Covid-19 pandemic? Mental health implications among nurses and Proposed interventions.

Background: With its abrupt and huge health and socio-economic consequences, the coronavirus disease (COVID-19) pandemic has led to a uniquely demanding, intensely stressful, and even traumatic period. Healthcare workers (HCW), especially nurses, were exposed to mental health challenges during those challenging times. Objectives: Review the current literature on mental health problems among nurses caring for COVID-19 patients. Methods: This is a narrative review and critical evaluation of relevant publications. Results: Nurses experienced higher levels of stress, burnout, anxiety, depression, frustration, stigma, and depersonalization compared to other HCW. Factors that increased this symptomatology included concerns about infection or infection of family members, inadequate staff protective equipment, extended working hours, insufficient information, a reduced sense of security, and post-traumatic stress disorder. The factors that improved the psychopathology included a general positive attitude, job satisfaction, adequate information and education, harmonious group relationships, post-traumatic development, emotional intelligence, psychological counseling, mindfulness-based stress reduction, stable leadership, guidance, and moral and practical administrative support. Conclusions: Recent studies clearly show that nurses, especially women, are the most vulnerable subgroup among HCW and are particularly prone to mental health impacts during the COVID-19 pandemic. The documented mental health vulnerability of frontline nursing staff during the COVID-19 pandemic requires preventive nursing management actions to increase resilience and to develop relevant defense mechanisms.

The efficacy of immunomodulators in the prevention and suppression of anti-drug antibodies to anti-tumor necrosis factor therapy in inflammatory bowel disease.

The development of biological agents against tumor necrosis factor (TNF) has revolutionized the management of inflammatory bowel disease (IBD), frequently achieving induction and maintenance of remission in both ulcerative colitis and Crohn's disease. However, a loss of response due to the development of anti-drug antibodies (ADA) is seen annually in approximately 20% of IBD patients receiving anti-TNF therapy. Current evidence suggests that the use of immunomodulators (IMM), such as thiopurines (azathioprine and 6-mercaptopurine) or methotrexate, may prevent or suppress ADA formation. In this article, we present a comprehensive review of the available literature regarding the efficacy of IMM in the prevention and suppression of ADA development to anti-TNF therapy in patients with IBD.

Inflammatory Bowel Disease and Patients With Mental Disorders: What Do We Know?

Inflammatory bowel disease (IBD) is a multisystemic disease with a wide range of extraintestinal manifestations in both ulcerative colitis and Crohn's disease, while increasing evidence supports the interaction between gut and central nervous system, described as "gut-brain axis". According to epidemiological studies, it seems that patients with IBD present more frequently with impaired mental status compared to the general population, leading to diagnostic and management problems in this group of patients. The association between IBD and mental disorders, such as dementia and autism spectrum disorders, has not been fully clarified; genetic factors and the gut-brain axis seem to be involved. The purpose of this review is to present and analyze the epidemiological data about this issue, describe the possible pathogenetic mechanisms and discuss some considerations about the management of patients with IBD and impaired mental status.

A 13-year real-life study on efficacy, safety and biological effects of Vespula venom immunotherapy.

BACKGROUND: Hymenoptera venom immunotherapy (VIT) is a clinically effective treatment. However, little is known about its long-term clinical efficacy and biological effects. Several mechanisms have been proposed to account for VIT efficacy, including reduction of specific IgE and induction of allergen-specific IgG4, but the overall picture remains elusive. We investigated Vespula VIT clinical efficacy up to 8 years after discontinuation and the kinetics of Vespula-specific IgE and IgG4. Out of 686 consecutive patients we retrospectively selected and analysed a series of 23 patients with Vespula allergy that underwent a 5-year IT course, followed by a prolonged follow-up. METHODS: Clinical efficacy of VIT was assessed as number and severity of reactions to Vespula re-stinging events. The presence of Vespula-specific IgE and IgG4 was also monitored over time. RESULTS: During the VIT treatment, patients were protected, reporting no reactions or mild reactions in occasion of re-stinging events. This protection was entirely maintained during the follow-up, up to 8 years. Skin reactivity (reflecting mast cell-bound Vespula-specific IgE) and circulating Vespula-specific IgE levels declined substantially during VIT. Notably, this reduction was maintained over time during the follow-up. Moreover, all the patients were analysed for IgG4. A robust induction of Vespula-specific IgG4 was observed during the VIT course, with a substantial decline during the follow-up. CONCLUSIONS: We conclude that Vespula VIT is a clinically effective treatment, which induces long-term protection after discontinuation. The reduction of specific IgE, assessed by skin tests and RAST, closely matches the VIT- induced protection, while the IgG4 induction seems not to be associated with VIT clinical efficacy in the long term.

Long-term "real-life" safety of omalizumab in patients with severe uncontrolled asthma: A nine-year study.

