Pre-pectoral Breast Reconstruction: Surgical and Patient-Reported Outcomes of Two-Stages vs Single-Stage Implant-Based Breast Reconstruction

BACKGROUND

Two-stages pre-pectoral breast reconstruction may confer advantages over direct to implant (DTI) and subpectoral reconstruction in selected patients who have no indication for autologous reconstruction. The primary endpoint of the study was to evaluate and compare the incidence of capsular contracture in the pre-pectoral two-stages technique versus the direct to implant technique. Complications related to the two surgical techniques and patient satisfaction were also evaluated.

METHODS

A retrospective review of 45 two stages and 45 Direct-to-implant, DTI patients was completed. Acellular dermal matrix was used in all patients. An evaluation of anthropometric and clinical parameters, surgical procedures and complications was conducted. Minimum follow-up was 12 months after placement of the definitive implant.

RESULTS

There was no statistically significant difference in the rate of capsular contracture in the two groups. Rippling occurred more in DTI reconstruction. In the two-stages reconstruction, lipofilling was applied more often and there was a higher incidence of seroma. Patient satisfaction extrapolated from the Breast Q questionnaire was better for patients submitted to two-stage implant-based breast reconstruction.

CONCLUSION

Dual-stage pre-pectoral reconstruction with acellular dermal matrix appears to be a good reconstructive solution in patients with relative contraindications for one-stage heterologous reconstruction with definitive prosthesis and no desire for autologous reconstruction.

Examining potential Long COVID effects through utilization of healthcare resources: a retrospective, population-based, matched cohort study comparing individuals with and without prior SARS-CoV-2 infection

BACKGROUND

A significant proportion of individuals reports persistent clinical manifestations following SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) acute infection. Nevertheless, knowledge of the burden of this condition-often referred to as 'Long COVID'-on the health care system remains limited. This study aimed to evaluate healthcare utilization potentially related to Long COVID.

METHODS

Population-based, retrospective, multi-center cohort study that analyzed hospital admissions and utilization of outpatient visits and diagnostic tests between adults aged 40 years and older recovered from SARS-CoV-2 infection occurred between February 2020 and December 2021 and matched unexposed individuals during a 6-month observation period. Healthcare utilization was analyzed by considering the setting of care for acute SARS-CoV-2 infection [non-hospitalized, hospitalized and intensive care unit (ICU)-admitted] as a proxy for the severity of acute infection and epidemic phases characterized by different SARS-CoV-2 variants. Data were retrieved from regional health administrative databases of three Italian Regions.

RESULTS

The final cohort consisted of 307 994 previously SARS-CoV-2 infected matched with 307 994 uninfected individuals. Among exposed individuals, 92.2% were not hospitalized during the acute infection, 7.3% were hospitalized in a non-ICU ward and 0.5% were admitted to ICU. Individuals previously infected with SARS-CoV-2 (vs. unexposed), especially those hospitalized or admitted to ICU, reported higher utilization of outpatient visits (range of pooled Incidence Rate Ratios across phases; non-hospitalized: 1.11-1.33, hospitalized: 1.93-2.19, ICU-admitted: 3.01-3.40), diagnostic tests (non-hospitalized: 1.35-1.84, hospitalized: 2.86-3.43, ICU-admitted: 4.72-7.03) and hospitalizations (non-hospitalized: 1.00-1.52, hospitalized: 1.87-2.36, ICU-admitted: 4.69-5.38).

CONCLUSIONS

This study found that SARS-CoV-2 infection was associated with increased use of health care in the 6 months following infection, and association was mainly driven by acute infection severity.

Second Victim Symptoms and Desired Support Strategies Among Italian Health Care Workers in Friuli-Venezia Giulia: Cross-Sectional Survey and Latent Profile Analysis

BACKGROUND AND OBJECTIVE

The second victim (SV) phenomenon concerns health care workers (HCWs) whose involvement in a medical error, as well as non-error patient safety events, has affected their well-being. Its prevalence ranges from 10% to 75% and can predispose HCWs to burnout, increasing the probability of committing errors. The primary aim of our study was to determine the prevalence of HCWs involved in an adverse patient safety event in Friuli Venezia Giulia Region (Italy). The secondary aims were to use latent profile analysis to identify profiles of SVs and factors influencing profile membership, and to evaluate the relationship between the severity of symptoms and desired support options.

METHODS

A cross-sectional survey through the Italian version of the Second Victim Experience and Support Tool tool was conducted in 5 local health authorities. Descriptive statistics were conducted for all variables. Associations and correlations were assessed with statistical tests, as appropriate. Latent profile analysis was based on the scores of dimensions measuring SVs' symptoms. Factors affecting profile membership were assessed through multinomial logistic regression.

RESULTS

A total of 733 HCWs participated. Of them, 305 (41.6%) experienced at least 1 adverse event. Among dimensions measuring SVs' symptoms, psychological distress had the highest percentage of agreement (30.2%). Three latent profiles were identified: mild (58.7%), moderate (24.3%), and severe (17.0%) symptoms. Severe symptoms profile was positively associated with the agreement for extraoccupational support and negatively associated with the agreement for organizational support. A respected colleague with whom to discuss the details of the incident (78.7%) and free counseling outside of work (71.2%) were the support options most desired by HCWs. The severity of symptoms was directly associated with the desire for support strategies.

CONCLUSIONS

The prevalence of HCWs involved in adverse events is consistent with the literature. Three latent profiles have been identified according to SV symptoms, and the higher the severity of symptoms, the greater the reliance on extraoccupational support.

COVID-19 vaccination effectiveness in the population of Friuli Venezia Giulia, North-East Italy. Control of bias associated with divergent compliance to policies in a test-negative case-control study

BACKGROUND

Vaccine effectiveness (VE) studies consolidate knowledge of real-world effectiveness in different contexts. However, methodological issues may undermine their conclusions: to assess the VE against COVID-19 within the Italian population, a specific threat to validity is related to the consequences of divergent compliance to the Green Pass policy.

METHODS

To address this challenge we conducted a test negative case-control (TNCC) study and multiple sensitivity analysis among residents aged ≥ 12 in Friuli Venezia Giulia Region (FVG), North-east Italy, from February 1, 2021 to March 31, 2022. Information regarding 211,437 cases of COVID-19 infection and 845,748 matched controls was obtained from the regional computerized health database. The investigation considered: COVID-19 infection, hospitalization, and death. Multiple conditional logistic regressions adjusted for covariates were performed and VE was estimated as (1-OR COVID-19vaccinated vs. unvaccinated)x100. Mediation analyses were carried out to offset potential collider variables, particularly, the number of swabs performed after the introduction of pandemic restrictions.

RESULTS

Full-cycle VE against infection decreased from 96% (95% CI: 96, 97) in the Alpha period to 43% (95% CI: 42, 45) in the Omicron period. Booster dose raised the protection in Omicron period to 67% (95% CI: 66, 67). Against the evasive Omicron variant, the protection of the booster dose was 87% (95% CI: 83, 90) for hospitalization and 90% (95% CI: 82, 95) for death. The number of swabs performed was included as a covariate in the adjustments, and the mediation analysis confirmed that it was a strong mediator between vaccination and COVID-19-related outcomes.

