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Background: Delirium is a serious and common condition that needs an upgrade of the scientific and clinical attention. Aim: To assess the delirium prevalence in an Italian university hospital. Methods: The monocentric 1-day observational study cohort has been conducted on March 15, 2018; the population was composed of adult hospitalized patients. All the eligible patients have been evaluated for the presence of delirium with the 4AT. Results: We enrolled 596 patients. Twenty-nine Acute and 3 Rehabilitation Units were involved in the study. The median age of the sample was 60 (IQR 48–74) and 52% (n = 313) were male. Patients from medical units were 42% (n = 252), from surgery units 41% (n = 249), and from rehabilitation units 15% (n = 95). Results of 4AT showed that 5.4% (n = 32) had delirium (4AT = 4), 12% (n = 73) had cognitive impairment (4AT = 1–3), and 82% (n = 491) had no delirium or cognitive impairment (4AT = 0). We found association between delirium and age, BMI, mortality at 30days, and hospital mortality. Delirium was related with Barthel Index, dementia, and anticholinesterase inhibitors. About devices in use, we observed a correlation of delirium with central venous catheter, feeding tube, and urinary catheter. Physical restraints were also correlated to delirium. Conclusions: We confirmed the presence of delirium across the hospital units, more in medical than in surgical ones. We found associations of delirium with conditions that limit movement, such as dementia, physical restraints, or devices. The development of delirium initiates a cascade of events culminating in the loss of independence and increased morbidity.

The home management of children with congenital heart disease (CHD) in the postsurgical phase represents one of the most complex phases for their parents. To date, the information available in the scientific landscape regarding the experiences and difficulties faced by the parents of children with CHD during this phase is still lacking. Accordingly, the study aims to synthesize the available qualitative evidence on parents’ experience during the home care management of children with CHD after cardiac surgery. Two databases were systematically searched to identify qualitative studies relating to parental experience about the home care management of children with CHD after cardiac surgery. Studies were carried out using Noblit and Hare's meta-ethnographic approach. The search yielded 183 results. After applying the inclusion criteria, nine articles were included in the meta-synthesis. The included articles were analyzed following the meta-ethnography approach. Five main themes were identified: (a) psychological and emotional impact and daily challenges; (b) continuity of care; (c) loneliness, isolation, and the need for knowledge; (d) new parental role; (e) assistance and support. The role of parents in the postsurgical phase of children with CHD is essential. However, numerous psychological nuances and emotional contradictions emerged from the experience of parents involved in this phase. Further studies are needed to identify parenting health and psychosocial support improvement strategies at home.

Vasoactive therapy represents a pivotal yet debated topic in critically ill patients and in those with chronic heart failure. Levosimendan, a calcium sensitizer agent with inodilating properties, has been in the market for 27 years and new indications came out over time. The aim of the present review is to highlight what is actually proven and what is debated on the use of levosimendan in light of its pharmacologic features and the pathophysiological evidence. Levosimendan was firstly seen as an inodilator acting through calcium sensitization in myocytes both in the myocardium and in vascular smooth muscle. Over the years, its anti-inflammatory properties became clearer and a role in preconditioning and weaning from mechanical circulatory support was postulated. More recently, a possible action on other muscular fibers, namely, diaphragmatic myocytes, was observed, leading to a possible application in mechanical ventilation-related diaphragmatic dysfunction. Preliminary data showed promising effects of levosimendan in patients with sepsis-related and stress-related (Takotsubo) myocardial dysfunction, in those difficult-to-wean from mechanical circulatory support and in ventilator-associated diaphragmatic dysfunction. Moreover, its vasodilating, anti-oxidant, and neuroendocrine properties pave the way to a number of additional possible applications. Larger studies yielding to more conclusive results on these indications are under way or need to be planned in the future.