BACKGROUND: Randomized Controlled Trials showed that omalizumab exhibited a good safety and tolerability profile in patients with moderate-to-severe asthma. However, safety data of long-term treatment with omalizumab are scarce. Our aim was to assess the safety of omalizumab in patients under long-term treatment in a real-life setting. METHODS: Difficult-to-control asthmatic patients treated with omalizumab up to 9 years were retrospectively evaluated. Mild to severe adverse events any and reasons for discontinuation were recorded. RESULTS: Ninety-one patients (26.4% males, mean age 49.9 ± 14.9 years) were included: mean treatment length, 3.8 ± 2.6 years; mean individual monthly dose, 514.5 ± 345.7 mg (range, 150-1200 mg). A total of 10,472 single injections were given cumulatively to the 91 patients (115 single injections per patients, on average, over a treatment period up to 9 years). Fifty-nine patients (64.8%) were treated for a period of time from 3 to 9 years, 14 of whom from 6 to 9 years. A high proportion of patients who discontinued treatment dropped out within the first year (18, 39.1%), mainly for reasons unrelated to treatment. Six patients (6.6%) discontinued omalizumab for treatment-related adverse events: arthralgia/myalgia (3 patients); urticaria, angioedema (1 patients); metrorrhagia (1 patient); relapsing herpes labialis (1 patient). Four other patients complained of mild adverse events (rhinitis/conjunctivitis, injection site reaction, fatigue, thrombosis) but continued the treatment. Anaphylaxis was not reported. CONCLUSIONS: Long-term treatment with omalizumab appears remarkably safe and well tolerated in real-life setting. Prolonged omalizumab treatment for many consecutive years did not increase the risk of side effects, particularly anaphylaxis.

Retrospective monitoring in the management of persistent asthma.

BACKGROUND: There is still considerable disagreement on several aspects of monitoring asthma with symptom score and peak expiratory flow (PEF). OBJECTIVE: To investigate patient adherence to a retrospective diary-card monitoring method in patients with poorly controlled persistent asthma, in a clinical management setting; to develop improved methods for fast manual entry data into a computer; and to generate real-time informative graphs of the data. METHODS: In 115 consecutive adult patients we applied a diary-card monitoring method in which the patient records symptom score and PEF. We analyzed the diary cards of 84 patients. We used SigmaPlot software to graph the data, and linear regression to analyze the relationship between days of expected diary-card completion and days of actual correct diary-card completion (completed entries). RESULTS: Linear regression gave an overall correlation coefficient (r(2)) of 0.65. Surprisingly, the r(2) values in the patients with mild, moderate, and severe asthma were 0.24, 0.44, and 0.99, respectively, revealing a striking correlation between adherence and severity. Moreover, when we arbitrarily set 75% as the minimum acceptable rate of days of completed diary-card entries, 68% of the patients were in the over-75% category. Remarkably, 100% of the patients with severe asthma were above the 75% cut-off. The graphing method we tested proved user-friendly, flexible, and quick, allowing computerized processing of 30 days of data sets in 5 min, and generation of high-quality self-explanatory graphs that facilitate rapid management decision making via visual pattern recognition. CONCLUSIONS: In a clinical setting, retrospective monitoring of patients with moderate and severe persistent asthma by symptom score and PEF is feasible, and patient adherence appears to be good, particularly in patients with severe asthma. We recommend a lower priority on retrospective monitoring in patients with mild persistent asthma. Monitoring should be carried out according to a definite follow-up protocol. Improving the quality and standardization of the monitoring graph is a priority.

Skin testing technique and precision in stinging insect allergy.

AIM: We report on quantitative analysis of skin tests in patients undergoing Hymenoptera venom immunotherapy. The need for accuracy, coupled with a sound manual technique, in performing this procedure is emphasized. Involuntary errors may occur and pose serious problems with interpretation of results. A revealing example is reported and the strategy devised to analyse the flaws and overcome the resulting problems is presented and discussed. BACKGROUND: Skin testing plays a key role in the diagnosis of most allergic disease and in the assessment of allergen immunotherapy. Particularly, insect sting allergy requires implementation of complex and demanding skin testing protocols and a competent nursing practice. METHODS: Sixteen patients were tested before starting the immunotherapy and after three years of treatment. Cutaneous response (expected to decline, following immunotherapy) was assessed as: (i) allergen-elicited wheal areas; (ii) ratios between allergen-elicited wheal areas and homologous histamine (positive controls) wheal areas. RESULTS: By using allergen-elicited areas, the paradoxical result was obtained that skin reactivity had increased instead of decreasing, upon immunotherapy. Histamine response analysis suggested that this paradox might rather be the result of a technical flaw. Analysis of written notes of routine clinical meetings revealed that an important manual flaw had been detected (and corrected) some years earlier, affecting the results of the baseline testing (viz. the allergen was injected deeper in the skin, yielding a weaker response). Skin reactivity evaluation in terms of allergen-histamine ratio confirmed this interpretation, as, when the baseline ratios were compared with the three years immunotherapy ratios, a distinct decline in skin reactivity was detected, as expected. CONCLUSIONS: Skin testing in insect sting allergy is a conceptually and manually complex procedure, which should be subjected to systematic quality control assessment, like a laboratory procedure. The personnel involved in the performance of this procedure should receive appropriate and extensive training. RELEVANCE TO CLINICAL PRACTICE: Diagnosis of allergic diseases and monitoring of immunotherapy largely rely on impeccable skin testing technique.