CONCLUSIONS

The study suggests that, under similar TNCC settings, mediation analysis and adjustment for number of diagnostic tests should be included, as an effective approach to the challenge of differential testing behavior that may determine substantial selection bias. This correction allowed us to align with results from other studies that show how full-cycle VE against infection was initially high but decreased over time by variant circulation, counterbalanced by booster dose that raised protection across variants and outcome severity.

Analysis of factors conditioning inappropriate visits in a paediatric emergency department

Recent studies estimated that about 20-30% of visits in a paediatric emergency department (PED) are inappropriate. Nonurgent visits have been negatively associated with crowding and costs, causing longer waiting and dissatisfaction among both parents and health workers. We aimed to analyze possible factors conditioning inappropriate visits and misuse in a PED. We performed a cross-sectional study enrolling children accessing an Italian PED from June 2022 to September 2022 who received a nonurgent code. The appropriateness of visits, as measured by the "Mattoni SSN" Project, comprises combination of the assigned triage code, the adopted diagnostic resources, and outcomes. A validated questionnaire was also administered to parents/caregivers of included children to correlate their perceptions with the risk of inappropriate visit. Data were analyzed using independent-samples t-tests, Wilcoxon-Mann-Whitney tests, chi-square tests, and Fisher's exact tests. The factors that were found to be associated with inappropriate visits to the PED were further evaluated by univariable and multivariable logistic regression analyses. Almost half (44.8%) of nonurgent visits resulted inappropriate. Main reasons for parents/caregivers to take their children to PED were (1) the perceived need to receive immediate care (31.5%), (2) the chance to immediately perform exams (26.7%), and (3) the reported difficulty in contacting family paediatrician (26.3%). Inappropriateness was directly related to child's age, male gender, acute illness occurred in the previous month, and skin rash or abdominal pain as complaining symptoms.     Conclusion: This study highlights the urgent need to finalize initiatives to reduce misuse in accessing PED. Empowering parents' awareness and education in the management of the most frequent health problems in paediatric age may help to achieve this goal. What is Known: • About 20-30% of pediatric urgent visits are estimated as inappropriate. • Several factors may be associated with this improper use of the emergency department, such as the misperception of parents who tend to overrate their children's health conditions or dissatisfaction with primary care services. What is New: • This study evaluated almost half of pediatric emergency department visits as inappropriate adopting objective criteria. • Inappropriateness was directly related to the child's age, male gender, acute illness that occurred in the previous month, and skin rash or abdominal pain as complaining symptoms. Educational interventions for parents aimed at improving healthcare resource utilization should be prioritized.

Prepectoral Direct-To-Implant One-Stage Reconstruction With ADMs: Safety and Outcome in "Thin Patients"

BACKGROUND

Prepectoral direct-to-implant reconstruction with acellular dermal matrix (ADM) represents a safe, fast, and successful option in breast reconstruction in a selected cohort of patients. Nowadays, this procedure is considered challenging in thin. Meanwhile, his cohort has not been accurately analyzed yet.

METHODS

A single institution retrospective cohort study was performed between January 2019 and March 2023 in all women who underwent mastectomy. Biometrical and clinical data were recorded. Also, surgical technique, operating room (OR) time, mastectomy weights, implant choice, and acellular dermal matrix (ADM) types were properly noted. Postoperative complications represented the main topic: these were classified into early and late ones based on onset time. At least 12-month follow-up was required. A comparison between thin and ideal body mass index (BMI) populations was performed.

RESULTS

Early complications did not seem to differ between the 2 groups with 37.8% and 38.9% of women having at least 1 early complication in thin and ideal-weight women, respectively (P = .919). In univariable regression analysis, compared with women with a BMI of 22.1 to 25.0, women with a BMI ≤ 22.0 were associated with an increased risk of late complications of 2.84 (1.13-7.14). Specifically, thin women appeared to have a 3-fold increased risk (OR = 2.97, 95% CI 1.08-8.18) of ripples/wrinkles compared with women with ideal weight.

CONCLUSIONS

Prepectoral reconstruction with ADM in thin patients may be considered as safe as in standard BMI patients. Rippling may be more frequent, but, whenever needed, easy to correct with a few sessions of lipo-grafts.

LEVEL OF EVIDENCE

III.

The impact of urbanization and wealth on house dust mite sensitization in children from north-central Nigeria

The impact of socio-economic status on the risk of allergy in African children is not clear.

This was a cross sectional study including children aged 6–14 years from urban and rural settings in north-central Nigeria. Participants underwent skin prick tests to house dust mite (HDM) and an interview investigating socio-economic status through the Family Affluence Scale (FAS) based on a score of 0–6.

A total of 346 children were enrolled (52.8% boys; mean age ± SD 9.6 ± 2.0 years), including 142 (41% of total) rural and 204 (59% of total) urban pupils. Prevalence of HDM sensitivity was 2.8% (4/142) in the rural setting and 15.6% (32/204) in the urban setting (P < 0.001). Among urban children, frequency of HDM sensitization was 8.6% (7/81) in the lowest socio-economic group (FAS 0–1), 13.1% (8/61) in the intermediate one (FAS 2–3) and 27.4% (17/62) in the highest one (FAS ≥ 4).

Urbanization and increasing wealth are associated with a higher frequency of sensitization to HDM in Nigerian children.

The Second Victim Experience and Support Tool: A Cross-Cultural Adaptation and Psychometric Evaluation in Italy (IT-SVEST)

OBJECTIVE

Second victims are defined as healthcare workers involved in an unanticipated adverse patient event, who experienced professional and psychological distress. The Second Victim Experience and Support Tool (SVEST) is a survey developed and validated in the United States, which describes the experience of second victims. This study aims to perform the cross-cultural adaptation of the SVEST and to evaluate its psychometric characteristics in the Italian context.

METHODS

Translation and cross-cultural adaptation process was performed according to the World Health Organization guidelines. Then, 349 healthcare workers, including nurses, doctors, residents, and technicians, involved in direct patient care-a potential second victim-completed the Italian version of SVEST in a validation survey at the Academic Hospital of Udine. The SVEST consists of 29 items, divided into 7 dimensions, 2 outcome variables, and 7 support options. The Italian version was assessed for internal consistency through Cronbach α, for content validity with content validity index for scales and for item and for construct validity with Confirmatory Factor Analysis.

RESULTS

The internal consistency of the instrument was adequate in its overall evaluation with Cronbach α value of 0.88 (95% confidence interval = 0.86). The content validity index for scales was 0.94 and that for item was 0.70. The confirmatory factor analysis results showed a good model fit for the 9-factor structure (χ2 = 676.18, df = 327, P < 0.001). Root mean squared error of approximation, Akaike information criterion, and comparative fix index Tucker-Lewis index values also suggested a good fit to the data.

CONCLUSIONS

The Italian version of the SVEST can be used to evaluate second victim experiences, demonstrating adequate validity, reliability, and good psychometric properties.

How to assure the quality of clinical records? A 7-year experience in a large academic hospital

INTRODUCTION

Clinical record (CR) is the primary tool used by healthcare workers (HCWs) to record clinical information and its completeness can help achieve safer practices. CR is the most appropriate source in order to measure and evaluate the quality of care. In order to achieve a safety climate is fundamental to involve a responsive healthcare workforce thorough peer-review and feedbacks. This study aims to develop a peer-review tool for clinical records quality assurance, presenting the seven-year experience in the evolution of it; secondary aims are to describe the CR completeness and HCWs' diligence toward recording information in it.

