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invito letturaIn questo numero:

-  The concept of chronic edema-a neglected public health issue and an international response: the LIMPRINT Study.
- The prevalence and associated factors of skin tears in Belgian nursing homes: A cross-sectional observational study.
- Pressure ulcers in patients receiving palliative care: A systematic review. 
- Negative pressure wound therapy for surgical wounds healing by primary closure.
- Skin complications associated with vascular access devices: A secondary analysis of 13 studies involving 10,859 devices.
- Preventing surgical site infections: Facilitators and barriers to nurses' adherence to clinical practice guidelines-A qualitative study.

CITAZIONE SECONDO PUBMED

Moffatt C, Keeley V, Quere I. The concept of chronic edema-a neglected public health issue and an international response: the LIMPRINT Study. Lymphat Res Biol. 2019 Apr;17(2):121-126. doi: 10.1089/lrb.2018.0085. PubMed PMID: 30995179.

       Abstract

Lymphedema has always been a neglected global health care problem. A central requirement for the development of any chronic disease is the clear use of public health definitions that can be used internationally to define populations. The term “lymphedema” has historically been defined as either primary, resulting from failure of lymphatic development, or secondary, following damage to the lymphatics (e.g., cancer treatment, injury, or filariasis). Attempts to integrate causes of edema arising from damage to the venous system or the effects of gravity, immobility, and systemic disease have rarely been integrated. More recently, the prominent role of the lymphatics in tissue fluid homeostasis in all forms of chronic edema has been recognized. These advances led to the development of the term: “Chronic edema: a broad term used to describe edema, which has been present for more than three months”. It can be considered an umbrella term that includes not only conventional “lymphedema” but also chronic swelling, which may have a more complex cause. This definition has been adapted in the international epidemiology study (LIMPRINT) that identified people throughout the health and social care systems in participating countries. Clearer definitions will allow for examination of this important public health problem that is likely to escalate given the projections of an aging population with multiple comorbidities. It will be possible to define both the hidden mortality and morbidity associated with complications, such as cellulitis and the impact on health-related quality of life. This evidence is urgently required to lobby for increased resource and effective health care in an increasingly competitive health care arena in which more established conditions have greater priority and funding.

Perché leggerlo:  Questo articolo fa parte di una serie di pubblicazioni scaturite da una interessante iniziativa, denominata LIMPRINT (Lymphoedema IMpact and PRevalence-INTernational Lympoedema Framework), uno studio internazionale finalizzato a definire l’entità e l’impatto di ciò che viene definito “edema cronico”, ossia “l’edema presente per più di tre mesi”, termine-ombrello che include anche il “linfedema convenzionale”.  Accanto alla raccolta dei dati epidemiologici in diverse nazioni (UK, Francia, Italia, Australia ecc), viene testimoniata una grande variabilità dei percorsi di cura, livelli assistenziali ecc a seconda dell’area geografica. Se da un lato emerge la scarsa considerazione che l’edema cronico/linfedema riceve agli occhi dei sistemi sanitari, dall’altro è indiscusso invece l’effetto peggiorativo che esso ha in termini di qualità della vita di coloro che ne sono affetti. 


CITAZIONE SECONDO PUBMED

Van Tiggelen H, Van Damme N, Theys S, Vanheyste E, Verhaeghe S, LeBlanc K, Campbell K, Woo K, Van Hecke A, Beeckman D. The prevalence and associated factors of skin tears in Belgian nursing homes: A cross-sectional observational study. J  Tissue Viability. 2019 May;28(2):100-106. doi: 10.1016/j.jtv.2019.01.003. Epub 2019 Feb 7. PubMed PMID: 30770306.

