Calidad de vida relacionada con la salud de los pacientes crónicos complejos / Health-related quality of life in complex chronic patients

OBJETIVO: determinar la calidad de vida relacionada con la salud de los pacientes crónicos complejos (PCC) mayores de 60 años en dos Zonas Básicas de Salud del Área Este de Valladolid, el perfil de las patologías crónicas que padecían y los factores influyentes en la calidad de vida relacionada con la salud (CVRS). MÉTODO: estudio descriptivo transversal entre enero y marzo de 2017. Se incluyó a los PCC con 60 años o más y sin deterioro cognitivo de dos zonas básicas de salud de Valladolid seleccionados mediante muestreo de conveniencia. Se recogieron variables sociodemográficas, clínicas y la variable CVRS (Cuestionario SF-36) mediante cuestionario y revisión de historias clínicas. Se realizaron índices de estadística descriptiva globales y desagregados por sexo y regresión lineal múltiple para la CVRS. RESULTADOS: participaron 73 personas (63% mujeres, edad media 77,4 años). El 71,2% padecía patologías cardiovasculares y osteomusculares. La CVRS global fue de 36,6 puntos, superior en el índice sumatorio mental (40,9) que en el físico (36,6) y menor en las mujeres en todos ellos (p< 0,05). El 24,5% de la variabilidad en CVRS fue explicada por el sexo (coeficiente en hombres 4,94), la presencia de patología mental (coeficiente -5,01) y patología osteomuscular (coeficiente -4,098). CONCLUSIÓN: las enfermedades cardiovasculares, las osteomusculares y la hipertensión arterial fueron los diagnósticos crónicos más prevalentes. Los pacientes crónicos complejos percibían mala CVRS. La CVRS global, física y mental fue inferior en las mujeres que los hombres. La variabilidad en CVRS fue explicada en un 24,5% por el sexo, la patología mental y osteomuscular. No se encontró asociación con la edad ni con otras patologías crónicas

OBJECTIVE: to determine the health-related quality of life in > 60-year-old complex chronic patients (CCPs) in two Basic Health Areas in Valladolid East, the profile of their chronic conditions, and the factors with impact on their HRQoL. METHOD: a descriptive cross-sectional study conducted between January and March, 2017. The study included ≥ 60-year-old CPPs without cognitive impairment from two Basic Health Areas in Valladolid, selected through convenience sampling. Sociodemographical and clinical variables were collected, as well as the HRQoL variable (SF-36 Questionnaire), through questionnaire and clinical record review. Overall descriptive indexes were applied, disaggregated by gender, and multiple linear regression for HRQoL. RESULTS: the study included 73 persons (63% women, mean age 77.4-year-old); 71.2% of them suffered cardiovascular and musculoskeletal conditions. The overall HRQoL score was 36.6, superior in the mental (40-9%) than in the physical summation index (36.6), and lower in women in all of them (p < 0.05). The 24.5% variability in HRQoL was explained by gender (4.94 ratio in men), the presence of mental conditions (-5.01 ratio) and musculoskeletal condition (-4.098 ratio). CONCLUSION: the most prevalent chronic diagnoses were cardiovascular and musculoskeletal conditions and hypertension. Complex chronic patients perceived a bad HRQoL. The variability in HRQoL was explained in 24.5% by gender, mental and musculoskeletal conditions. No association with age or other chronic conditions was found

A Day in the Life: Advanced Practice Nurses Providing Care to Patients with Musculoskeletal Conditions: Preparation, Role, and Impact.

Nurse practitioners (NPs) play an increasingly greater role in the delivery of orthopedic patient care. NPs practice in a wide variety of orthopedic settings having a significant positive impact on orthopedic care delivery. Few formal educational outlets exist for training NPs for orthopedic care. Many new orthopedic NPs rely on continuing education and an apprenticeship model of learning "on the job" with their surgeon counterparts. This article describes the preparation, role, and impact that today's NPs have on orthopedic care delivery.

Legal Implications in the Care of Orthopedic Patients: Serious Complications.

To help reduce potentially devastating outcomes from spinal complications and venous thromboembolism, it is essential for the bedside nurse to have a comprehensive understanding of risk factors and assessments. The orthopedic nurse carries a responsibility for accurately assessing, documenting, and mobilizing the team when abnormal changes occur. Nurses act as patient advocates. The bedside nurse must communicate with the physician. If a patient or family sues the health care team, after a careful screening of the case for merit, the legal process begins. A health care provider should never give in to the temptation to alter medical records.

