TIAP: an observational procedure for assessing family relationships: a clinical case from the parenting evaluation context.

TIAP is an observational procedure to assess family functioning detecting simultaneously the role of each participant and the interdependence of relational behaviors. In particular, the procedure requires family members to play according to different interactive configurations (parent1-children; parent2-children, all together, children and parents as separate units) and therefore different microtransitions from one configuration to another. As such, the procedure allows to study how family members coordinate to maintain stability, promote change, and encourage members to explore different interactive configurations within the family system. TIAP has been validated through several studies conducted with different non-clinical groups of families that have highlighted the salient aspects of family functioning, and significant correlations with variables external to the family system, such as children's social-emotional competence in the educational context. This paper focuses on the use of TIAP in the contexts of assessing parental competence. Specifically, the article aims to describe, through the reference to a clinical case, the results emerged from a study conducted with 33 families involved in a parenting assessment process. The study is part of a broader collaborative project between the Child and Adolescent Neuropsychiatry Clinic of the Italian National Health Service in Parma, the University of Parma, and the Bologna Family Therapy Center. TIAP was administered to all the families involved as a complement to other tools routinely used for all cases handled by the professionals of the clinic. The coding system includes different indices. Some analyze the interactive family modes: family coordination (mutual attention and responsiveness), the responses to potentials for change (disregard, absorption, amplification), and intra-familiar exploration. Other indices concern the quality of the interactions: the relational triadic dynamic of microtransition (detaching-entrusting-welcoming-joining) and the consistency/inconsistency of the communication channels. The results highlighted how TIAP makes it possible to identify the specific interactive modalities of the different members and their interdependence and reciprocity, favoring the identification of both family weaknesses and family resources, including the children's contribution. Furthermore, the general data trend showed that TIAP indices detect some important prognostic elements capable of guiding the court's decisions.

Reversible myocardial injury aggravated by complex arrhythmias in three Toxoplasma gondii-positive dogs.

Although Toxoplasma gondii represents an oft-cited cause of myocarditis in veterinary medicine, the existing literature on the pre-mortem demonstration of T. gondii-associated myocardial injury (MI) in dogs is scant. In this case series, we provide detailed clinical, laboratory, echocardiographic and electrocardiographic description of three T. gondii-positive dogs diagnosed with MI. In all cases, etiological diagnosis was based on the antibody screening test (all dogs had IgM titres ≥1:64) and MI was demonstrated by a concomitant increase of the serum concentration of cardiac troponin I (0.25-9.6 ng/ml, upper hospital limit <0.15 ng/ml). In all dogs, MI was aggravated by complex arrhythmias (ventricular in two dogs, and either ventricular and supraventricular in the remaining dog). In one case, left ventricular systolic dysfunction was also present. All dogs underwent an extensive diagnostic work-up aimed at excluding additional comorbidities, either cardiac and extra-cardiac, possibly able to contribute to MI, arrhythmias and systolic dysfunction. All dogs received appropriate antiprotozoal (i.e., clindamycin) and antiarrhythmic (i.e., amiodarone, sotalol) therapy. This was systematically followed by a simultaneous decline in T. gondii serology titres, normalisation of troponin level and left ventricular systolic function, and the resolution of clinical and electrocardiographic abnormalities. In light of this result, therapies were interrupted and subsequent controls ruled out any disease relapse. In these cases, the clinical and instrumental findings obtained at admission and rechecks strongly supported the clinical suspicion of toxoplasmic myocarditis.

Reflective Practice: A Method to Improve Teachers' Well-Being. A Longitudinal Training in Early Childhood Education and Care Centers.