METHODS

To assess the completeness of CRs a peer-review tool was developed in a large Academic Hospital of Northern Italy. This tool included measurable items that examined different themes, moments and levels of the clinical process. Data were collected every three months between 2010 and 2016 by appointed and trained HCWs from 42 Units; the hospital Quality Unit was responsible for of processing and validating them. Variations in the proportion of CR completeness were assessed using Cochran-Armitage test for trends.

RESULTS

A total of 9,408 CRs were evaluated. Overall CR completeness improved significantly from 79.6% in 2010 to 86.5% in 2016 (p<0.001). Doctors' attitude showed a trend similar to the overall completeness, while nurses improved more consistently (p<0.001). Most items exploring themes, moments and levels registered a significant improvement in the early years, then flattened in last years. Results of the validation process were always above the cut-off of 75%.

CONCLUSIONS

This peer-review tool enabled the Quality Unit and hospital leadership to obtain a reliable picture of CRs completeness, while involving the HCWs in the quality evaluation. The completeness of CR showed an overall positive and significant trend during these seven years.

The impact of the second victim phenomenon in an Italian Academic Hospital: a cross-sectional study

Background

Adverse patient safety events (AEs) can negatively impact on healthcare workers (HCWs) by causing emotional distress and affecting professional ability. The challenge of healthcare organizations is to support HCWs involved in AEs. This study aims to investigate the second victim phenomenon in a large Italian Academic Hospital (AH).

Methods

A cross sectional survey was conducted from June to November 2019 involving all HCWs working at the AH of Udine. HCWs' demographic characteristics and answers to the Second Victim Experience and Support Tool, Italian version (IT-SVEST; 29 items representing 7 dimensions and 2 outcome variables; Likert-scale: 1-5) were collected. Higher scores indicated a greater negative impact of the AEs and a perceived inadequacy of support resources. Median (M) and interquartile range (IQR) were assessed for each item. The agreement (AGR) (respondents with a mean score ≥4) was assessed for each dimension. Relationship between items score and demographic aspects was analyzed with non-parametric tests.

Results

A total of 349 HCWs joined the survey. Women were 79.4% and mean age was 39.4±10.7 years. 58.7% of respondents referred to be involved in a AEs. Lots of HCWs expressed feelings of psychological distress (AGR=26.9%) and less experienced HCWs were more affected by feelings of shame than senior ones (M = 4, IQR=1.5 vs M = 3, IQR=2; p &lt; 0.01). Physical distress (AGR=10.9%) and professional self-efficacy (AGR=11.8%) did not had a great impact on HCWs, but younger (M = 3, IQR=2 vs M = 2, IQR=2; p &lt; 0.01) and female (M = 3, IQR=2 vs M = 2, IQR=2; p &lt; 0.01) HCWs were more inclined to question their skills. Support services offered by Hospital organization may be improved (AGR 8,9%).

Conclusions

Psychological impact of the AEs is relevant in our cohort and less experienced and female HCWs resulted more inclined to doubt their professional abilities when involved. Improvements in support resources should be desirable to create a safer working environment.

Key messages

HCWs’ psychological dimension and perceived professional self-esteem can be negatively affected by adverse events, especially for less experienced and female professionals. Healthcare organizations need to develop and to implement a second victim support program designed to provide emotional, psychological and professional support for HCWs.

Do medical students and residents impact the quality of patient care? An assessment from different stakeholders in an Italian academic hospital, 2019

Medical students and residents play an important role in patient care and ward activities, thus they should follow hospital procedures and ensure best practices and patient safety. A survey concerning staff on training was conducted to assess the perceived quality of healthcare from healthcare workers (HCWs), residents, medical students and patients in Udine Academic Hospital, Italy. Between December, 2018 and March, 2019, a 5-point Likert-scale questionnaire was administered in 21 units, covering four thematic areas: patients and medical staff satisfaction with the quality of care provided by residents and students, patient privacy, clinical risk management, patient perception of staff on training. Data analysis included descriptive analysis and ordered logistic regressions. A total of 596/1,863 questionnaires were collected from: HCWs (165/772), residents (110/355), students (121/389), and patients (200/347). Residents were rated high both by patients (median = 5, IQR = 4–5, OR 0.49, 95%CI 0.26–0.93) and HCWs (median = 4, IQR = 3–5, OR 0.14, 95%CI 0.08–0.26), with a lower score for medical students on the same topic, both by patients (median = 4, IQR = 3–5, OR 2.94, 95%CI 1.49–5.78) and HCWs (median = 3, IQR = 2–3, OR 0.41, 95%CI 0.25–0.67). Therefore, the role of staff on training in quality and safety of healthcare deserves integrated regular evaluation, since direct interaction with patients contributes to patients’ perception of healthcare.

Assessment of the impact of clinical recommendations on antibiotic use for CAP and HCAP: results from an implementation program in an Academic Hospital

BACKGROUND

Local guidelines and recommendations to treat common infectious diseases are a cornerstone of most Antimicrobial Stewardship programs. The evaluation of the adherence to guidelines is an effective quality measure of the programs themselves; the proposed evaluation model aimed at examining antibiotic treatment for pneumonia.

STUDY DESIGN

A retrospective pre-post intervention study was conducted in a North-Eastern Italian Academic Hospital.

METHODS

231 patients with Community-Acquired Pneumonia and 95 with Healthcare-Associated Pneumonia were divided into pre- and post-intervention groups (188 and 138, respectively). A course and a pocket summary of Pneumonia Regional Recommendations were the stewardship activities adopted. The compliance degree of prescriptions with Regional Recommendations was tested for drug(s), dosage and duration of treatment in both groups for Community-Acquired and Healthcare-Associated Pneumonia and a comparison with International guidelines was performed.

RESULTS

A significant improvement in the compliance with Regional Recommendations for the variable drug emerged for Community-Acquired (38.8% vs 52.2%), but not for Healthcare-Associated Pneumonia; no significant variation in compliance was registered for dosage and duration of treatment. The significant decrease in consumption of levofloxacin showed the positive impact of the Regional Antimicrobial Stewardship programs. A high level of adherence to International Guidelines for the variable drug for Community-Acquired Pneumonia was found in both groups (75.5% and 77.2%, respectively).

CONCLUSIONS

Our study highlighted that room for improvement in antibiotic prescription in Community-Acquired and Healthcare-Associated Pneumonia currently remains. New strategies for a better use of the adopted tools and definition of new antimicrobial stewardship initiatives are needed to improve compliance to Regional Recommendations.

[Impact of the COVID-19 epidemic in Friuli Venezia Giulia Region (Northern Italy): assessment of factors associated with the risk of death by competing risks analysis]

OBJECTIVES

to investigate the role of gender, age, province of residence, and nursing home residency on the risk of death for residents in the Friuli Venezia Giulia (FVG) Region (Northern Italy) tested positive for Covid-19, considering recovery as a competing event. The secondary objective is to describe the impact of the Covid-19 epidemic in FVG and in the Regions of Northern and Central Italy in terms of incidence and mortality compared to the national data.

DESIGN

retrospective cohort study.

