta-analysis was to evaluate exercise training with NIV in terms of physiologic effects after the completion of a pulmonary rehabilitation program. The second aim was to investigate the dose-response relationship between physical improvement and training intensity. METHODS: Literature research was performed using MEDLINE, Embase, and CINAHL. Meta-analysis and meta-regressions were performed using random effects models. RESULTS: Eight studies provided a proper description of a training schedule in stable COPD patients. A similar effect between NIV and placebo was observed for the outcomes considered despite differences between studies. However, subjects experienced a relevant and statistically significant improvement after rehabilitation for almost all of the outcomes considered. Heart rate (6 beats/min [95% CI 0.94–11.01], P = .02), work load (9.73 W [95% CI 3.78–15.67], P < .001), and oxygen consumption (242.11 mL/min [95% CI 154.93–329.9], P < .001) significantly improved after training. Improvements in heart rate and work load were significantly correlated to training intensity. CONCLUSIONS: Given the small number of available studies, the small sample sizes, and the complete absence of power calculation, we think that this topic deserves a more in-depth investigation. Randomized clinical trials with larger sample sizes based on statistical power calculations and designed to investigate the effect of training duration and intensity on rehabilitation are needed to confirm results in this important field.

Tolerance of enteral feeding: from quantity to quality of gastric residual volume?

Dear Sir: Nutritional support is essen-tial in the management of critically illpatients; enteral nutrition is preferredto parenteral [1], because the lattermay favour immune compromise andinfections, is more costly, and leads toadverse outcome in some subsets ofpatients. Moreover, many studies haveshown that this evidence is even morepronounced with the use of early ent-eral nutrition [2].The major concerns with its use arethe potential development of upperdigestive intolerance (UDI, i.e. thepresence of gastric residual volumes,GRV, of 150–500 ml in two consec-utive measurements, or[500 ml, orvomiting) [3] and the risk of aspira-tion of gastric content andpneumonia. Recently, some authorshave demonstrated that GRVs arepoor markers of gastric aspiration inenterally fed, critically ill patients [4],downsizing their role in the develop-ment of aspiration pneumonia.To the best of our knowledge thereare no reports on the role that thepresence of air in the stomach mayplay in the development of aspiration.The objective of our study was to testthe association between UDI, thepresence of air, and the developmentof pneumonia in enterally fed, criti-cally ill patients.We enrolled all adult patientsthe last year, received enteral nutri-tion and stayed more than four days.Admission and main outcome data forthe 78 patients are shown in Table 1.During ICU stay 43 (55.1%) receivedvasoactives, 44 (56.4%) opioids, and17 (21.8%) prokinetics. Ventilatorysupport was provided for 78.6% days,and CPAP for 9.9% days; 11.6% dayswere on spontaneous ventilation.Sedation was endovenous in 4.1%days, totally enteral [5] on 78.1%days, and mixed enteral/parenteral on17.8% days; as a result mean RASSscore was -0.85 ± 1.43 (52.1% dayswere on RASS 0). Patients were in asemi-recumbent position (mean headinclination 35.6 ± 8.9 ). Energysupply was, on average,17.8 ± 6.7 kcal/kg per day; time tostart of nutrition from admission was6 [4–16] h, and we took 72[46–100] h to reach full support.A total of 2695 GRV measure-ments were performed (every fourhours, or every two hours in presenceof GRV or air). On 339 occasionsGRV was found (on average158 ± 117 ml); 226 times there wasair (mean volume: 140 ± 110 ml).UDI was developed by 11 patients,whereas 15 patients were defined as‘‘aerophagic’’ ([2 consecutive find-ings of at least 150 ml of air).Developing of pneumonia during ICUstay was not associated with UDI(P = 0.782), but occurred signifi-cantly more frequently in aerophagicpatients (odds-ratio 4.0 ± 2.7,P = 0.041). The presence of air wasnot associated with UDI (P = 0.132).Consistent with the literature, ourstudy reconfirms the poor value ofUDI as a risk factor for the develop-ment of aspiration pneumonia, andsuggests a potential role for thepresence of air in the stomach. Thisfinding has a physiopathologicalrationale, because air tends to locatein the upper parts, thus in critically ill,semi-recumbent patients it may con-centrate against the loweroesophageal sphincter, facilitatingreflux of gastric content. Furtherstudies are needed to better elucidatethis relationship, and to find thedeterminants of air presence.

