Giancarlo Cicolini

Cyclooxygenase and prostaglandin synthases in atherosclerosis: Recent insights and future perspectives

Cyclooxygenase (COX) is the key enzyme in the conversion of arachidonic acid to prostanoids, lipid mediators involved in several physiological and pathological processes. Two COX isoenzymes have been characterized, COX-1 and COX-2, that differ in terms of regulatory mechanisms of expression, tissue distribution, substrate specificity, and preferential coupling to upstream and downstream enzymes. Both isoforms play fundamental roles in atherothrombosis; however, whereas the function of COX-1 in this setting is well established, the role of COX-2 remains unclear. Indeed, the intracellular pathways regulating COX-2 induction appear numerous and complicated, varying between cell types and cellular stimulus. In recent years a long series of studies has been performed with the aim of clarifying the role of COX-2 in atherothrombosis, with the major finding that the COX-2 expression pattern in arterial vessels may be associated with either protective or plaque-destabilizing phenotypes according to the downstream synthase that couples with COX-2. In this review we summarize the role of COX-2 as well as the different downstream synthases in atherosclerosis and atherothrombosis. Finally, we briefly review the controversial vascular effects on prostanoid inhibition by COX-2 inhibitors.

Electronic Cigarettes Efficacy and Safety at 12 Months: Cohort Study

Objective To evaluate the safety and efficacy as a tool of smoking cessation of electronic cigarettes (e-cigarettes), directly comparing users of e-cigarettes only, smokers of tobacco cigarettes only, and smokers of both. Design Prospective cohort study. Final results are expected in 2019, but given the urgency of data to support policies on electronic smoking, we report the results of the 12-month follow-up. Data Sources Direct contact and structured questionnaires by phone or via internet. Methods Adults (30–75 years) were included if they were smokers of ≥1 tobacco cigarette/day (tobacco smokers), users of any type of e-cigarettes, inhaling ≥50 puffs weekly (e-smokers), or smokers of both tobacco and e-cigarettes (dual smokers). Carbon monoxide levels were tested in a sample of those declaring tobacco smoking abstinence. Main Outcome Measures Sustained smoking abstinence from tobacco smoking at 12 months, reduction in the number of tobacco cigarettes smoked daily. Data Synthesis We used linear and logistic regression, with region as cluster unit. Results Follow-up data were available for 236 e-smokers, 491 tobacco smokers, and 232 dual smokers (overall response rate 70.8%). All e-smokers were tobacco ex-smokers. At 12 months, 61.9% of the e-smokers were still abstinent from tobacco smoking; 20.6% of the tobacco smokers and 22.0% of the dual smokers achieved tobacco abstinence. Adjusting for potential confounders, tobacco smoking abstinence or cessation remained significantly more likely among e-smokers (adjusted OR 5.19; 95% CI: 3.35–8.02), whereas adding e-cigarettes to tobacco smoking did not enhance the likelihood of quitting tobacco and did not reduce tobacco cigarette consumption. E-smokers showed a minimal but significantly higher increase in self-rated health than other smokers. Non significant differences were found in self-reported serious adverse events (eleven overall). Conclusions Adding e-cigarettes to tobacco smoking did not facilitate smoking cessation or reduction. If e-cigarette safety will be confirmed, however, the use of e-cigarettes alone may facilitate quitters remaining so. Registration Number NCT01785537.

Position of peripheral venous cannulae and the incidence of thrombophlebitis: an observational study.