        Abstract

BACKGROUND: Although skin tears are among the most prevalent acute wounds in nursing homes, their recognition as a unique condition remains in its infancy. Elderly patients are at risk of developing skin tears due to increased skin fragility and other contributing risk factors. In order to provide (cost-) effective prevention, patients at risk should be identified in a timely manner. OBJECTIVES: (1) To determine the point prevalence of skin tears and (2) to identify factors independently associated with skin tear presence in nursing home residents. METHODS: A cross-sectional observational study was set up, including 1153 residents in 10 Belgian nursing homes. Data were collected by trained researchers and study nurses using patient records and skin observations. A multiple binary logistic regression model was designed to explore independent associated factors (significance level α<0.05). RESULTS: The final sample consisted of 795 nursing home residents, of which 24 presented with skin tears, resulting in a point prevalence of 3.0%. Most skin tears were classified as category 3 (defined as complete flap loss) according to the International Skin Tear Advisory Panel (ISTAP) Classification System and 75.0% were located on the lower arms/legs. Five independent associated factors were identified: age, history of skin tears, chronic use of corticosteroids, dependency for transfers, and use of adhesives/dressings. CONCLUSIONS: This study revealed a skin tear prevalence of 3.0% in nursing home residents. Age, history of skin tears, chronic use of corticosteroids, dependency for transfers, and use of adhesives/dressings were independently associated with  skin tear presence. 

Perché leggerlo:  Come è noto, le skin tears (ST) interessano prevalentemente i soggetti anziani, soprattutto se istituzionalizzati. Questo studio belga infatti è condotto nel setting delle RSA, e gode di un campione decisamente rappresentativo. Sebbene la prevalenza non sia particolarmente elevata, la maggior parte delle ST risulta essere della categoria più grave. Alla luce di ciò appare di estrema importanza l’applicazione delle misure preventive, alcune delle quali di semplice attuazione, come ad esempio la corretta rimozione di prodotti adesivi o, ancor meglio, la loro eliminazione ogni qual volta sia possibile. 


CITAZIONE SECONDO PUBMED

Ferris A, Price A, Harding K. Pressure ulcers in patients receiving palliative care: A systematic review. Palliat Med. 2019 Apr 24:269216319846023. doi: 10.1177/0269216319846023. [Epub ahead of print] PubMed PMID: 31018829.

        Abstract

BACKGROUND: Pressure ulcers are associated with significant morbidity and mortality as well as high cost to the health service. Although often linked with inadequate care, in some patients, they may be unavoidable. AIM: This systematic review aims to quantify the prevalence and incidence of pressure ulcers in patients receiving palliative care and identify the risk factors for pressure ulcer development in these patients as well as the temporal relationship between pressure ulcer development and death. DESIGN: The systematic review is registered in the PROSPERO database (CRD42017078211) and conducted in accordance with the 'PRISMA' pro forma. Articles were reviewed by two independent authors. DATA SOURCES: MEDLINE (1946-22 September 2017), EMBASE (1996-22 September 2017), CINAHL (1937-22 September 2017) and Cochrane Library databases were searched. In all, 1037 articles were identified and 12 selected for analysis based on pre-defined inclusion and exclusion criteria. RESULTS: Overall pressure ulcer prevalence and incidence were found to be 12.4% and 11.7%, respectively. The most frequently identified risk factors were decreased mobility, increased age, high Waterlow score and long duration of stay. CONCLUSION: The prevalence of press ure ulcers is higher in patients receiving palliative care than the general population. While this should not be an excuse for poor care, it does not necessarily mean that inadequate care has been provided. Skin failure, as with other organ failures, may be an inevitable part of the dying process for some patients.

Perché leggerlo:  Tra gli operatori sanitari è molto diffusa la percezione che le lesioni da pressione siano frequenti nei pazienti assistiti in cure palliative, e questa revisione sistematica dà corpo e numeri a tale percezione. E inesorabilmente ci si scontra con il perenne dilemma di quando diventi “inevitabile” una lesione cutanea, e se e in quale misura a ‘fallire’ sia l’organo cute, in conseguenza del processo di fine vita, oppure l’assistenza erogata a questi pazienti. 


CITAZIONE SECONDO PUBMED

Webster J, Liu Z, Norman G, Dumville JC, Chiverton L, Scuffham P, Stankiewicz M, Chaboyer WP. Negative pressure wound therapy for surgical wounds healing by primary closure. Cochrane Database Syst Rev. 2019 Mar 26;3:CD009261. doi: 10.1002/14651858.CD009261.pub4. PubMed PMID: 30912582; PubMed Central PMCID: PMC6434581.