Various studies focused on educational contexts (0-6 years) point out that early childhood multi-age classrooms provide better learning strategies and socio-emotional competences of children, compared to single-grade classrooms. However, these studies have also shed light on the significant role of teachers. The multi-age classroom in particular is an opportunity for child development, provided that teachers consider problem-solving, flexibility, and co-construction as effective education strategies. Starting from these reflections, this study aimed to verify the efficacy of longitudinal training for the purpose of advancing the perceived well-being of early childhood teachers of multi-age groupings (18-54 months). Eight teachers and one pedagogical coordinator of an Italian Early Childhood Education and Care center took part in the study. All the participants were females. The critical aspect identified by the teachers was the multi-age classroom, which was perceived as making teaching and learning very difficult and ineffective for both themselves and for the children. The training lasted 10 months and implied a methodology focused on observations of some activities and reflective practice in the group that concerned both teachers and the pedagogical coordinator. The training involved the drafting of two types of written protocols: the observational reports of the specific activities observed (20), and the descriptive reports of reflective sessions (6). The content analysis of the reports revealed various and interesting themes regarding the teachers' perceived well-being, in terms of thoughts, behaviors, and feelings. The qualitative and longitudinal analysis of the themes that emerged in these protocols highlighted different processes of change in the teachers' perception, in particular with respect to three specific dimensions of well-being: sense of belonging, self-efficacy, and agency. At the end of the training, the teachers experienced a greater sense of belonging to the group of colleagues, a greater sense of self-efficacy, and an idea of themselves as active and meaningful participants. These results supported different reflections regarding the modalities through which to enhance the perceived well-being of teachers.

The study of Triadic Family Interactions: the Proposal of an Observational Procedure.

In the present article we provide an analytical review of 26 recent studies, which investigated triadic mother-father-child interactions through observational procedures. We focused on the methodological framework and compared the studies according to different criteria, in order to highlight the complexity of the object of study as well as the variety of dimensions and measures that have been used. Even if all the considered studies were designed to analyze triads, very few used coherently triadic categories; most of them focused on the individual members of the triad or on the parents with respect to the child. Joining the research that have stressed the importance of focusing on the reciprocal interactions of all members of the triad, we propose a methodological procedure that allows to describe the triad as a system without losing sight of the single participants and the simultaneity, interdependence, and processuality of their actions.

A prospective multicentric study of pulmonary rehabilitation in patients with chronic obstructive pulmonary disease and different clinical phenotypes.

BACKGROUND: Recently, it has been proposed that different clinical phenotypes can be recognized in patients with chronic obstructive disease (COPD), namely predominant airway disease or parenchymal destructive changes. OBJECTIVES: The aim of this prospective multicenter study was to evaluate whether these two phenotypes may influence outcomes following a pulmonary rehabilitation program (PRP). METHODS: We have prospectively evaluated 364 consecutive COPD patients (70 ± 8 years, 76.3% males) admitted to a standard hospital-based PRP in 6 Italian centers. According to their phenotype, the study cohort was divided into two groups: patients with airway obstructive (group 1, n = 208) or parenchymal destructive COPD (group 2, n = 156). Before and after PRP, values of 6-min walking distance, perceived breathlessness (Medical Research Council), health-related quality of life (St. George's Respiratory Questionnaire) and respiratory muscle function (maximal inspiratory and expiratory pressure) were recorded. RESULTS: PRP resulted in significant improvements in all outcome measures without any significant differences between groups. CONCLUSIONS: Our study confirms that COPD patients may benefit from pulmonary rehabilitation independent of their clinical phenotype.

Exercise performance after standard rehabilitation in COPD patients with lung hyperinflation.

The role of pulmonary rehabilitation (PR) in COPD patients with lung hyperinflation has not yet been fully investigated. We retrospectively evaluated the effect of a standard PR course on exercise tolerance and symptoms according to the presence or absence of associated lung hyperinflation, as defined by lung function parameters in three Italian rehabilitation centres. In a cohort of 823 COPD patients (age 71 ± 8 years, FEV1 56 ± 18% pred.) we have systematically recorded: changes (∆) in 6-minute walking test (6MWD) as the primary outcome; dyspnoea (D); muscle fatigue (F); SO2nadir during effort; perceived breathlessness score (MRC); and specific health-related quality of life (SGRQ). Outcomes were compared between patients with lung hyperinflation (n = 283, LH) or without (n = 540 No-LH). Groups were comparable for age, body mass index, baseline exercise tolerance, and breathlessness. ∆-6MWD (+72 ± 47 vs. +62 ± 42 m, p < 0.05); ∆-D (-2.3 ± 1.7 vs. -1.9 ± 1.3 point, p < 0.05) and ∆-SO2nadir (+1.4 ± 3.0 and +0.5 ± 3.3 point, p < 0.05) were greater in LH than in No-LH. Using a multivariate linear regression model, ∆-6MWD in the LH group significantly correlated with lower functional residual capacity (p = 0.021) and baseline 6MWD (p = 0.004). Tolerance, gas exchange and perceived symptoms during effort are the parameters that gain a significant benefit from standard rehabilitation in COPD patients with a lung hyperinflation condition.