SETTING AND PARTICIPANTS

resident population in FVG in the period between 29 February and 25 June 2020.

MAIN OUTCOME MEASURES

in order to describe the impact of the Covid-19 outbreak in FVG, in terms of incidence and mortality compared to the national data, the standardized incidence (SIR) and mortality (SMR) ratios and their respective 95% confidence intervals (95%CI) were calculated compared to the Italian population for the northern and central Regions of Italy and the autonomous Provinces (PA) of Trento and Bolzano. A retrospective cohort study was conducted on subjects residing in FVG to whom at least one naso-oropharyngeal swab (hereafter, named swab) resulted positive for Covid-19. For each subject included in the cohort, the observation period started with the first positive swab and ended with the first of the following events: death, recovery or censored, which means that at the end of the observation period the subject was still alive and positive. The cause of death was assigned to Covid-19 if a subject had not yet recovered at the time when the event occurred. Cohort members were considered recovered after two negative consecutive swabs. The sub-hazard ratio (SHR) was estimated by applying the regression model of competing risks by Fine and Gray, in which the event of interest was the death caused by Covid-19 and the competing event was recovery. The explanatory variables included in the multiple models are: gender, age at the beginning of the observation period, the Province of residence, and nursing home residency. The cause-specific hazard was estimated using Cox proportional hazard regression.

RESULTS

during the observation period, 3,305 cases and 345 deaths were recorded in FVG; SIR and SMR resulted, respectively, equal to 0.64 (95%CI 0.61-0.68) and 0.43 (95%CI 0.37-0.50). The FVG was the Northern Region one with the lowest incidence and mortality. The cohort consisted of 3,121 residents in FVG with at least one swab with a positive Covid-19 result during the study period. The SHR of dying for Covid-19 is equal to 16.13 (95%CI 9.73-26.74) for people with age 70-79 years and 35.58 (95%CI 21.77-58.15) with age >=80 years respect those with age <70 years. It is higher in males (SHR 1.71; 95%CI 1.34-2.17). There is no evidence that being resident in a nursing home affects the SHR (SHR 0.91 and 95%CI 0.69-1.20). As regards the province as an explanatory variable, the sub-hazard of death in the province of Trieste appears to overlap to the sub-hazard of Pordenone used as a reference; for the provinces of Udine and Gorizia the sub-hazards seem lower than the reference.

CONCLUSIONS

while other Northern Regions and autonomous Provinces show higher standardized incidence and mortality compared with Italy, FVG and Veneto do not. In FVG, male gender and age are important determinants of death while there is no evidence that the condition of guest in a nursing home increases the sub-hazard of death.

Mediterranean diet adherence in pregnant women: results of a survey in North East of Italy

Background

In literature, few studies evaluated Mediterranean diet (MD) adherence in pregnant women, so we decided to conduct a survey to analyze MD and healthy habits in pregnant women living in North East of Italy, in 2018.

Methods

In our monocentric observational study, we enrolled &gt;18 years pregnant women (2nd-3rd trimester) to evaluate MD adherence through “PREDIMED” validated questionnaire. Based on previous studies on MD score, women were classified into High-MD adherence (score &gt;8; range 0-14) and low-MD adherence group (score ≤ 8). Comparisons between groups were performed using a t-test, Wilcoxon-Mann-Whitney test, chi square test and regression models as appropriate. We also investigated BMI (body mass index) and healthy habits before and during pregnancy.

Results

We analyzed 113 questionnaires and MD score, ranging from 3 to 13, had a mean value of 8.04 (SD 1.95), with low MD adherence in 63% (71) of our sample. Women (mean age 32 years; min 22- max 43; SD 1.95) were mostly employed (95; 84%) and alcohol consumers before pregnancy 79 (70%), especially wine 53 (47%). 5 (4%) didn't quit smoking while pregnant. Comparing BMI data before and during pregnancy to international recommendations, we found inadequate weight gain for each BMI category (100% in underweight, 70.7% in normal weight, 35% in overweight, 50% in obese range). Age was associated with MD adherence (β 0.11; 95%CI 0.04-0.17). Employment was also positively associated with higher MD values (p 0.002). Wine assumption before pregnancy was statistically significant associated with high MD group (p 0.0334).

Conclusions

In our study we found MD adherence levels lower than expected and an inadequate weight gain during pregnancy. MD seems also to be age and employment-related. Wine consumption before pregnancy and its positive association with MD need to be further analyzed.

Key messages

Mediterranean Diet adherence among pregnant women studied is not high and weight gain is frequently inadequate. Age and employment status might influence MD adherence in pregnancy.

Second Victim Experience and Support Tool: cultural adaptation and psychometric evaluation in Italy

Background

”Second victims” are defined as “healthcare workers (HCWs) involved in an unanticipated adverse patient event, who experienced professional and psychological distress”. The Second Victim Experience and Support Tool (SVEST) is a survey developed and validated in the United States, which describes the experience of second victims. This study aims to perform the cross-cultural adaptation of the SVEST and to evaluate its psychometric characteristics in the Italian context.

Methods

The translation and cross-cultural adaptation process was performed according to the World Health Organization’s guidelines, from March to May 2019. Then HCWs involved in direct patient care (a potential second victim) were asked to complete the Italian version of SVEST in a validation survey, from June to November 2019 at the Academic Hospital of Udine. SVEST consists of 29 items, divided into 7 dimensions, 2 outcome variables and 7 support options. The IT-SVEST was assessed for internal consistency through Cronbach’s α, for content validity with Content Validity Index for Scales (S-CVI) and for Item (I-CVI) and for construct validity with Confirmatory Factor Analysis (CFA).

Results

Collected surveys were 349. Women were 79.4%. Nurses were 40.1%, 18.9% were doctors and 8.6% were residents. HCWs involved in a patients’ adverse event were 205 (58.7%). Out of these, 66.3% were near misses. The internal consistency of the instrument was adequate in its overall evaluation with Cronbach α = 0.88 (95% C.I.=0.86). S-CVI was 0.94 and I-CVI was 0.70. The CFA results showed a good model fit for the nine-factor structure (chi2=676.18, 327 df, p &lt; 0.001). Root Mean Squared Error of Approximation, Akaike’s information criterion, Comparative Fix Index Tucker-Lewis Index values also suggested a good fit to the data.

Conclusions

The Italian version of the SVEST (IT-SVEST) can be used to evaluate second victim experiences, demonstrating adequate validity, reliability and good psychometric properties.

Key messages

Healthcare institutions need an instrument that can direct efforts to prevent and reduce the second victim experience. IT-SVEST is a reliable and valid instrument to obtain accurate information on second victim experience.

Second victim experience: cross-sectional survey at the Department of Maternal-Child Health in Udine

Introduction

Healthcare workers (HCWs) can experience psychological distress if involved in adverse patient events, becoming second victims. The aim of this study is to determine the extension of the second victim phenomenon and the preference of the support resources of the HCWs working in the Department of Maternal and Child Health (DMC) at the Academic Hospital of Udine.

Methods

A cross-sectional survey was carried out from June to November 2019. All HCWs involved in direct patient care working in the three units of DMC [Obstetrics and Gynaecology (OG), Neonatology (Neo), Pediatrics (Ped)] were included. A validated version in Italian language of the Second Victim Experience and Support Tool (SVEST) was used to assess the experience of second victim and the support resources preferred by the HCWs (Likert-scale: 1-5). Agreement of the support options were considered with an overall mean subscale score of ≥ 4.0. The Wilcoxon signed rank sum test was used to calculate the statistically significant differences (p &lt; 0.01).