BACKGROUND The ostomy patient's quality of life also depends on their peristomal health and thus first and foremost on keeping healthy peristomal skin. This is by no means an easy task, given that the incidence of peristomal skin disorders can be a factor in up to 80% of cases. Over the past 15 years, several tools have been developed to classify peristomal skin lesions to facilitate the management of the problem. These tools, however, meet the needs of healthcare professionals and those of patients. Hence the decision to work on an advanced version of the SACS©, currently the most widely used tool, with the setting up of the SACS Evolution Consensus Group. METHODS By applying the simplified Delphi method, the SACS Evolution Consensus Group critically re-read what had been garnered from the literature in the light of their personal clinical experience, identified the key issues to be addressed, and processed and refined the relevant statements. This made it possible to achieve the challenging objective of creating a peristomal health tool to help prevent peristomal skin lesions. RESULTS SACS Evolution is, indeed, a promising tool for preventing peristomal lesions. It is structured on two different levels, one for the patient and one for the healthcare professional, each characterized by specific language and based on an innovative concept of healthy peristomal skin, which is essential for those who work on peristomal health. CONCLUSIONS The SACS Evolution Consensus Group thus aims to validate this peristomal health tool and has already started a validation process so that the tool can be used in clinical practice.

Aim To describe the facilitators and barriers perceived by healthcare teams after the implementation of the Awakening, Breathing, Coordination, Delirium monitoring/management and Early mobility bundle in an intensive care unit in Italy. This multicomponent intervention strategy has been associated with lower probabilities of delirium, improved functional outcomes and shorter duration of mechanical ventilation. Methods A survey study conducted between June 2015 and May 2016 explored variables related to intensive care unit team members: perceptions of delirium; knowledge of the Awakening, Breathing, Coordination, Delirium monitoring/management and Early mobility bundle; teamwork perception and resource availability. Results Most of the participants affirmed having reasonable knowledge of delirium, outcomes of delirious episodes, Awakening, Breathing, Coordination, Delirium monitoring/management and Early mobility bundle components and their effectiveness. Low coordination between healthcare professionals was identified as a barrier. Overall, the time elapsing from the beginning of implementation of the bundle determined an increase in levels of awareness and confidence in the application of the bundle protocol and the Confusion Assessment Method Intensive Care Unit scale. Conclusion Issues with the Awakening, Breathing, Coordination, Delirium monitoring/management and Early mobility bundle relating to coordination, management and interdisciplinary ward rounds are critical and should be remedied and monitored. This study could provide the basis for improving bundle implementation strategies and surveying levels of progression in other intensive care units.

What is the degree of knowledge and awareness regarding testicular cancer and what interventions may improve information about testicular cancer in the male population? Testicular cancer incidence rates are increasing among young men, who typically demonstrate poor awareness and a lack of knowledge about this disease. Although testicular self-examination might be an effective method for early detection, few people know about this process or regularly perform it. This lack of examination could delay the diagnosis, which would affect treatment outcomes and mortality rates. A literature review was conducted starting from a bibliographic research in the major databases, and 450 documents were identified. The final analysis included 19 studies and found that men feel anxious about testicular cancer, which leads to a delay in their diagnosis and treatment, especially in developing countries. A widespread lack of awareness and knowledge about testicular cancer and self-examination exists in these nations. Few males performed testicular self-examination; most considered this procedure to be an invasion of their privacy and masculinity. The most effective tools to disseminate awareness about testicular cancer prevention were television, radio and YouTube. It is important to educate young males to spread information and improve awareness and knowledge about testicular cancer and self-examination. However, the support of regular self-examination is controversial, as this practice might also produce more harm than benefits due to the resulting false positives, fear and anxiety. Regular testicular cancer screening is therefore recommended in limited populations, including patients with risk factors, such as cryptorchidism or a family history of this cancer.

Self-care is a key concept for ostomy patients as much as for chronically ill patients. Many studies describe how reaching a good self-care level permits patient to perceive a higher quality of life, to adjust faster to the new condition, to grow empowerment feelings and to reduce readmissions and negative outcomes. There are many studies that state the negative impact of living with an ostomy on patients' quality of life. Quality of life is proven to be strictly related to self-care ability. Health professionals cannot fail to consider this aspect of ostomized patients' life to identify existing lacking areas of self-care abilities and to be able to project-specific educative interventions so to improve the impact that living with an ostomy has on patients. Specific self-care assessment tools could ensure self-care measurement, specific educational intervention planning and evaluation of caregivers' role.