        Abstract

BACKGROUND: Indications for the use of negative pressure wound therapy (NPWT) are broad and include prophylaxis for surgical site infections (SSIs). While existing evidence for the effectiveness of NPWT remains uncertain, new trials necessitated an updated review of the evidence for the effects of NPWT on postoperative wounds healing by primary closure. OBJECTIVES: To assess the effects of negative pressure wound therapy for preventing surgical site infection in wounds healing through primary closure. SEARCH METHODS: We searched the Cochrane Wounds Specialised Register, CENTRAL, Ovid MEDLINE (including In-Process & Other Non-Indexed Citations), Ovid Embase, and EBSCO CINAHL Plus in February 2018. We also searched clinical trials registries for ongoing and unpublished studies, and checked reference lists of relevant included studies as well as reviews, meta-analyses, and health technology reports to identify additional studies. There were no restrictions on language, publication date, or setting. SELECTION CRITERIA: We included trials if they allocated participants to treatment randomly and compared NPWT with any other type of wound dressing, or compared one type of NPWT with another type of NPWT. DATA COLLECTION AND ANALYSIS: Four review authors independently assessed trials using predetermined inclusion criteria. We carried out data extraction, 'Risk of bias' assessment using the Cochrane 'Risk of bias' tool, and quality assessment according to GRADE methodology. MAIN RESULTS: In this second update we added 25 intervention trials, resulting in a total of 30 intervention trials (2957 participants), and two economic studies nested in trials. Surgeries included abdominal and colorectal (n = 5); caesarean  section (n = 5); knee or hip arthroplasties (n = 5); groin surgery (n = 5); fractures (n = 5); laparotomy (n = 1); vascular surgery (n = 1); sternotomy (n = 1); breast reduction mammoplasty (n = 1); and mixed (n = 1). In three key domains four studies were at low risk of bias; six studies were at high risk of bias; and 20 studies were at unclear risk of bias. We judged the evidence to be of low or very low certainty for all outcomes, downgrading the level of the evidence on the basis of risk of bias and imprecision. Primary outcomes Three studies reported mortality (416 participants; follow-up 30 to 90 days or unspecified). It is uncertain whether NPWT has an impact on risk of death compared with standard dressings (risk ratio (RR) 0.63, 95% confidence interval (CI) 0.25 to 1.56; very low-certainty evidence, downgraded once for serious risk of bias and twice for very serious imprecision). Twenty-five studies reported on SSI. The evidence from 23 studies (2533 participants; 2547 wounds; follow-up 30 days to 12 months or unspecified) showed that NPWT may reduce the rate of SSIs (RR 0.67, 95% CI 0.53 to 0.85; low-certainty evidence, downgraded twice for very serious risk of bias).Fourteen studies reported dehiscence. We combined results from 12 studies (1507 wounds; 1475 participants; follow-up 30 days to an average of 113 days or unspecified) that compared NPWT with standard dressings. It is uncertain whether NPWT reduces the risk of wound dehiscence compared with standard dressings (RR 0.80, 95% CI 0.55 to 1.18; very low-certainty evidence, downgraded twice for very serious risk of bias and once for serious imprecision). Secondary outcomes We are uncertain whether NPWT increases or decreases reoperation rates when compared with a standard dressing (RR 1.09, 95% CI 0.73 to 1.63; 6 trials; 1021 participants; very low-certainty evidence, downgraded for very serious risk of bias and serious imprecision) or if there is any clinical benefit associated with NPWT for reducing wound-related readmission to hospital within 30 days (RR 0.86, 95% CI 0.47 to 1.57; 7 studies; 1271 participants; very low-certainty evidence, downgraded for very serious risk of bias and serious imprecision). It is also uncertain whether NPWT reduces incidence of seroma compared with standard dressings (RR 0.67, 95% CI 0.45 to 1.00; 6 studies; 568 participants; very low-certainty evidence, downgraded twice for very serious risk of bias and once for serious imprecision). It is uncertain if NPWT reduces or increases the risk of haematoma when compared with a standard dressing (RR 1.05, 95% CI 0.32 to 3.42; 6 trials; 831 participants; very low-certainty evidence, downgraded twice for very serious risk of bias and twice for very serious imprecision. It is uncertain if there is a higher risk of developing blisters when NPWT is compared with a standard dressing (RR 6.64, 95% CI 3.16 to 13.95; 6 studies; 597 participants; very low-certainty evidence, downgraded twice for very serious risk of bias and twice for very serious imprecision).Quality of life was not reported separately by group but was used in two economic evaluations to calculate quality-adjusted life years (QALYs). There was no clear difference in incremental QALYs for NPWT relative to standard dressing when results from the two trials were combined (mean difference 0.00, 95% CI -0.00 to 0.00; moderate-certainty evidence).One trial concluded that NPWT may be more cost-effective than standard  care, estimating an incremental cost-effectiveness ratio (ICER) value of GBP 20.65 per QALY gained. A second cost-effectiveness study estimated that when compared with standard dressings NPWT was cost saving and improved QALYs. We rated the overall quality of the reports as very good; we did not grade the evidence beyond this as it was based on modelling assumptions. AUTHORS’ CONCLUSIONS: Despite the addition of 25 trials, results are consistent with our earlier review, with the evidence judged to be of low or very low certainty for all outcomes. Consequently, uncertainty remains about whether NPWT compared with a standard dressing reduces or increases the incidence of important outcomes such as mortality, dehiscence, seroma, or if it increases costs. Given the cost and widespread use of NPWT for SSI prophylaxis, there is an urgent need for larger, well-designed and well-conducted trials to evaluate the effects of newer NPWT products designed for use on clean, closed surgical incisions. Such trials should initially focus on wounds that may be difficult to heal, such as sternal wounds or incisions on obese patients. 