Reducing Urine Leakage After Radical Retropubic Prostatectomy: Pelvic Floor Exercises, Magnetic Innervation or No Treatment? A Quasi-Experimental Study

Background In Italy, nurses can use pelvic floor muscle exercises (PFMEs) and extracorporeal magnetic innervation (ExMI) to treat urinary incontinence after radical retropubic prostatectomy (RRP). The efficacy of these treatments remains unclear. Purpose: To compare PFMEs, ExMI, in the management of post‐RRP urinary incontinence. Methodology: This study compared PFMEs versus no treatment in reducing bladder continence difficulties, and PFMEs versus ExMI in reducing urine leakage. A total of 87 patients were treated with PFMEs, 23 with ExMI; 22 refused rehabilitation (control group). Findings Three months after RRP, both interventions reduced the International Prostate Symptom Score, when compared to control group. After 6 months, no significant differences between the treatments were found (p = .8346). After a complete ExMI treatment (6 weeks), 63.88% lost less than 10 grams of urine per day (32.73% in the PFMEs group, p < .0001). Conclusions PFMEs are useful up to the 3rd month after surgery; ExMI reduces leakages faster than PFMEs.

[Validation of the Italian Clinical Learning Environment Instrument (SVIAT): study protocol].

UNLABELLED . Validation of the Italian Clinical Learning Environment Instrument (SVIAT): study protocol. INTRODUCTION Nursing students obtain most of their university credits in internship environments whose quality can affect their clinical learning. Several tools are available to measure the quality of the clinical learning environment (CLE) as perceived by students: these instruments developed in other countries, were validated in Italian but do not discriminate those CLEs capable (or not) to promote significant clinical learning. AIM To validate an instrument to measure the capability of the CLE to generate clinical learning; the secondary aim is to describe the learning environments as perceived by nursing students according to individual course site and tutorial models adopted. METHODS The study will be developed in three phases: a) instrument development and pilot phase, b) validation of the psychometric properties of the instrument and c) description of the CLEs as perceived by the students including factors/item confirmed in the validation process. Expected outcomes. A large validation, with more than 8,000 participating students is expected; the construct under lying will be confirmed through exploratory and confirmatory factor analysis and will report high internal consistency; the instrument will report also a high test-retest and inter-rater reliability; in addition, the instrument will demonstrate predictive ability by discriminating those units able (or not) to activate effective learning processes.

Determinazione del valore predittivo di una scala di valutazione del rischio di cadute in pazienti anziani ospedalizzati

Obiettivo. Le cadute costituiscono un evento avverso di rilievo negli ospedali, perche possono condurre a conseguenze gravi, soprattutto nei pazienti anziani. Sebbene in letteratura siano stati suggeriti numerosi strumenti per la valutazione del rischio di caduta, il loro livello di predittivita non e soddisfacente. Lo studio proposto e stato condotto per valutare sensibilita, specificita, valore predittivo positivo/negativo della scala FRASS (Fall Risk Assessment Scoring System). Pazienti e metodi. Tutti i pazienti di eta >65 anni, ricoverati, dal 1 novembre 2007 al 31 gennaio 2008 presso 7 Unita Operative (medicina o specialita mediche) dell’Azienda Ospedaliera Ospedali Riuniti di Bergamo, sono stati valutati per il rischio di cadute. Risultati. Sono stati valutati 564 pazienti; 16 (2.8%), sono caduti. La sensibilita e la specificita della FRASS sono risultate basse (50% e 59% rispettivamente). Questo potrebbe far supporre che la FRASS classifichi a rischio pazienti che in realta potrebbero non esserlo mentre sovrastimi il numero di quelli ritenuti non a rischio, che poi incorrono in cadute. Conclusioni. I risultati emersi, sembrano non raccomandare l’utilizzo delle scale di FRASS nell’ambito locale