Nutritional status is considered a significant factor determining the post-operative outcomes after RC. The aim of this literature review is to describe the impact of early oral nutrition on functional outcomes in patients underwent cystectomy. Usually, these patients are not fed orally until the return of gastrointestinal function, because early oral nutrition is often perceived as detrimental for the anastomosis integrity and is believed to cause nausea and vomiting. This phase of nutritional deprivation may vary from a few days to a few weeks, depending on the return of bowel movements. In clinical practice, patients are fed on a substitutive nutritional support based on the use of total parenteral nutrition or enteral nutrition, which have not demonstrated positive effects on bowel function recovery time, infection complication rates or length of hospital stay. The early introduction of oral feeding seems to allow early mobilization and to lead to an improvement of post-operative outcomes: bowel functions, pain, complications, patient's comfort and length of hospital stay. The early implementation of oral diet after cystectomy is associated with an improvement of considered outcomes, allowing an early recovery of patient's general conditions and reducing length of hospital stay.

Does the postoperative use of chewing gum in patients undergoing radical cystectomy (RC) facilitate intestinal motility recovery, reduce intestinal recanalization times and decrease length of stay? Postoperative ileus is a temporary impairment of intestinal motility and a frequent complication after RC. It is characterized by abdominal distention and absence of bowel functions, with symptoms including nausea, vomiting, pain and cramps. This results in an increase in length of stay, patient discomfort and costs. Different studies investigated the efficacy of chewing gum use, as a form of simulated feeding, in accelerating the resolution of ileus after several abdominal surgical procedures. Considering the lack of specific studies, some other conducted in similar abdominal procedures were included in this literature review. Despite the diversity of type of surgery, all considered studies show for patients who received chewing gum, a significant reduction in the time of first flatus and faeces, a reduction in the time of first bowel movements; not all included studies instead have found a significant decreasing in morbidity and length of stay. The chewing gum use seems to be a simple and inexpensive way to enhance recovery of bowel function, although it is probably still a little known procedure. It is possible recommending the administration of chewing gum in patients after cystectomy, monitoring the effectiveness, upon the recognition of possible conditions that might contraindicate its use.

ObjectivePhase-contrast magnetic resonance imaging (PC-MRI) is a non-invasive method used to compute blood flow velocity and volume. This systematic review aims to discuss the current status of renal PC-MRI and provide practical recommendations which could inform future clinical studies and its adoption in clinical practice.MethodologyA comprehensive search of all the PC-MRI studies in human healthy subjects or patients related to the kidneys was performed.ResultsA total of 39 studies were included in which PC-MRI was used to measure renal blood flow (RBF) alongside other derivative hemodynamic parameters. PC-MRI generally showed good correlation with gold standard methods of RBF measurement, both in vitro and in vivo, and good reproducibility. Despite PC-MRI not being routinely used in clinical practice, there are several clinical studies showing its potential to support diagnosis and monitoring of renal diseases, in particular renovascular disease, chronic kidney disease and autosomal dominant polycystic kidney disease.DiscussionRenal PC-MRI shows promise as a non-invasive technique to reliably measure RBF, both in healthy volunteers and in patients with renal disease. Future multicentric studies are needed to provide definitive normative ranges and to demonstrate the clinical potential of PC-MRI, likely as part of a multi-parametric renal MRI protocol.