Perché leggerlo:  Questa revisione sistematica ha l’obiettivo di valutare gli effetti del trattamento con pressione topica negativa sulla prevenzione delle infezioni del sito chirurgico nelle ferite che riparano per prima intenzione. Nonostante rispetto alla precedente RS del 2014 siano stati inclusi ben 25 nuovi studi, le conclusioni non cambiano, così come non cambia il livello della qualità – da bassa a molto bassa – degli studi pubblicati. Gli autori sottolineano che, nel 2019 come nel 2014, è incerto se l’utilizzo di TPN vs medicazioni standard riduca o aumenti l’incidenza di mortalità, deiscenze, seromi, o se semplicemente determini un incremento dei costi. Ma questa RS è “da leggere” per una annotazione finale dei ricercatori, che vogliamo porre in forma di domanda: Dato il costo della TPN, e dato la disseminata diffusione dell’utilizzo della TPN per la profilassi delle infezioni del sito chirurgico, non sarebbe il caso di fermarsi un attimo e condurre studi ben disegnati, ben condotti,  e con dimensioni significative del campione di pazienti, sui quali basare le nostre decisioni? 


CITAZIONE SECONDO PUBMED

Ullman AJ, Mihala G, O'Leary K, Marsh N, Woods C, Bugden S, Scott M, Rickard CM. Skin complications associated with vascular access devices: A secondary analysis of 13 studies involving 10,859 devices. Int J Nurs Stud. 2019 Mar;91:6-13. doi: 10.1016/j.ijnurstu.2018.10.006. Epub 2018 Dec 12. PubMed PMID:  30658228.

        Abstract

BACKGROUND: Vascular access devices are widely used in healthcare settings worldwide. The insertion of a vascular access device creates a wound, vulnerable to irritation, injury and infection. Vascular access-associated skin complications are frequently reported in the literature, however very little evidence is available regarding the incidence and risk factors of these conditions to inform practice and technology development. OBJECTIVES: To estimate the incidence of vascular access-associated skin complications, and to identify patient, catheter and healthcare-related characteristics associated with skin complication development. DESIGN: Secondary data analysis from 13 multi-centre randomised controlled trials and observational studies evaluating technologies and performance of vascular access devices in clinical settings between 2008 and 2017. SETTINGS: Six hospitals (metropolitan and regional) in Queensland, Australia. PARTICIPANTS: The 13 studies involved paediatric and adult participants, across oncology, emergency, intensive care, and general hospital settings. A total of 7669 participants with 10,859 devices were included, involving peripheral venous  (n=9933), peripheral arterial (n=341), and central venous access (n=585) devices. ANALYSIS: Standardised study data were extracted into a single database. Clinical and demographic data were descriptively reported. Cox proportional hazards regression models (stratified by peripheral vs central) were used for time-to-event, per-device analyses to examine risk factors. Univariate associations were undertaken due to complexities with missing data in both outcomes and covariates, with p<0.01 to reduce the effect of multiple comparisons. RESULTS: Over 12% of devices were associated with skin complication, at 46.2 per 1000 catheter days for peripheral venous and arterial devices (95% confidence interval, CI 42.1-50.7), and 22.5 per 1000 catheter days for central devices (95% CI 16.5-306). The most common skin complications were bruising (peripheral n=134, 3.7%; central n=33, 6.8%), and swelling due to infiltration for peripheral devices (n=296; 2.9%), and dermatitis for central devices (n=13; 2.2%). The significant risk factors for these complications were predominantly related to device (e.g., skin tears associated with peripheral arterial catheters [hazard ratio, HR 16.0], radial insertion [HR 18.0] basilic insertion [HR 26.0])) and patient characteristics (e.g., poor skin integrity associated with increased  risk of peripheral device bruising [HR 4.12], infiltration [HR 1.98], and skin tear [HR 48.4]), rather than management approaches. CONCLUSIONS: Significant skin complications can develop during the life of peripheral and central vascular access devices, and these are associated with several modifiable and non-modifiable risk factors. Further research is needed to evaluate effectiveness technologies to prevent and treat skin complications associated with vascular access devices. 