Results

The response rate was 44,9% (120/267). Women were 95.8%. Mean age was 38.7±9.7; HCWs from OG were 48.3%, 26.7% from Neo and 25% from Ped. Nurses were 34.2%, 32.5% were obstetrics, 15.8% were doctors and 8.3% were residents. HCWs who experienced adverse patient events were 80 (66.7%). Out of these, 63 (52.5%) were near-miss events. The overall mean score of the first two dimensions of SVEST (”Psychological distress” and “Physical distress”, as representative of the trauma experience) was respectively 3.3±1.0 and 2.3±1.1. The difference between their scores was statistically significant (p &lt; 0.01). The most preferred support option was: “a respected peer to discuss the details of what happened” with the 80.0%.

Conclusions

The study highlights that HCWs of the DMC are frequently involved in adverse patient events. Psychological distress was significative more impactful than physical distress. The majority of HCWs preferred a peer for colleagues support.

Key messages

SVEST is an instrument that helps to determine the support resources preferred by HCWs in order to develop a support program for second victim. A peer for colleagues support is the support resource preferred by the HCWs working in the Department of Maternal and Child Health.

The role of mercury, selenium and the Se-Hg antagonism on cognitive neurodevelopment: A 40-month follow-up of the Italian mother-child PHIME cohort

Despite a 15-year long effort to define the "safety" of fish intake during pregnancy, there remains still uncertainty on this important public health issue. The evaluation of the toxic effects of contaminants, particularly mercury (Hg) in fish-eating populations is complicated by the fact that sea-food is also rich in beneficial nutrients, such as selenium (Se). There is toxicological plausibility of an antagonistic effects between Se and Hg, and some theoretical support for the inclusion of the Se-Hg interaction to better assess the risk linked with fish intake. To assess the effects of exposure to low-level Hg through fish consumption on the developing brain and the interaction between Hg and Se, we conducted an analysis at age 40 months in Italian children, enrolled in a prospective mother-child cohort, comparing additive and multiplicative models. Participant subjects were the 470 children born within the Northern Adriatic Cohort II (NAC-II) cohort who were tested by using the Bayley Scales of Infant and Toddler Development third edition (Bayley-III) (BSID-III) at age 40. Family demographic and socioeconomic information, pregnancy and delivery history, parental and child medical history and food consumption were assessed through questionnaires. Maternal blood samples were collected during pregnancy, cord blood at birth and maternal milk 1 month after delivery. As other exposures of interest, we considered the level of Se in maternal and cord blood and in breast milk and the potential Se-Hg antagonism. Se and inverse of THg (1:THg) concentrations were categorized according to the tertiles of their distributions, in low, medium and high levels of exposure. The lower end of the composite cognitive score distribution closest to 20% was defined as suboptimal development. Multiple logistic regression were applied to assess the association between the dichotomized composite cognitive score and the categorized exposure to Se and 1:THg, and the antagonism between Se and 1:THg. In the recruiting period, 900 pregnant women were enrolled in the cohort; 767 of these remained in the study at delivery and 470 children at 40 months. After excluding preterm births, 456 children were used in the final analyses. The larger difference in risk for suboptimal neurodevelopment was observed for the category with High THg and Low Se with OR = 2.55 (90% CI 1.02; 6.41) under the multiplicative and OR = 1.33 (90% CI 0.80; 1.87) under the additive model. The category High THg and High Se showed a very slightly better fit of the additive model (OR = 1.07, 90% CI 0.65; 1.50) versus the multiplicative (OR = 1.66, 90% CI 0.73; 1.77). A negative - antagonistic - interaction term for this category was estimated under the multiplicative model giving an OR = 1.17 (90% CI 0.42; 3.28). Although this evidence of the effects of the Se-Hg antagonism on the children neuro-development needs to be confirmed, if Se can counterbalance Hg toxicity, the evaluation of the effect on human health of fish consumption, should also consider the diverse ratios between Se and Hg concentration in different fish species.

Measuring the impact of a social programme on healthcare: a 10-year retrospective cohort study in Trieste, Italy

OBJECTIVES

Poor social conditions are strong determinants of poor health but positive health and healthcare changes caused by social interventions are difficult to demonstrate. In 2006, in Trieste (Italy), a social intervention known as 'Habitat Microaree' (HM) project was implemented in eight deprived neighbourhoods. In 2016, an observational study was launched to assess the impact of the HM project on healthcare.

DESIGN

Retrospective cohort study.

SETTING

The eight geographically defined neighbourhoods of Trieste involved in the 2006 HM project, accounting for a total of 11 380 residents.

PARTICIPANTS

Participants were all residents in the intervention areas. By means of a propensity score based on deprivation index, age, sex, Charlson index and drug utilisation, a non-participating, comparison group was defined.

INTERVENTION

The community-based intervention consisted of facilitating access to social services and outpatient healthcare facilities, coordinating intersectoral public services and specifically planning hospital discharge. These services were not provided in other areas of the city.

OUTCOME MEASURES

Hospital admissions and emergency department access.

RESULTS

We followed 16 256 subjects between 2008 and 2015. Living in microareas was associated with an HR for first hospital admission, for all causes, of 0.95 (95% CI 0.91 to 0.99); while the HR for urgent admissions in females was 0.92 (95% CI 0.85 to 1.00). The HR for psychiatric disorders, in females, was 0.39 (95%CI 0.18 to 0.82); in particular, the HR for psychosis was 0.15 (95% CI 0.05 to 0.51). The HR for acute respiratory diseases in females was 0.44 (95% CI 0.21 to 0.95). In males, the HR for genitourinary diseases and heart diseases were 0.65 (95% CI 0.42 to 1.01) and 0.72 (95% CI 0.54 to 0.97), respectively. Concerning urgent multiple admissions, the OR for fractures in females was 0.75 (95% CI 0.58 to 0.97).

CONCLUSION

In the study period, the effects on healthcare appear evident, especially in females.

Regional ventilation inhomogeneity in survivors of extremely preterm birth

INTRODUCTION

Survivors of extreme prematurity may have disrupted lung development. We hypothesized that the multiple breath washout (MBW) index Scond, which is intended to reflect ventilation inhomogeneity from the conducting airways, could be a sensitive marker of respiratory impairment in this group.

METHODS

Spirometry, TLco, and MBW were cross-sectionally evaluated at 8 to 14 years of age in children born at <28 weeks between 2004 and 2010 in Udine, Italy. Age-matched controls born at term were also included. Bronchopulmonary dysplasia (BPD) was defined as oxygen-dependence at 36 weeks postmenstrual age. The limits of normal were the 5th percentile of the reference population (Global Lung Initiative) for spirometry and TLco and the 95th percentile of controls for Lung Clearance Index, Scond, and Sacin from MBW.

