Laura Rasero

Digital ulcers in scleroderma: staging, characteristics and sub-setting through observation of 1614 digital lesions

OBJECTIVE To evaluate in SSc, the frequency of digital lesions and the morphology, characteristics, natural course and time to healing of 1614 digital ulcers (DUs). METHODS One hundred SSc patients were followed up for 4 years. In the first step, the digital lesions were observed and classified at the time of presentation [digital pitting scar (DPS); DU; calcinosis; gangrene]. In the second step, DUs were divided into subsets according to their origin and main features. In the third step, the time to healing was recorded for each DU and the influence of DU main characteristics on time to healing was also evaluated. RESULTS In the first step, 1614 digital lesions were observed: DPS, 712 (44.1%) lesions; DU, 785 (48.6%); calcinosis, 110 (6.8%); and gangrene, 7 (0.8%). In the second step, DUs were subsetted as follows: DU developed on DPS (8.8%), pure DU; DU developed on calcinosis (60%); DU derived from gangrene. In the third step, the mean time to healing was 25.6 (15.6) days in DPS, 76.2 (64) days in pure DU, 93.6 (59.2) days in calcinosis ulcers and 281.1 (263.3) in gangrene. CONCLUSIONS In SSc, digital lesions are represented by DPS, DU, calcinosis and gangrene, and provide an evidence-based DU subsetting according to their origin and main characteristics. Subsetting may be helpful for a precise DU evaluation and staging, and in randomized controlled trials for a precise identification of those DUs that are to be included in therapeutic studies.

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.

Interventions to reduce the risk of violence toward emergency department staff: current approaches

Introduction The phenomenon of workplace violence in health care settings, and especially in the emergency department (ED), has assumed the dimensions of a real epidemic. Many studies highlight the need for methods to ensure the safety of staff and propose interventions to address the problem. Aim The aim of this review was to propose a narrative of the current approaches to reduce workplace violence in the ED, with a particular focus on evaluating the effectiveness of emergency response programs. Methods A search was conducted between December 1, 2015 and December 7, 2015, in PubMed and CINAHL. Ten intervention studies were selected and analyzed. Results Seven of these interventions were based on sectoral interventions and three on comprehensive actions. Conclusion The studies that have attempted to evaluate the effectiveness of interventions have shown weak evidence to date. Further research is needed to identify effective actions to promote a safe work environment in the ED.

Prenatal Paracetamol Exposure and Wheezing in Childhood: Causation or Confounding?

Background Several studies have reported an increased risk of wheezing in the children of mothers who used paracetamol during pregnancy. We evaluated to what extent this association is explained by confounding. Methods We investigated the association between maternal paracetamol use in the first and third trimester of pregnancy and ever wheezing or recurrent wheezing/asthma in infants in the NINFEA cohort study. Risks ratios (RR) and 95% confidence intervals (CI) were estimated after adjustment for confounders, including maternal infections and antibiotic use during pregnancy. Results The prevalence of maternal paracetamol use was 30.6% during the first and 36.7% during the third trimester of pregnancy. The prevalence of ever wheezing and recurrent wheezing/asthma was 16.9% and 5.6%, respectively. After full adjustment, the RR for ever wheezing decreased from 1.25 [1.07–1.47] to 1.10 [0.94–1.30] in the first, and from 1.26 [1.08–1.47] to 1.10 [0.93–1.29] in the third trimester. A similar pattern was observed for recurrent wheezing/asthma. Duration of maternal paracetamol use was not associated with either outcome. Further analyses on paracetamol use for three non-infectious disorders (sciatica, migraine, and headache) revealed no increased risk of wheezing in children. Conclusion The association between maternal paracetamol use during pregnancy and infant wheezing is mainly, if not completely explained by confounding.

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.

Pressure Ulcers in Older Adults: A Prevalence Study.

OBJECTIVE: The purpose of this study was to measure the prevalence of pressure ulcers (PrUs) in an older adult population. DESIGN: A cross-sectional study. SETTING: The study included all the individuals being cared for in the units of medicine, surgery, intensive care, and medical-surgical specialties of 47 hospitals, 57 public nursing homes, and 37 home care services. PARTICIPANTS: The authors’ observational study included 11,957 patients older than 70 years. MAIN OUTCOME MEASURES: Of the population, 50.75% (6067) were assessed to be at risk of developing PrUs according to the Braden Scale, and 24.66% (2949) had already developed PrUs. In addition, a significant association was found between increased risk (Braden <16) and the presence of PrUs with an odds ratio (OR) of 8.71 (confidence interval [CI], 7.52–10.10) in high-risk subjects (Braden ⩽12) and an OR of 3.86 (CI, 3.36–4.44) in very high-risk patients (Braden 13–16). In the survey, 84.6% of the subjects with PrUs were incontinent, and incontinence increased the risk of developing PrUs in the authors’ sample (OR, 1.54; CI, 1.34–1.77). CONCLUSIONS: The authors’ data reported in the literature show that the prevalence of PrUs increases as an individual ages. The authors gathered data that showed a large area of intervention in managing the prevention of PrUs, such as an adequate use of protective aids, correcting malnutrition, and controlling incontinence. These results suggest that clinicians should focus more on the prevention of PrUs in older adults.