The shift work increased the metabolic syndrome and urolithiasis in nurses? Problem metabolic syndrome and urolithiasis are two worldwide important health problems. Shift work and consequent sleep disorders are risk factors of developing metabolic syndrome. The aim of this literature review is to describe the effects of shift work on metabolic syndrome and urolithiasis in nurses. Search terms (free terms, MeSH): ‘metabolic syndrome’, ‘urologic diseases’; papers published in the last 10 years (2009-2019) were searched in some databases (PUBMED, CINAHL, Scopus, Embase and Cochrane Database of Systematic Review). We included all randomized controlled trials (RCTs), observational studies, reviews and we included papers studying metabolic syndrome and urolithiasis. Quality assessment of the papers was verified according to Dixon-Woods checklist. Seven articles were analysed. The literature review has shown that insulin resistance, hypertension, obesity, cardio vascular disease have a relationship with metabolic syndrome. People with obesity, insulin resistance or hypertension have a low urinary pH. The prevalence of obesity and insulin resistance has increased the risk of urolithiasis in both men and women. This risk has further increased in shift workers especially in nurses. There seems to be a bilateral association between hypertension and urolithiasis. Nurses are a population at risk of developing metabolic syndrome and consequently urolithiasis. It is important to understand whether nurses may be at risk of urolithiasis, to prevent bad habits and to anticipate days off. Nurses are a population at risk of developing metabolic syndrome and consequently urolithiasis.

PURPOSE: To evaluate chest computed tomography (CT) and pulmonary function test (PFT) findings in severe COVID-19 patients after discharge and correlate CT pulmonary involvement with PFT results. METHODS: COVID-19 patients admitted to our hospital between February 25 and May 2, 2020, were retrospectively included according to the following criteria: (a) COVID-19 defined as severe based on the WHO interim guidance (i.e., clinical signs of pneumonia plus respiratory rate > 30 breaths/min, severe respiratory distress, and/or SpO2 < 90 % on room air); (b) chest radiograph in the acute setting; (c) post-discharge unenhanced chest CT; and (d) post-discharge comprehensive PFT. Imaging findings were retrospectively evaluated in consensus by two readers, and volume of abnormal lung was measured on CT using 3D Slicer software. Differences between demographics, comorbidities, acute radiographic findings, PFT, and post-discharge clinical and laboratory data of patients with normal and abnormal CT findings were assessed by Mann-Whitney or Fisher tests, and the compromised lung volume-PFT association by Pearson correlation after removing possible outliers. RESULTS: At a median of 105 days from symptom onset, 74/91 (81 %) patients had CT abnormalities. The most common CT pattern was combined ground-glass opacity and reticular pattern (46/74, 62 %) along with architectural distortion (68/74, 92 %) and bronchial dilatation (66/74, 89 %). Compromised lung volume had a median value of 15 % [11-23], was higher in dyspneic patients, and negatively correlated with the percentage of predicted DLCO, VA, and FVC values (r = -0.39, -0.5, and -0.42, respectively). These PFT parameters were significantly lower in patients with CT abnormalities. Impairment of DLCO and KCO was found in 12 (13 %) cases, possibly implying an underlying pulmonary vasculopathy in this subgroup of patients. CONCLUSIONS: Most severe COVID-19 survivors still had physiologically relevant CT abnormalities about three months after the disease onset, with an impairment of diffusion capacity on PFT. A pulmonary vasculopathy was suggested in a minor proportion of patients.

Introduction ABO blood type A was reported to correlate with an increased risk of acute respiratory distress syndrome (ARDS) in white patients with severe sepsis and major trauma compared with patients with other blood types. Information regarding ABO phenotypes and major outcomes in patients with ARDS is unavailable. The primary aim was to determine the relationship between ABO blood type A and intensive care unit (ICU) mortality in patients with acute hypoxemic respiratory failure (AHRF). The secondary aim was to describe the association between ABO blood type A and ICU length of stay (LOS) in this study population. Methods In a multicenter, retrospective cohort study, we collected the clinical records of patients admitted from January 2012 to December 2014 in five ICUs of Northern Italy. We included adult white patients admitted to the ICU who were diagnosed with AHRF requiring mechanical ventilation. Results The electronic records of 1732 patients with AHRF were reviewed. The proportion of patients with ABO blood type A versus other blood types was 39.9% versus 60.1%. ICU mortality (25%) and ICU LOS (median [interquartile range], 5 [2–12] days) were not different when stratified by ABO blood type (ICU mortality, overall p value = 0.905; ICU LOS, overall p value = 0.609). SAPSII was a positive predictor of ICU mortality (odds ration [OR], 32.80; 95% confidence interval [CI], 18.80–57.24; p < 0.001) and ICU LOS (β coefficient, 0.55; 95% CI, 0.35–0.75; p < 0.001) at multivariate analyses, whereas ABO blood type did not predict ICU outcome when forced into the model. Conclusion ABO blood type did not correlate with ICU mortality and ICU LOS in adult patients with AHRF who were mechanically ventilated.