Respiratory muscle training in patients recovering recent open cardiothoracic surgery: a randomized-controlled trial.

OBJECTIVES: To evaluate the clinical efficacy and feasibility of an expiratory muscle training (EMT) device (Respilift) applied to patients recovering from recent open cardiothoracic surgery (CTS). DESIGN: Prospective, double-blind, 14-day randomised-controlled trial. PARTICIPANTS AND SETTING: A total of 60 inpatients recovering from recent CTS and early admitted to a pulmonary rehabilitation program. Interventions. Chest physiotherapy plus EMT with a resistive load of 30 cm H2O for active group and chest physiotherapy plus EMT with a sham load for control group. MEASURES: Changes in maximal expiratory pressure (MEP) were considered as primary outcome, while maximal inspiratory pressures (MIP), dynamic and static lung volumes, oxygenation, perceived symptoms of dyspnoea, thoracic pain, and well being (evaluated by visual analogic scale-VAS) and general health status were considered secondary outcomes. RESULTS: All outcomes recorded showed significant improvements in both groups; however, the change of MEP (+34.2 mmHg, P < 0.001 and +26.1%, P < 0.001 for absolute and % of predicted, resp.) was significantly higher in active group. Also VAS dyspnoea improved faster and more significantly (P < 0.05) at day 12, and 14 in active group when compared with control. The drop-out rate was 6%, without differences between groups. Conclusions. In patients recovering from recent CTS, specific EMT by Respilift is feasible and effective. This trial is registered with ClinicalTrials.gov NCT01510275.

Predicting walking-induced oxygen desaturations in COPD patients: a statistical model.

BACKGROUND: Oxygen desaturation during walking can have important consequence on prognosis of COPD patients. However, a standard 6-min walk test (6MWT), useful in detecting desaturation in COPD patients, can be difficult to execute in some settings of COPD management, as in the community healthcare service. We evaluated a new scoring system for the risk of oxygen desaturation during walking in COPD patients: the walking desaturation score. METHODS: We collected data from symptomatic COPD in-patients admitted for rehabilitation (derivation cohort) and out-patients referred to the local community health service (validation cohort). S(pO2) was monitored during 6MWT, and the subjects were classified as walking desaturators or non-desaturators. By a regression analysis model we assigned a weighted score proportional to the measured percentage of explained variance for each variable. Risk estimates were computed as odds ratios. A receiver operating characteristic curve analysis and a Hosmer-Lemeshow goodness-of-fit test were then performed to measure discrimination and calibration of walking desaturation score. RESULTS: Baseline characteristics in the derivation cohort (n = 435, 74% of whom were walking desaturators) and the validation cohort (n = 238, 37% of whom were walking desaturators) were different. Resting arterial oxygen saturation measured from an arterial blood sample, P(aO2), and percent-of-predicted FEV1 were the variables that predicted walking desaturation. The proportion of walking desaturators (and odds ratio estimate) gradually increased according to walking desaturation score (range 0-6) and associated categories of desaturation risk (total walking desaturation score: low 0 or 1, high 2-3, very high 4-6) (chi-square P < .001). There was considerable predictive discrimination (area under the curve 0.90, 95% CI 0.86-0.93, P < .001), and calibration (Hosmer-Lemeshow chi-square 1.31, P = .86) values have been shown. CONCLUSIONS: Walking desaturation score accurately predicts and classifies the risk of walking desaturation in COPD patients. ClinicalTrials.gov Number NCT01303913.