RESULTS

Results were obtained in 47 extremely preterm children (53% boys, mean ± standard deviation age 11.3 ± 2.0 years, 40% with BPD) and 60 controls (50% boys, 11.6 ± 1.9 years). There were significant differences between preterm children and controls in all lung function outcomes, except for Sacin. Among children born <28 weeks, Scond tended to be frequently abnormal than FEV₁ z-score (29% vs 14%, P = .06). At multivariable linear regression, in the preterm group, current asthma was significantly associated with a higher Scond (B = 0.019, 95% confidence interval, 0.000-0.038), whereas BPD was not.

CONCLUSION

Almost a third of extremely preterm children at school age showed Scond alterations that affected also children without BPD. Longitudinal studies should clarify the prognostic meaning of Scond abnormalities in this group.

Capsular closure after hip arthroscopy: our experience

BACKGROUND AND AIM OF THE WORK

In the last decade, arthroscopic treatment of hip diseases has significantly spread and evolved and currently it represents the gold standard for the treatment of femoral- acetabular impingement. In the recent years, the function of the joint capsule (and therefore the results of an arthroscopic capsulotomy) has been hugely developed, opening a heated debate. The Literature is still torn about the need for a capsular suture, but more recent studies are more oriented in its execution at the end of the surgical procedure. According to these recent studies, the joint capsule performs an essential function of primary stability, and its closure is therefore necessary to restore the native anatomy and physiology. Nevertheless, capsular management remains a controversial topic. This is a retrospective study with the aim of assessing the influence of capsular suture on the patient's functional outcome in a cohort of patients with femoral-acetabular impingement arthroscopically treated.

HYPOTHESIS

Our hypothesis is that an adequate capsular suture positively influences the patient's functional outcome.

METHODS AND RESULTS

50 patients treated with hip arthroscopy for femoral-acetabular impingement have been retrospectively enrolled at the Orthopaedic Clinic of Academic Hospital of Udine during a period of two-years (2017-2018); collected data have been analysed and compared with a retrospective model. Patients have been divided into two equivalent groups, 25 treated with capsular suture, 25 without performing the suture. Patient's post-operative functional outcome has been analysed using the modified Harris Hip Score (mHHS), the Non-Arthritic Hip Score (NAHS) and the Hip Outcome Score-Sport Scale (HOS-SS). The functional outcome in patients where capsular sutures were performed was better than in non-sutured patients, in all three analysed scales.

CONCLUSIONS

Capsular suture with a single side-to-side stitch at the end of the procedure can positively influence the patient's functional outcome.

VATS-US1: Thoracoscopic ultrasonography for the identification of nodules during lung metastasectomy

Open thoracotomy during pulmonary metastasectomy allows lung palpation and may discover unexpected further nodules. We assess the validity of intraoperative lung ultrasonography via thoracoscopy in identifying lung nodules. A first surgeon will perform an ultrasonographic investigation on the deflated lung by thoracoscopy. A second surgeon will then perform a manual exploration of the organ by thoracotomy. Data on number and localization of nodules will be matched and compared with final histology report. Sensitivity and specificity will be assessed. Concordance will be assessed with Cohen K test. Calculated sample size is 89 patients. This study might have an important role in shifting the surgical practice towards a less invasive approach, with consequent benefits for the patient. Protocol is registered on clinicaltrials.gov. Protocol registration number: NCT03864874.

Medical records completeness: can Link Professionals improve quality in a Rehabilitation Hospital?

Background

The completeness of Medical Record (MR) is an indicator of the quality of care provided. IMFR (Medical and Physical Rehabilitation Institute), a hospital part of the Udine Healthcare Trust with 400 discharges yearly, launched at the end of 2017 a MR-quality program based on the involvement of Link Professionals (LP): doctors, nurses and therapists specifically trained. The main aim of this study is to determine if involving LP would improve MR completeness and would keep it over time. The second aim is to describe the 1-year experience of MR completeness and professional attitude toward recording medical information in it.

Methods

In December 2017 a new MR was introduced at the IMFR and its completeness was evaluated in January 2018. From January to April 2018, 17 LP educated all colleagues on the recording behavior through periodic meetings and focus groups. Then, LP peer-reviewed 20 inpatients paper-based MRs, assessing completeness, in April 2018 and then quarterly until January 2019. The evaluation was performed with a tool including a total of 73 items, divided in pertinence to the three professional figures involved. Feedbacks on MR completeness were given to professionals by LP in two-weeks. External data validation was performed to ensure data consistency. Significance (p &lt; 0.01) was assessed by Cochran-Armitage test for trends.

Results

The overall completeness of MR improved significantly from 59.6% (552 items out of 926; Jan-18) to 77.0% (738/959; Apr-18), settling to 78.3% (696/889) in January-19, with an overall trend of + 18.7%. Items pertaining to doctors improved significantly from 56.4% (217/385) to 81.4% (1173/1441), nurses’ from 60.7% (165/272) to 78.6% (740/941), therapists’ from 79.0% (79/100) to 91.7% (277/302). External validation results in 75% of agreement.

Conclusions

The involvement of LP proved effectiveness in encouraging professionals behavior, supporting the MR completeness improvement and keep it over one year time.

Key messages

Professionals involvement and short-term feedbacks contribute to the healthcare quality improvement. Peer-reviewing medical records improves professionals attitude in recording behavior.

What doctors and nurses think about the residents’ role within the Academic Hospital of Udine?

Background

Residents have a significant role in both patient’s care and daily ward activities; thus, they should be trained to adhere to hospital procedures and to guarantee best clinical practices and patient’s safety. A survey was carried out to assess healthcare workers’ (HCWs) opinions about residents’ role and performance.

Methods

Between February and March 2019, a paper-based/online survey was developed and distributed among both doctors (d) and nurses (n) in 17 (10 medical, 7 surgical) wards of Udine Academic Hospital, Italy. 22 Likert Scale questions (1-totally disagree, 5-totally agree) investigated 5 areas: respect of patient safety and privacy, healthcare quality, clinical risk management, role played within medical team, satisfaction concerning training activities planning. Profession, ward (medical/surgical), age and sex were considered as exposures. Descriptive analysis, median(M)±interquartile range, and ordered logistic regressions were performed with Stata software.

Results

The survey involved 153/785 HCWs’ (112/477 nurses and 41/308 doctors). All the units were represented with at least 1 HCWs; answers from both categories were collected in 82% of wards. Data analysis showed that nurses gave lower scores about residents’ respect of patient privacy than doctors: patient privacy protection: M(d)=4±0, M(n)=4±1, OR(d/n) 2.60, [95%CI, 1.04-6.52]; sensitive data management: M(d)=4±0, M(n)=3±1, OR(d/n) 2.97, [95%CI, 1.26-7.02]. The same resulted regarding clinical risk management: patient record management: M(d)=4±0, M(n)=3±2, OR(d/n) 13.64 [95%CI 5.30-35.12]; proper hand hygiene: M(d)=4±1, M(n)=3±1, OR(d/n) 5.56 [95%CI 2.35-13.17]; incident reporting: M(d)=4±1, M(n)=3±2, OR(d/n) 7.05 [95%CI 3.14-15.86].

Conclusions

Nurses appeared to be more critical than doctors about residents performances in safety and privacy and clinical risk management areas. Reasons behind these different opinions should be investigated in order to improve constantly healthcare’s quality.

Key messages

Residents hold a key role in healthcare quality, therefore it is significant evaluate their practice regarding patient’s safety and privacy. Doctors and nurses opinions on residents adherence to hospital procedures in order to guarantee best clinical practices and patient’s safety differ significantly.