Perché leggerlo:  Utilizzare un dispositivo per l’accesso vascolare: quale operatore sanitario non l’ha mai fatto? Meno frequente invece è andare a calcolare l’incidenza delle complicanze cutanee associate agli accessi vascolari, e individuare le caratteristiche del paziente, catetere e contesto sanitario correlate allo sviluppo di tali complicanze. Questo studio, basato sull’analisi secondaria dei dati di oltre 7600 utenti, per un totale complessivo di 10.859 dispositivi, riporta che il tasso complessivo di complicanze cutanee è risultato del 12,3% per quanto riguarda i dispositivi periferici, e del 11,7% per quelli centrali. Sebbene a prima vista queste percentuali potrebbero sembrare poco rilevanti , bisogna tenere conto che vanno esplose sui oltre 2 miliardi di dispositivi per accessi vascolari inseriti ogni anno. 


CITAZIONE SECONDO PUBMED

Lin F, Gillespie BM, Chaboyer W, Li Y, Whitelock K, Morley N, Morrissey S, O'Callaghan F, Marshall AP. Preventing surgical site infections: Facilitators and barriers to nurses' adherence to clinical practice guidelines-A qualitative study. J Clin Nurs. 2019 May;28(9-10):1643-1652. doi: 10.1111/jocn.14766. Epub 2019 Jan 22. PubMed PMID: 30589979.

       Abstract

AIMS: To identify the facilitators of and barriers to nurses' adherence to evidence-based wound care clinical practice guidelines (CPGs) in preventing surgical site infections (SSIs) in an Australian tertiary hospital. BACKGROUND: Current research suggests that up to 50% of nurses are unaware of the evidence-based recommendations to prevent SSIs and that adherence to evidence-based CPGs is suboptimal. However, little is known regarding the facilitators and barriers to adherence to evidence-based CPGs.DESIGN: A qualitative study incorporating ethnographic data collection techniques. METHODS: Data collection included semi-structured individual interviews and focus groups (N = 20), and examination of existing hospital policy and procedure documents. Thematic analysis using inductive and deductive approaches was conducted. This manuscript adheres to the COnsolidated criteria for Reporting Qualitative research (COREQ) guidelines. FINDINGS: Data analysis revealed four themes: adhering to aseptic technique, knowledge and information seeking, documenting wound care and educating and involving patients in wound care. Facilitators and barriers within each theme were identified. Facilitators included participants' active information-seeking behaviour, a clear understanding of the importance of aseptic technique, and patient participation in wound care. Barriers included participants' knowledge and skills deficits regarding application of aseptic technique principles in practice, the availability of the hospital's wound care procedure document, suboptimal wound care documentation and the timing of patient education. CONCLUSIONS: There is a need to develop interventions to improve nurses’adherence to recommended CPGs including following aseptic technique principles, hand hygiene, documentation and patient education. Hospital procedure documents that outline wound care need to reflect current recommended CPGs. RELEVANCE TO CLINICAL PRACTICE: Adhering to evidence-based CPGs has been found to be effective in reducing and preventing SSIs. Our study provides an in-depth understanding of the barriers and facilitators to nurses' adherence to recommended CPGs. The findings may inform future practice improvements in wound care.

Perché leggerlo:  Applicare i principi dell’Evidence Based Practice nella gestione delle ferite chirurgiche permette di prevenire le infezioni. Conoscere quali sono i fattori che ostacolano questi comportamenti e quelli che li facilitano consente di ridurre la distanza tra quanto si scrive e quanto si mette in atto al letto del paziente.

 

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