Opportunity to discuss ethical issues during clinical learning experience

Background: Undergraduate nursing students have been documented to experience ethical distress during their clinical training and felt poorly supported in discussing the ethical issues they encountered. Research aims: This study was aimed at exploring nursing students’ perceived opportunity to discuss ethical issues that emerged during their clinical learning experience and associated factors. Research design: An Italian national cross-sectional study design was performed in 2015–2016. Participants were invited to answer a questionnaire composed of four sections regarding: (1) socio-demographic data, (2) previous clinical learning experiences, (3) current clinical learning experience quality and outcomes, and (4) the opportunity to discuss ethical issues with nurses in the last clinical learning experience (from 0 – ‘never’ to 3 – ‘very much’). Participants and research context: Participants were 9607 undergraduate nursing students who were attending 95 different three-year Italian baccalaureate nursing programmes, located at 27 universities in 15 Italian regions. Ethical considerations: This study was conducted in accordance with the Human Subject Research Ethics Committee guidelines after the research protocol was approved by an ethics committee. Findings: Overall, 4707 (49%) perceived to have discussed ethical issues ‘much’ or ‘very much’; among the remaining, 3683 (38.3%) and 1217 (12.7%) students reported the perception of having discussed, respectively, ‘enough’ or ‘never’ ethical issues emerged in the clinical practice. At the multivariate logistic regression analysis explaining 38.1% of the overall variance, the factors promoting ethical discussion were mainly set at the clinical learning environment levels (i.e. increased learning opportunities, self-directed learning, safety and nursing care quality, quality of the tutorial strategies, competences learned and supervision by a clinical nurse). In contrast, being male was associated with a perception of less opportunity to discuss ethical issues. Conclusion: Nursing faculties should assess the clinical environment prerequisites of the settings as a context of student experience before deciding on their accreditation. Moreover, the nursing faculty and nurse managers should also enhance competence with regard to discussing ethical issues with students among clinical nurses by identifying factors that hinder this learning opportunity in daily practice.

The Italian Version of the Opening Minds Stigma Scale for Healthcare Providers: Validation and Study on a Sample of Bachelor Students

AbstractPrejudices on psychiatric disorders frequently turn into stigmatizating attitudes, also among health care providers. The Opening Minds Stigma Scale for Health Care Providers (OMS-HC) was introduced in 2012 to measure stigma. No Italian versions of this tool exist so far. We wanted to investigate stigma among healthcare students in Italy, and to prepare an Italian version of the scale. A multicentric, cross-sectional study was conducted on a sample of Nursing, Physiotherapy, Occupational therapy, and Dietistics students. The Italian version of the scale was obtained through back-translation.
561 students were enrolled, median age 21 years, IQR [20;23], 62.22% females (n = 349). 262 students declared having met subjetcs affected by psychiatric disorders during their training; 50 had one or more psychiatric disorders in their lives. The Italian version proved valid and reliable. Older students had lower stigma scores. No differences existed between stigma scores according to gender and personal experience of mental illness.

Relationship between capillary refill time at triage and abnormal clinical condition: a prospective study.

Background: Capillary refill time has been studied in literature as a perfusion indicator. Two pilot studies have proposed possible reference values in healthy adults. No data exist regarding capillary refill time as an indicator of abnormal clinical conditions in adults, which might be of help for triage nurses. Objective: We wanted to assess if any relationships existed, between altered capillary refill time and abnormal clinical conditions in the emergency department. We investigated relations between capillary refill time and vital signs recorded in triage and blood tests, by analyzing the clinical records. Mortality at 24 hours, 7 days and over 14 days was investigated by calling the patients after discharge. Method: Observational, single-center study on a sample of consecutive patients aged ≥ 18 years in the Emergency Department of a major Milan hospital, from June to October 2014. Multivariate logistic regression was used to investigate the impact of clinical variables on capillary refill time. Results: 1001 patients were enrolled, aged 59 ± 21 (473 aged 65 or more). Longer refill times were found in patients admitted to hospital units after medical consultations in the emergency department compared to those discharged or sent to outpatients. In elderly patients, statistically significant association was found between increased capillary refill time and sepsis (sensitivity 100%, specificity 83.33%, area under the receiver operating characteristics curve 65.95% CI 47-83), oxygen saturation, mean blood pressure, and lactates. In persons aged 45 to 64, altered refill times were associated with abnormal values of glicemia, platelets, and urea. Conclusion: Capillary refill time can be used by nurses at triage as a complementary parameter to normal vital signs. This is one of the few studies investigating refill time in adult patients.