Recording educational information in medical record: the experience of a Rehabilitation Hospital

Issue/Problem

Healthcare organizations have the responsibility to provide education to patients and families so that they have the knowledge to participate in the care process and make decisions. Rehabilitative organizations, on account of the long hospitalization period and the specific care plans, have to organize education resources in the most effective manner, ensuring the registration of what has been done in the medical record (MR).

Description of the problem

During the accreditation process, IMFR (Medical and Physical Rehabilitation Institute - an hospital part of the Udine Healthcare Trust) launched a MR-quality program. A dedicated team of 3 doctors, 4 nurses and 4 therapists changed the way in recording educational information in MR, introducing in April 2018 a specific, independent form, part of the MR, where documenting the achievement of two educational phases: assessment and delivery. The aim of this project is to determine if the introduction of this specific educational form and its sharing process, included in the wider MR-quality program, would improve the recording behavior. Twenty MRs were quarterly analyzed from December 2017 to December 2018, assessing educational forms completeness. Significance (p &lt; 0.01) was assessed by Cochran-Armitage test for trends.

Results

The recording behavior improved significantly from 53% (21/40; Dec-17) to 88% (30/34) in June 2018, after the introduction of the specific education form and remained high also in Sept.2018 (90%, 34/38) and in Dec.2018 (82%, 31/38), with an overall trend of + 29%.

Lessons

Sharing elements in the creation of the specific educational form with a multidisciplinary approach, within a wider MR-quality program, allows to improve the recording behavior of educational information in it. Hopefully this method would help healthcare professionals and organizations to ensure the education needed to patients and families.

Key messages

A multidisciplinary approach is a good model to deal with specific aspects of quality programs. A specific form, part of the MR, allows to improve behavior in recording educational information.

Differences in lung function between children with sickle cell anaemia from West Africa and Europe

Introduction

Lung function abnormalities are common in sickle cell anaemia (SCA) but data from sub-Saharan Africa are limited. We hypothesised that children with SCA from West Africa had worse lung function than their counterparts from Europe.

Methods

This prospective cross-sectional study evaluated spirometry and anthropometry in black African individuals with SCA (haemoglobin phenotype SS) aged 6–18 years from Nigeria and the UK, when clinically stable. Age-matched controls were also included in Nigeria to validate the Global Lung Initiative spirometry reference values.

Results

Nigerian SCA patients (n=154) had significant reductions in both FEV1 and FVC of ~1 z-score compared with local controls (n=364) and ~0.5 z-scores compared with the UK patients (n=101). Wasting (body mass index z-score<−2) had a prevalence of 27% in Nigerian patients and 7% in the UK ones (p<0.001). Among children with SCA, being resident in Nigeria (OR 2.4, 95% CI 1.1 to 4.9), wasting (OR 2.3, 95% CI 1.1 to 5.0) and each additional year of age (OR 1.2, 95% CI 1.1 to 1.4) were independently associated with increased risk of restrictive spirometry (FVC z-score<−1.64+FEV1/FVC≥−1.64).

Conclusions

This study showed that chronic respiratory impairment is more severe in children with SCA from West Africa than Europe. Our findings suggest the utility of implementing respiratory assessment in African children with SCA to early identify those with chronic lung injury, eligible for closer follow-up and more aggressive therapies.

Lung function in children with sickle cell disease from Central Africa

Lung function in patients with sickle cell anaemia (SCA) living in sub-Saharan Africa is largely unknown. Anthropometry and spirometry were cross-sectionally evaluated in patients with SCA (HbSS) aged 6–18 years and in schoolchildren from the Democratic Republic of the Congo. The Global Lung Initiative 2012 spirometry reference values were used. A total of 112 patients and 377 controls were included. Twenty-six per cent of patients with SCA had spirometry findings suggestive of a restrictive pattern and 41% had a FEV1 z-score <5th percentile. Wasting, increasing age and female sex were independently associated with increased risk of restrictive spirometry pattern in patients with SCA. Longitudinal studies could clarify the prognostic meaning of these findings.

Prenatal mercury exposure and child neurodevelopment outcomes at 18 months: Results from the Mediterranean PHIME cohort

INTRODUCTION

Neurotoxicity due to acute prenatal exposure to high-dose of mercury (Hg) is well documented. However, the effect of prenatal exposure to low Hg levels on child neurodevelopment and the question about "safety" of fish-eating during pregnancy remain controversial. International comparisons of Hg concentrations in mother-child biological samples and neurodevelopmental scores embedded in birth cohort studies may provide useful evidence to explore this issue.

MATERIALS AND METHODS

The Mediterranean (Italy, Slovenia, Croatia, and Greece) cohort study included 1308 mother-child pairs enrolled in the Public Health Impact of long-term, low-level, Mixed Element exposure in a susceptible population EU Sixth Framework Programme (PHIME). Maternal hair and venous blood, cord blood and breast milk samples were collected, and total Hg (THg) levels were measured. Demographic and socioeconomic information, lifestyles and nutritional habits were collected through questionnaires at different phases of follow-up. Children at 18 months of age underwent neurodevelopmental testing using the Bayley Scales of Infant and Toddler Development, Third Edition (BSID-III). Multivariate linear and logistic regressions were performed, for each country, to assess the association between THg and BSID-III scores, obtaining adjusted β coefficients and odds ratios (ORs). These values were used to conduct a meta-analysis, to explore possible heterogeneity among countries and to obtain combined estimates of the association between THg exposure and BSID-III scores.

RESULTS

Median THg (ng/g) was: 704 in maternal hair, 2.4 in maternal blood, 3.6 in cord blood, and 0.6 in breast milk. THg concentrations were highest in Greece and lowest in Slovenia. BSID-III neurodevelopmental scores were higher in Croatia and Slovenia. The meta-analysis of multivariate linear models found an overall positive association between language composite score and receptive communication scaled score and increasing THg in maternal hair (n = 1086; β = 0.55; 95%CI: 0.05-1.05 and n = 1075; β = 0.12; 95%CI: 0.02-0.22, respectively). The meta-analysis of logistic regression models showed that the overall adjusted OR between THg in cord blood and suboptimal gross motor score was borderline significant (n = 882; OR = 1.03; 95%CI: 1.00-1.07). Heterogeneity was found across the four sub-cohorts for language composite score in maternal blood, and for fine motor scaled score in cord blood and breast milk. Language composite score and THg concentrations in maternal venous blood were positively related (n = 58; β = 4.29; CI95% (-0.02, 8.60)) in Croatia and an increase of 1 ng/g of THg in maternal venous blood was associated with a reduced risk for children to fall in the lowest quintile of language score by 31% (n = 58; OR = 0.69; CI 95%: 0.37, 1.01). The comparison of β coefficients obtained by multiple linear regression model showed an inverse association between fine motor score and THg concentrations in cord blood for Croatia (n = 54; β = -0.53; CI 95%: -1.10, 0.04) and Slovenia (n = 225; β = -0.25; CI 95%: -0.49, -0.01). In Slovenia THg level in breast milk was associated with suboptimal fine motor performance (n = 195; OR = 5.25; CI 95%: 1.36, 21.10).