Assessment, Definition, and Classification of Lower Limb Ulcers in Systemic Sclerosis: A Challenge for the Rheumatologist

Objective. To evaluate pathogenesis and clinical features of lower limb ulcers in systemic sclerosis (SSc) and to propose a classification that could be used in clinical practice. Methods. Charts of 60 patients with SSc who had lower limb cutaneous lesions were reviewed. All patients had videocapillaroscopy and arterial and venous lower limb color Doppler ultrasonography (US). Arteriography was performed if occlusive peripheral arterial disease was suspected. Results. The 554 lesions were classified as hyperkeratosis, ulcers, and gangrenes. There were 341 (61.6%) hyperkeratoses, 208 (37.5%) ulcers, and 5 (0.9%) gangrenes. Ulcers were divided into pure ulcers, ulcers associated with hyperkeratosis, and ulcers secondary to calcinosis. Involvement of arterial and venous macrocirculation as determined by color Doppler US was observed in 17 (18.3%) and 18 (30%) patients, respectively. Seventeen out of 37 patients with pure ulcers (45.9%) presented neither venous insufficiency nor hemodynamically significant macrovascular arterial disease. In these patients, pure ulcers were most likely caused by isolated SSc-related microvascular involvement (pure microvascular ulcers). The only significant risk factor for development of pure microvascular ulcers in the multivariate analysis was the history of lower limb ulcers (OR 26.67, 95% CI 2.75–259.28; p < 0.001). Conclusion. Results of our study indicate that lower limb ulcers in SSc often have a multifactorial pathogenesis that may be difficult to manage. Further studies are needed to validate the proposed classification and to assess the most appropriate management of lower limb ulcers in SSc.

Measuring elderly care through the use of a nursing conceptual model and the international classification for nursing practice

INTRODUCTION   Nursing models and terminologies can contribute to research the nature of nursing care. AIM   The aim of this study was to describe nursing diagnoses in acute- and long-term elderly care. METHODS   A point prevalence survey was conducted on 240 patients. The International Classification for Nursing Practice was used to describe nursing diagnoses, and a conceptual model was used to categorize them in nursing needs. RESULTS   A total of 2,673 diagnoses were detected. Mean was higher in nursing home than in hospital (t test =-3.688; p = .0003). Prevalent diagnoses were significantly different. DISCUSSION   High complexity, with different issues for nurses, was observed both in acute- and in long-term settings. CONCLUSION   The results could help to comprehend the nature of older persons needs and could contribute to the development of an International Classification for Nursing Practice catalogue for elderly care.

Workplace violence against nurses in Korea and its impact on professional quality of life and turnover intention.

Dear Editor, We read with interest the paper by Choi and Lee (2017) titled ‘Workplace violence against nurses in Korea and its impact on professional quality of life and turnover intention’ published in the Journal of Nursing Management. We were impressed by the high rates of workplace violence (WPV) (95.5% of the respondents, in a time frame of 12 months) recorded by the authors, indicating the real importance of this phenomenon. Even if the most frequent kind of WPV is verbal abuse, a consistent percentage of respondents reported threatening behaviours (89.9%). We would like to add some considerations emerging from data recorded in Italy. According to our recent national survey about violence towards emergency nurses, which involved 1,093 respondents, accounting for 6.9% of the 15,618 Italian emergency nurses currently in service (Ramacciati, Ceccagnoli, Addey, & Rasero, 2017), the turnover intention and, the desire to leave the profession are significantly related to being a victim of violence, regardless of the type of violence suffered (whether verbal or physical), even if a formal transfer request is not submitted, as shown in Table 1. This is consistent with a previous Italian study (Becattini, Bambi, Palazzi, & Lumini, 2007). Moreover, an issue studied by Choi and Lee is that of horizontal violence (HV), which is a type of abuse perpetrated among nurses. In two recent Italian studies performed with critical care and emergency department nurses the reported rates of HV experienced in the last year were 81.6% (Bambi, Becattini, Pronti, Lumini, & Rasero, 2013) and 79.1% (Bambi et al., 2014), respectively. Actually, we are talking about reports of abuse that are at least single episodes, while the systematic occurrence of this kind of abuse perpetrated by peers (at least once a week for not less than 6 months) is called horizontal bullying (Tomei et al., 2007). Our data reported that 22.4% of nurses working in critical care units, operating rooms, emergency departments and ambulances were bullied by other nurses (Bambi et al., 2014). Interestingly, the bullied nurses made formal requests to leave their units in rates significantly higher than nurses that experienced HV but not in a consistent way (29.3% vs. 6.1%; χ2 = 110.262; p < .0001) (Bambi et al., 2014). At the same time, this group of nurses have more frequently thought to leave definitively the nursing profession (31.2% vs. 7.8%; χ2 = 98.654; p < .0001) (Bambi et al., 2014). Therefore, we think it is important to distinguish the various kinds of WPV (verbal abuse, physical aggression), and to grade the intensity of the abuse to understand the relationship between the violence and its consequences for nurses. We would like to know if the authors found any results similar to ours. Sharing knowledge can help nursing managers find effective solutions to counteract this phenomenon (Ramacciati, Ceccagnoli, Addey, Lumini, & Rasero, 2016). In our opinion, one of the most important elements to solve these problems is a fundamental commitment, starting from nurse executives and managers. Nurses should not be left alone in the face of violence (Ramacciati, Ceccagnoli, & Addey, 2015).