Efficacy of temporary positive expiratory pressure (TPEP) in patients with lung diseases and chronic mucus hypersecretion. The UNIKO® project: a multicentre randomized controlled trial.

OBJECTIVE: To evaluate whether temporary positive expiratory pressure provides benefit in patients with lung diseases and chronic hypersecretion. DESIGN: Single blind multicentre randomized trial. SETTING: Five Italian rehabilitation centres. PARTICIPANTS: Ninety-eight patients with chronic obstructive pulmonary disease and/or chronic bronchitis (n=78), or bronchiectasis (n=20), with a peak cough expiratory flow >150 l/min and sputum production >30 ml/day, randomly included into two treatment groups. INTERVENTIONS: For 10 consecutive days, the active group performed twice a day 20-minute cycles of manually assisted breathing techniques in sequence with the addition of 15 minutes of temporary positive expiratory pressure, while the control group was treated by manually assisted breathing techniques alone. MEASURES: Within and between group changes of arterial oxygenation index, lung volumes and respiratory muscles strength were recorded at enrolment and after 3 and 10 treatment sessions. Pre-to-post treatment change of sputum volume and bronchial encumbrance (Δ-visual analog scale), sputum density and purulence were compared daily within the study period. RESULTS: No significant changes were recorded for the oxygenation index, while dynamic lung volumes and respiratory muscle strength significantly (P <0.05) improved in the active group. The group comparison analysis of the pre-to-post change showed that inspiratory capacity was significantly higher in the active than in the control group (+19.5% and +2.2%, P=0.044) at day 10. A greater improvement in Δ-visual analog scale was recorded in the active group at day 3 and 8. CONCLUSIONS: These preliminary data suggest that temporary positive expiratory pressure improves lung volumes and speeds up the improvement of bronchial encumbrance in patients with lung diseases and hypersecretion.

Rehabilitation in COPD patients admitted for exacerbation.

Recovery of lung function is delayed by up to two months following acute exacerbation (AE) of COPD patients. After AE, even with optimal medical therapy, it takes a considerable time for COPD patients to recover to baseline ability to perform routine physical activities. Although pulmonary rehabilitation (PR) has long been considered a useful non-pharmacological therapy in stable COPD individuals, there have been only a few studies into the effects of rehabilitation during and/or just after AE. This review updates the application of early PR and main physical therapies both during hospital acute care and following discharge of COPD patients who have experienced exacerbation. It is only recently that literature has demonstrated the feasibility and effectiveness of early PR in COPD patients undergoing AE. Nonetheless, early PR clearly appears to be a treatment indicated just after, or even during, an acute episode in hospital. Future studies should be able to clarify the practical role and effects of a timely application of rehabilitation to acute COPD, as well as the preferred modalities, duration and techniques to apply in this condition.

Intrinsic innervation of the horse ileum.

This paper describes the morphology and distribution of the enteric nervous system (ENS) cells and fibres immunoreactive for choline acetyltransferase (ChAT), neuronal nitric oxide synthase (nNOS), substance P (SP), calcitonin gene-related peptide (CGRP), NF200kDa (NF200), and S100 protein. The percentages of subclasses of enteric neurons in the total neuronal population were investigated by the use of anti-PGP 9.5 or anti-NSE antibodies. ChAT-IR myenteric plexus (MP) and submucosal plexus (SMP) neurons were 66+/-7% and 74+/-15%, respectively, whereas those cells expressing nNOS-IR were 38+/-7% and 5+/-1%, respectively. MP and SMP neurons expressing both phenotypes were also present. SP-IR was expressed by 14+/-13% of MP and 66+/-8% of SMP neurons whereas CGRP-IR was observed only in the SMP (43+/-6%). NF200-IR was expressed by 61+/-15% and 91+/-10% of the MP and SMP neurons, respectively. The majority of the CGRP-IR SMP neurons expressed also SP-IR. Almost all SP-IR neurons in both the plexuses were cholinergic. The present study quantifies the main neuronal subpopulations of the ENS of the horse ileum; these data might be utilized to understand the neuronal modifications which occur in several gastrointestinal tract disorders.