CONCLUSIONS

This study showed an inverse relation between THg levels and developmental motor scores at 18 months, although the evidence was weak and partially internally and externally inconsistent. No evidence of detrimental effects of THg was found for cognitive and language outcomes at these concentrations and age.

Measuring empathy in pediatrics: validation of the Visual CARE measure

Background

Empathy is a key element of “Patient and Family Centered Care”, a clinical approach recommended by the American Academy of Pediatrics. However, there is a lack of validated tools to evaluate paediatrician empathy. This study aimed to validate the Visual CARE Measure, a patient rated questionnaire measuring physician empathy, in the setting of a Pediatric Emergency Department (ED).

Methods

The empathy of physicians working in the Pediatric ED of the University Hospital of Udine, Italy, was assessed using an Italian translation of the Visual Care Measure. This test has three versions suited to different age groups: the 5Q questionnaire was administered to children aged 7–11, the 10Q version to those older than 11, and the 10Q–Parent questionnaire to parents of children younger than 7.

The internal reliability, homogeneity and construct validity of the 5Q and 10Q/10Q–Parent versions of the Visual Care Measure, were separately assessed. The influence of family background on the rating of physician empathy and satisfaction with the clinical encounter was also evaluated.

Results

Seven physicians and 416 children and their parents were included in the study. Internal consistency measured by Cronbach’s alpha was 0.95 for the 10Q/10Q–Parent versions and 0.88 for the 5Q version. The item-total correlation was > 0.75 for each item. An exploratory factor analysis showed that all the items load onto the first factor.

Physicians’ empathy scores correlated with patients’ satisfaction for both the 10Q and 10Q–Parent questionnaires (Spearman’s rho = 0.7189; p < 0.001) and for the 5Q questionnaire (Spearman’s rho = 0.5968; p < 0,001). Trust in the consulting physician was lower among immigrant parents (OR 0.43. 95% CI 0.20–0.93).

Conclusions

The Visual Care Measure is a reliable second-person test of physician empathy in the setting of a Pediatric Emergency Room. More studies are needed to evaluate the reliability of this instrument in other pediatric settings distinct from the Emergency Room and to further evaluate its utility in measuring the impact of communication and empathy training programmes for healthcare professionals working in pediatrics.

Professional attitudes toward incident reporting: can we measure and compare improvements in patient safety culture?

Objective

To establish categories of professionals' attitudes toward incident reporting by analyzing the trends in incident reporting while accounting for general risk indicators.

Design

The incident reporting system was evaluated over 6 years. Reporting rates, stratified by year and profession, were estimated using the non-mandatory reported events/full-time equivalent (NM-IR/FTE) rate. Other indicators were collected using the hospital's official database. Staff attitudes toward self-reporting were analyzed. Univariate and multivariable analyses were performed.

Setting

A 1000-bed Italian academic hospital.

Participants

Staff of the hospital (over 3200 professionals).

Interventions

None.

Main outcome measures

NM-IT/FTE rates, self-reported rates, patient complaints/praises, work accidents among professionals and 30-day readmissions.

Results

The overall reporting rate was 0.44 (95% confidence interval [CI]: 0.42-0.46) among doctors and 0.40 (95% CI: 0.39-0.41) among nurses. Between 2010 and 2015, only the doctors' reporting rate increased significantly (P = 0.04), from 0.29 (95% CI: 0.25-0.34) to 0.67 (95% CI: 0.60-0.73). Patient complaints decreased from 384 to 224 (P < 0.001) and work accidents decreased from 296 to 235 (P = 0.01), while other indicators remained constant. Multivariable logistic regression showed that self-reporting was more likely among nurses than doctors (odds ratio: 1.51; 95% CI: 1.31-1.73) and for severe events than near misses (odds ratio: 1.78; 95% CI: 1.11-2.87).

Conclusions

Because the doctors' reporting rates increased during the study period, doctors may be more likely to report adverse events than nurses, although nurses reported more events. Incident reporting trends and other routinely collected risk indicators may be useful to improve our understanding and measurement of patient safety issues.

[Cancer mortality of residents near a steel factory in Udine (Friuli Venezia Giulia Region, Northern Italy)]

OBJECTIVES

to evaluate the association between distance of residence from a steel factory, a point source of air pollution within an industrial area in Udine (Friuli Venezia Giulia Region, Northern Italy), and cancer mortality.

DESIGN

retrospective study. To evaluate the association between mortality rates and distance from the source, a Stone test analysis for all cases occurred in the entire area was conducted. The significance level was determined using Monte Carlo simulations.

SETTING AND PARTICIPANTS

a GIS mapped residential history of Friuli Venezia Giulia population was completed. Among residents within 5 km from the principal industrial plant of the area from 1989 to 2012, deaths caused by cancer were selected. Furthermore, according to the prevalent wind direction, an analysis was conducted also in a subgroup of residents located into the South-Western quadrant. A set of 8 bands with increasing distance from the point-source was defined. The total population was 37,473 inhabitants.

MAIN OUTCOME MEASURES

in each band, observed and expected cancer-related deaths (calculated on the basis of mortality rates in the entire area) and standardized mortality ratios (SMRs) were computed to test for decline in risk of mortality at different distances from the main chimney. Stone test, in which a decline in risk of disease with an increase in distance from the source of pollution is tested, was used.

RESULTS

the risk for all cancers and lung cancer was higher than expected. For male residents located within 2 km into the South-Western quarter there were 21 observed deaths from lung cancer vs. 13 expected (SMR: 1.62; p-value=0.02).

CONCLUSION

despite the fact that in the whole area cancer mortality is not increased, this study seems to support evidence of an excess of cancer deaths, especially lung cancer among males, near a steel factory. However, the study has limitations because of the small number of cases and the lack of individual exposure data and information about confounders (e.g., smoke habits and professional exposure). Therefore, a possible cause-effect interpretation of this association should be considered with caution.

Helicobacter pylori infection in immunized mice lacking major histocompatibility complex class I and class II functions

The role of major histocompatibility complex (MHC) class I- and class II-restricted functions in Helicobacter pylori infection and immunity upon oral immunization was examined in vivo. Experimental challenge with H. pylori SS1 resulted in significantly greater (P </= 0.025) colonization of MHC class I and class II mutant mice than C57BL/6 wild-type mice. Oral immunization with H. pylori whole-cell lysates and cholera toxin adjuvant significantly reduced the magnitude of H. pylori infection in C57BL/6 wild-type (P = 0.0083) and MHC class I knockout mice (P = 0.0048), but it had no effect on the H. pylori infection level in MHC class II-deficient mice. Analysis of the anti-H. pylori antibody levels in serum showed a dominant serum immunoglobulin G1 (IgG1) response in immunized C57BL/6 wild-type and MHC class I mutant mice but no detectable serum IgG response in MHC class II knockout mice. Populations of T-cell-receptor (TCR) alphabeta+ CD4(+) CD54(+) cells localized to gastric tissue of immunized C57BL/6 wild-type and MHC class I knockout mice, but TCRalphabeta+ CD8(+) cells predominated in the gastric tissue of immunized MHC class II-deficient mice. These observations show that CD4(+) T cells engaged after mucosal immunization may be important for the generation of a protective anti-H. pylori immune response and that CD4(+) CD8(-) and CD4(-) CD8(+) T cells regulate the extent of H. pylori infection in vivo.