Lo strumento italiano di misurazione della qualità dell’apprendimento clinico degli studenti infermieri. [The Italian instrument evaluating the nursing students clinical learning quality]

. The Clinical Learning Quality Evaluation Index for nursing students. INTRODUCTION The Italian nursing programs, the need to introduce tools evaluating the quality of the clinical learning as perceived by nursing students. Several tools already exist, however, several limitations suggesting the need to develop a new tool. AIM A national project aimed at developing and validating a new instrument capable of measuring the clinical learning quality as experience by nursing students. METHODS A validation study design was undertaken from 2015 to 2016. All nursing national programs (n=43) were invited to participate by including all nursing students attending regularly their clinical learning. The tool developed based upon a) literature, b) validated tools already established among other healthcare professionals, and c) consensus expressed by experts and nursing students, was administered to the eligible students. RESULTS 9606 nursing in 27 universities (62.8%) participated. The psychometric properties of the new instrument ranged from good to excellent. According to the findings, the tool consists in 22 items and five factors: a) quality of the tutorial strategies, b) learning opportunities; c) safety and nursing care quality; d) self-direct learning; e) quality of the learning environment. CONCLUSIONS The tool is already used. Its systematic adoption may support comparison among settings and across different programs; moreover, the tool may also support in accrediting new settings as well as in measuring the effects of strategies aimed at improving the quality of the clinical learning.: . The Clinical Learning Quality Evaluation Index for nursing students. INTRODUCTION: The Italian nursing programs, the need to introduce tools evaluating the quality of the clinical learning as perceived by nursing students. Several tools already exist, however, several limitations suggesting the need to develop a new tool. AIM: A national project aimed at developing and validating a new instrument capable of measuring the clinical learning quality as experience by nursing students. METHODS: A validation study design was undertaken from 2015 to 2016. All nursing national programs (n=43) were invited to participate by including all nursing students attending regularly their clinical learning. The tool developed based upon a) literature, b) validated tools already established among other healthcare professionals, and c) consensus expressed by experts and nursing students, was administered to the eligible students. RESULTS: 9606 nursing in 27 universities (62.8%) participated. The psychometric properties of the new instrument ranged from good to excellent. According to the findings, the tool consists in 22 items and five factors: a) quality of the tutorial strategies, b) learning opportunities; c) safety and nursing care quality; d) self-direct learning; e) quality of the learning environment. CONCLUSIONS: The tool is already used. Its systematic adoption may support comparison among settings and across different programs; moreover, the tool may also support in accrediting new settings as well as in measuring the effects of strategies aimed at improving the quality of the clinical learning.

A tool for assessing the quality of nursing handovers: a validation study

AIM Handover, in particular between two shifts, is a crucial aspect of nursing for patient safety, aimed at ensuring continuity of care. During this process, several factors can affect quality of care and cause errors. This study aimed to assess quality of handovers, by validating the Handoff CEX-Italian scale. METHOD The scale was translated from English into Italian and the content validity index was calculated and internal consistency assessed. The scale was used in several units of the San Paolo Teaching Hospital in Milan, Italy. RESULTS A total of 48 reports were assessed (192 evaluations). The median score was 6, interquartile range (IQR) [5;7] and was not influenced by specific (p=0.21) or overall working experience (p=0.13). The domains showing the lowest median values (median=6, IQR [4;8]) were context, communication, and organisation. Night to morning handovers obtained the lowest scores. CVI-S was 0.96, Cronbachs alpha was 0.79. DISCUSSION The Handoff CEX-Italian scale is valid and reliable and it can be used to assess the quality of nurse handovers.