AIM This paper is a report of a study conducted to investigate the most suitable location of peripheral venous cannulae to reduce the incidence of thrombophlebitis. BACKGROUND Peripheral intravenous cannulae are used for vascular access, but the site of insertion and size of the cannula could expose patients to local and systemic infectious complications. Small cannula size is an important factor in reducing the incidence of thrombophlebitis, but cannula location has not yet been studied. Evidence-based knowledge on how to prevent these complications is needed. METHOD An observational survey carried out was carried out in 2007 with 427 patients in one Italian hospital. A structured observation protocol was used to survey the frequency of thrombophlebitis and the relationship of location and size of peripheral intravenous cannulae. The variables evaluated were age, gender, cannula size and site of cannula location. Chi-square or Student t tests were used, and the adjusted odds ratios and relative 95% confidence intervals are reported. RESULTS The frequency of peripheral intravenous cannulae thrombophlebitis was higher in females (OR:1.91;CI:1.20-3.03;P < 0.006). The highest incidence was found in patients with cannulae inserted in the dorsal side of the hand veins compared to those with cannulae inserted in cubital fossa veins (OR:3.33;CI:1.37-8.07; P < 0.001). CONCLUSION The use of cubital fossa veins rather than forearm and hand veins should be encouraged to reduce the risk of thrombophlebitis in patients with peripheral intravenous cannulae.

Efficacy of a nurse-led email reminder program for cardiovascular prevention risk reduction in hypertensive patients: A randomized controlled trial §

BACKGROUND Many strategies have been evaluated to improve the prevention and control of cardiovascular (CVD) risk factors. Nursing telephonic and tele-counseling individualized lifestyle educational programs have been found to improve blood pressure control and adherence to lifestyle recommendation. This study tested the efficacy of a nurse-led reminder program through email (NRP-e) to improve CVD risk factors among hypertensive adults. METHODS All participants received usual CVD prevention and a guideline-based educational program. Subjects in the NRP-e group also received weekly email alerts and phone calls from a nurse care manager for 6 months. Emails contained a reminder program on the need for adherence with a healthy lifestyle based upon current guidelines. Follow-up visits were scheduled at 1, 3 and 6 months after enrollment; randomization was made centrally and blood samples were evaluated into a single laboratory. RESULTS The final sample consisted of 98 (control) and 100 (NRP-e) subjects (mean age 59.0 ± 14.5 years; 51.0% males). After 6 months, the following CVD risk factors significantly improved in both groups: body mass index, alcohol and fruit consumption, cigarette smoking, adherence to therapy hours, systolic and diastolic blood pressure, fasting blood glucose, low-density lipoproteins (LDL) and total cholesterol, triglycerides, and physical activity. In the NRP-e group, however, the prevalence of several behaviors or conditions at risk decreased significantly more than in the control group: obesity (-16%), low fruit consumption (-24%), uncontrolled hypertension (-61%), LDL (-56%), and total cholesterol (-40%). CONCLUSIONS The NRP-e improved a range of CVD risk factors. The program had low costs, required only an average of <20 min per day in addition to normal practice, and may deserve further evaluation for the inclusion among existing care management approaches.

In)accuracy of blood pressure measurement in 14 Italian hospitals

Objectives: The diagnosis and control of hypertension depend on accurate measurement of blood pressure (BP). The literature on the accuracy of BP recording by health professionals is, however, limited, and no study directly interviewed patients in the hospital setting. This multicenter cross-sectional study aimed at evaluating the compliance to current recommendations on BP measurement by health professionals directly from patients and to investigate potential predictors of higher quality in BP recording. Methods: A trained nurse interviewed a random sample of adult patients hospitalized for an ordinary admission (except in the emergency room) lasting more than one night, without mental disorder, who had their BP routinely measured by the hospital personnel less than 3 h before. The questionnaire contained 15 items on the main procedures that are common to current guidelines. Results: Fourteen public hospitals from seven regions of Italy participated, and 1334 questionnaires were collected. Nine of the recommended practices were followed in the majority (>70%) of BP recordings, whereas some others were infrequent or rare: in 98.6, 82.2 and 81.1% of the participants, respectively, the arm circumference was never recorded, BP was measured only once, and BP was never recorded in both arms. Overall, 10 or more recommended procedures were followed during 33.4% recordings. At multivariate analysis, physicians were less likely than nurses to provide a more accurate BP measurement. Conclusions: The operators compliance to some recommendations in BP measurement is unacceptably low. This survey provides detailed indications for medical directors on the procedures and settings to prioritize in educational programs, which are definitely needed.