Patients with an indwelling urinary catheter are at risk of developing urinary tract infection: for each day of the catheter remaining in situ, there is an increasing risk from 3% to 7% for infection to appear. One of the main complications of catheterization is the onset of encrustations, frequently resulting in obstruction of the catheter. Aim of this study is to describe the problem of indwelling urinary catheter encrustation and prevention strategies. A narrative review of the literature was conducted. Indwelling urinary catheter encrustations originate more easily when urine contains high concentrations of poorly soluble constituents and when the state of the urinary tract enables their precipitation as an alkaline urinary pH, often associated with the presence of bacteria urease-producers, for instance Proteus mirabilis. Urease can generate crystals and this process keeps going until the accumulation of crystalline deposits block the urine flow within the catheter lumen. The literature suggests that there are manifold pharmacological and non-pharmacological strategies to prevent encrustations. The literature analysis suggests that the permanence of the catheter could potentially be one of the most relevant causes of encrustation. The catheterization duration is the most important risk factor for bacteriuria, essential for the process of encrustation to start off. There are many prevention strategies, among which promotion of nucleation pH (pHn) supplementation in the daily diet with liquids containing citrate; this is the most simple and suitable for all patients being inexpensive and effective.

Pulmonary Embolism (PE) incidence increases with age. Data on mortality and prognosis in elderly patients with suspected PE are lacking. (1) To assess 30- and 90-day mortality in subjects with PE from an elderly population seen in the emergency department (ED); (2) to test the prognostic accuracy of a simplified Pulmonary Embolism Severity Index (sPESI) coupled to a highly sensitive cardiac Troponin T (hs-cTnT) level. A retrospective cohort study was performed, including patients evaluated in the ED of Vimercate Hospital for clinically suspected PE from 2010 to 2012. Study population: n = 470, 63.4 % women, mean age ± SD 73.06 ± 16.0 years, 40 % aged ≥80 and 77.7 % ≥65 years old, confirmed PE: 22.6 % (106 cases). Within 30 and 90 days, mortality among patients with confirmed PE was 14.2 % (8.8–22.0) and 20.8 % (16.5–41.7). In subjects aged ≥80 years, 30-day mortality was 18.9 % among patients with confirmed PE, and 12.6 % among those with PE excluded (p = 0.317). Ninety-day mortality rates were 29.7 and 19.9 %, respectively (p = 0.193). In patients with confirmed PE, Negative Predictive Value of sPESI was 94.1 % (80.3–99.3) for 30 days and 88.2 % (72.3–96.7) for 90-day mortality. Adding the hs-cTnT level to sPESI did not improve its performance. (1) In an elderly population referring to the ED with clinically suspected PE, mortality was high both in subjects with and without confirmed PE; (2) the ability of sPESI and hs-cTnT to predict PE mortality seems to be lower than reported in studies based on data from younger populations. Better risk stratification tools will be necessary to improve clinical management in this setting.