Percutaneous and mucocutaneous exposures in nursing students: an Italian observational study.

PURPOSE To investigate occupational exposures to biological material potentially infected by blood-borne viruses in nursing student population during the course years. DESIGN AND METHODS An observational retrospective study was designed. Data were collected in May 2007. Two-thousand-two-hundred-fifteen nursing students from the 3 years of degree course were enrolled in the four Italian universities. A structured questionnaire was constructed and was given out unannounced to nursing students in four universities on a randomly chosen day. The likelihood of association between nursing student exposure and certain assumed risk factors was measured. FINDINGS The exposure risk is associated with each study year of nursing students. Specifically, the probability of accidental exposure is reduced significantly with the increase of clinical skills during the training period. The risk for exposure in the 1st year students appears significantly higher than in those of the next years (odds ratio [OR] 1.465; 95% confidence interval [CI] 1.105-1.943). Data highlighted a gradual increase of bio-safety knowledge in nursing students from the 1st to the 3rd years of study. However, a statistically significant association exists only between awareness of a correct use of gloves and exposure risk (OR 0.435; 95%CI 0.227-0.834). Mucocutaneous exposures are more frequent than percutaneous exposures (62.2%), and the hollow-bore needle is the device most often involved. In 42.5% of cases, accidental exposures occurred when nursing students are working alone in a medical ward or surgery area. CONCLUSIONS During their clinical training, nursing students can encounter a real risk for percutaneous and mucocutaneous exposures to blood potentially infected with blood-borne viruses. However, this risk is reduced with an increase in clinical skills. CLINICAL RELEVANCE Results show that some new strategies are necessary for exposure risk reduction such as development of simulation laboratories for nursing practice and the adequate presence of tutors in clinical training education.

Phlebitis risk varies by peripheral venous catheter site and increases after 96 hours: a large multi‐centre prospective study

AIMS This multi-centre prospective field study evaluated whether peripheral venous catheter site of insertion influences the risk of catheter-related phlebitis. Potential predictors of phlebitis were also investigated. BACKGROUND Millions of patients worldwide use peripheral venous catheters, which frequently cause local complications including phlebitis, infection and obstruction. Although phlebitis predictors have been broadly investigated, uncertainties remain on the potential effect of cannulation anatomical site, duration and the appropriate time for catheter removal. DESIGN A prospective cohort design was carried out from January-June 2012. METHODS The clinical course of each patient who received a new peripheral venous catheter for any cause in five Italian hospitals was followed by trained nurses until catheter removal. The presence of phlebitis was assessed every 24 hours using the Visual Infusion Phlebitis score. Analyses were based upon multilevel mixed-effects regression. RESULTS The final sample consisted of 1498 patients. The average time for catheters in situ was 65·6 hours and 23·6% of the catheters were in place beyond 96 hours. Overall phlebitis incidence was 15·4%, 94·4% of which were grade 1. The likelihood of phlebitis independently increased with increasing catheter duration, being highest after 96 hours. Compared with patients with catheter placed in the dorsum of the hand (22·8% of the sample), those with the catheter located in the antecubital fossa (34·1%) or forearm were less likely to have a phlebitis of any grade. CONCLUSIONS Antecubital fossa and forearm veins may be preferential sites for peripheral venous cannulation. Our results support Centers for Disease Control and Prevention recommendations to replace catheters in adults no later than 96 hours. A relevant proportion of healthcare personnel did not adhere to such guidelines - more attention to this issue is required.

Differences in Blood Pressure by Body Position (Supine, Fowler's, and Sitting) in Hypertensive Subjects

BACKGROUND Although blood pressure (BP) differences from supine to sitting position have long been recognized, limited data are available on other commonly used body positions. We performed a cross-sectional study to compare BP values obtained in supine, sitting, and Fowlers positions in essential hypertensive subjects. METHODS Systolic BP (SBP) and diastolic BP (DBP) were recorded using an automatic oscillometric device. Nine measurements were taken: three measurements, in random order, in supine, Fowlers, and sitting position. Two generalized estimating equations models were used to evaluate potential predictors of SBP and DBP adjusting for heart rate and measurement order. RESULTS The sample consisted of 250 subjects (mean age 66.3 ± 13.4 years; 44.4% males). Measured in supine, Fowlers, and sitting position, mean SBPs were 139.3 ± 14.0; 138.1 ± 13.8; 137.2 ± 13.7 mm Hg, respectively, and mean DBPs 80.1 ± 9.1; 81.9 ± 9.4; 83.0 ± 9.6 mm Hg, respectively. At multivariate analysis, mean SBP significantly decreased if measured in Fowlers and sitting positions, as compared to supine. In contrast, DBP significantly increased. A relevant proportion of subjects showed large differences (≤ or ≥10 mm Hg) in mean SBP across positions: i.e., 30.0% comparing supine vs. sitting SBP. An even higher prevalence of large differences was observed according to the measurement order within the same positions, with no univocal direction (random variation). CONCLUSIONS Fowlers position may represent a valid alternative to sitting and supine positions for BP measurement in clinical practice. BP random variability was found to be large regardless of body position, reinforcing the need for operators to closely follow current guidelines that recommend ≥2 recordings at each measurement.

A structured telephonic counselling to promote the exclusive breastfeeding of healthy babies aged zero to six months: A pilot study

This pilot study aimed to test the effectiveness of a structured telephonic counselling (STC) on exclusive breastfeeding (EB) on healthy babies. The study was carried out on 114 primiparous women from February to March 2009. After randomization, women were divided into two groups: 55 receiving STC and 59 receiving conventional counselling. At 1, 3 and 5 months after delivery, a nurse specialist evaluated the EB rates, the influence of mothers educational level and employment status on EB. Breastfeeding rates in STC were higher compared to conventional counselling (P < 0.01); resuming work was not an EB discouraging variable as 74.5% women in the STC resumed work vs. 54.2% of the conventional counselling. Breastfeeding promotion should start during pregnancy, advising women about benefits for the child in receiving human milk. STC should be used to improve EB in primiparous women.

Physical assessment techniques performed by Italian registered nurses: a quantitative survey

AIMS AND OBJECTIVES The aims of the study were to describe which of the core techniques of the physical assessment are regularly performed by a sample of Italian nurses, and to investigate the potential predictors of a more complete examination. BACKGROUND Physical examination is among the essential tasks of nursing professionals, who are requested to perform a correct and complete physical assessment. DESIGN Cross-sectional survey. METHODS The study was performed between August 2013 and January 2014 in 17 Italian regions. A total of 1182 questionnaires were collected. RESULTS Most participants were females (age range 41-50 years), and worked in Internal Medicine, Intensive Care and Surgical hospital units. Of the 30 core techniques that are currently taught and performed according to the Italian Baccalaureate degree requirements, 20 were routinely performed, 6 were seldom used and 4 were learnt but almost never performed (auscultation of lung, heart and bowel sounds and spine inspection). Graduate and postgraduate nurses, working in Intensive Care Units and Nursing Homes, were more prone than the others to carry out a more complete physical assessment. CONCLUSIONS The skills to perform a physical assessment are suboptimal among this sample of Italian nurses. Health and educational providers should pose more attention and efforts to provide nurses with an acceptable training in physical examination practice. RELEVANCE TO CLINICAL PRACTICE This study describes the specific physical techniques performed by nurses in real practice and provides information on which skills require more attention in nursing educational programmes.