Introduction D-dimer is commonly used in the workup of suspected Pulmonary Embolism (PE), but its specificity decreases with age. We evaluated whether using a higher cutoff value for D-dimer could increase the test specificity without reducing its sensitivity for ruling-out PE in elderly and very elderly patients presenting to the Emergency Department (ED). Material and Methods All patients with D-dimer and pulmonary Computed Tomography Angiography (CTA) performed in the ED of Vimercate Hospital, from 2010 through 2012 for clinical suspicion of PE were included in this retrospective cohort study. Results Study population 481 patients (63.4% women, mean age 73.0 ± 16.1 years, confirmed PE 22.5%). In very elderly patients (aged 80 or more years, n = 191), compared with standard 490 ng/mL D-dimer threshold, both higher fixed (1000 ng/mL) and age-adjusted cutoffs increase the specificity of D-dimer for the exclusion of PE maintaining a Negative Predictive Value of 100%. Potentially avoided CTAs were 12(6.3%) using 1000 ng/mL cutoff and 10(5.2%) age-adjusted. In very elderly patients the Number Needed to Test was incalculable for the standard cutoff (0 cases), 16 for 1000 ng/mL and 19 for age-adjusted. In patients with PE, index episode mortality was 6.5%, and death occurred only in subjects with D-dimer values above 1000 ng/mL and age-adjusted thresholds. Conclusion For very elderly patients with suspected PE in ED, both higher fixed D-dimer (1000 ng/mL) and age-adjusted thresholds increase test specificity for excluding PE without reducing its sensitivity, leading to a safe reduction in the number of CTAs.

We analyzed scores obtained at the Neuropsychiatric Inventory (NPI) by 20 patients with posterior cortical atrophy (PCA) and contrasted it with 20 patients having Alzheimer disease (AD). Patients with hallucinations and delusions were not included due to the high probability of a diagnosis of Lewy body disease. Prevalence of behavioral and psychological symptoms (BPSD) was 95% in the PCA group, the most frequent being apathy and anxiety. Cluster analysis on NPI subscales highlighted a behavioral subsyndrome characterized by agitated temper and irritability. Depression, anxiety, and apathy did not cluster with any other BPSD nor with each other. The PCA group showed a significantly higher proportion of anxious patients and worse anxiety score than patients with AD. No correlation was found between NPI data and demographic, clinical, or neuropsychological features nor were there significant differences for the same variables between anxious and nonanxious cases with PCA. In agreement with anecdotal reports, anxiety seems particularly relevant in PCA.

Background\ud \ud Phase‐contrast (PC) MRI is a feasible and valid noninvasive technique to measure renal artery blood flow, showing potential to support diagnosis and monitoring of renal diseases. However, the variability in measured renal blood flow values across studies is large, most likely due to differences in PC‐MRI acquisition and processing. Standardized acquisition and processing protocols are therefore needed to minimize this variability and maximize the potential of renal PC‐MRI as a clinically useful tool.\ud \ud \ud \ud Purpose\ud \ud To build technical recommendations for the acquisition, processing, and analysis of renal 2D PC‐MRI data in human subjects to promote standardization of renal blood flow measurements and facilitate the comparability of results across scanners and in multicenter clinical studies.\ud \ud \ud \ud Study Type\ud \ud Systematic consensus process using a modified Delphi method.\ud \ud \ud \ud Population\ud \ud Not applicable.\ud \ud \ud \ud Sequence Field/Strength\ud \ud Renal fast gradient echo‐based 2D PC‐MRI.\ud \ud \ud \ud Assessment\ud \ud An international panel of 27 experts from Europe, the USA, Australia, and Japan with 6 (interquartile range 4–10) years of experience in 2D PC‐MRI formulated consensus statements on renal 2D PC‐MRI in two rounds of surveys. Starting from a recently published systematic review article, literature‐based and data‐driven statements regarding patient preparation, hardware, acquisition protocol, analysis steps, and data reporting were formulated.\ud \ud \ud \ud Statistical Tests\ud \ud Consensus was defined as ≥75% unanimity in response, and a clear preference was defined as 60–74% agreement among the experts.\ud \ud \ud \ud Results\ud \ud Among 60 statements, 57 (95%) achieved consensus after the second‐round survey, while the remaining three showed a clear preference. Consensus statements resulted in specific recommendations for subject preparation, 2D renal PC‐MRI data acquisition, processing, and reporting.\ud \ud \ud \ud Data Conclusion\ud \ud These recommendations might promote a widespread adoption of renal PC‐MRI, and may help foster the set‐up of multicenter studies aimed at defining reference values and building larger and more definitive evidence, and will facilitate clinical translation of PC‐MRI.\ud \ud \ud \ud Level of Evidence\ud \ud 1\ud \ud \ud \ud Technical Efficacy Stage\ud \ud 1