Nurse-managed basal-bolus versus sliding-scale insulin regimen in subjects with hyperglycemia at admission for orthopedic surgery: a propensity score approach.

AIMS: A sliding-scale (SS) regimen is discouraged to correct hyperglycemia in hospital patients, but there is resistance to adoption of basal-bolus (BB) treatment in surgical units. We tested the feasibility and the effects of a nurse-based BB regimen in orthopedic surgery. METHODS: Following an intense training to implement a protocol amenable by nurses, a group of patients admitted with hyperglycemia in an orthopedic institute were prospectively followed according to a basal-bolus insulin regimen (BB, n = 80). They were compared with a hyperglycemic group eventually treated by sliding-scale insulin on demand (SS, n = 122). Diabetes was present in 196 cases. Metabolic control was assessed during the first 3 days of surgery; outcome data were tested by logistic regression, after adjusting for propensity score. RESULT: Average blood glucose and glucose variability were lower in BB versus SS (P < 0.001), in the presence of similar 3-day insulin doses. Complications were recorded in 68 cases (16.2% vs. 45.1% in BB and SS, respectively). BB regimen was associated with propensity-adjusted reduction in all adverse events [odds ratio (OR) 0.36; 95% confidence interval (CI) 0.17-0.76] and of systemic infections (OR 0.18; 95% CI 0.07-0.50) and with shorter hospital stay (8.8 ± SD 5.2 days vs. 12.5 ± 7.4; P < 0.01). The superiority of BB regimen was confirmed in the pair-matched analysis. CONCLUSIONS: The study proves the feasibility and the superiority of nurse-based BB versus SS treatment in metabolic control and on the risk of adverse events in orthopedic surgery patients with hyperglycemia.

Still too noisy - An audit of sleep quality in trauma and orthopaedic patients.

INTRODUCTION: An adequate amount of sleep is fundamental to health and well-being, especially for individuals recovering from an illness or injury. Trauma patients sustain musculoskeletal and tissue injuries and require a sufficient amount of sleep to promote recovery. However, it is known that patients can face difficulties sleeping in hospitals which impacts on their recovery. AIM: To determine the quality of sleep, influence of sleep quality and the impact of sleep quality on recovery in trauma and orthopaedic patients. METHODOLOGY: An exploratory descriptive design was applied using a clinical audit. As no standardised sleep assessment tool was identified, a sleep audit tool was developed. FINDINGS: A total of 40 patients were recruited from two trauma and orthopaedic wards from a London Hospital in the United Kingdom. Of these 17 patients (43%) rated the quality of sleep as 'poor' and nearly half (n = 19, 46%) reported that the quality of their night-time sleep had affected their recovery. Two-thirds of patients reported noise was the main factor that disrupted their sleep, making it the highest contributing sleep disruptor (n = 26, 65%). CONCLUSION: A significant association between poor quality of sleep and patient recovery was identified in this small sample of trauma and orthopaedic patients. The findings suggest that nurses should try to create a suitable sleeping environment to enhance patient recovery. There is a need for a standardised sleep assessment tool and sleep audit tool so that the quality of patients' sleep can be accurately assessed and documented.

Nurse's role in geriatric patients rehabilitation with musculoskeletal system diseases.

OBJECTIVE: Introduction: There is the increasing number of elderly patients with motion disabilities who require help and infatuations from nursing stuff. According to the Central Statistic Department (GUS), 25,4% people in Poland is over 60. In 2050 this number will increase to 40%(39,9%). This is very important topic because when the number of old people will increase the geriatric care will be more important. Especially because this is partially covered by nursing team. They should be satisfied and content of the job they do, and they should fulfill the aim they had when they started this profession. The aim: Analysis of nurse's work with patients, nursing procedures evaluation, how this procedure is scored by the nurse, what is the nurse's role in the rehabilitation process. PATIENTS AND METHODS: Material and methods: There were nursing process with geriatric patients analyzed in this article. There were nursing procedures investigated with the opinion of the person who performed this procedure. Role of the nurse in rehabilitation process was and the satisfaction from typical work load was analyzed. RESULTS: Results: Analyzed results showed that there is a deficit in the nurse's knowledge and the lack of the complex care in elderly patient with disabilities. There is lack of the preparation and education program to perform holistic patient care. This includes monitoring, examination and elderly needs. CONCLUSION: Conclusions: The nurse is the first link that helps the patient to understand his disease. The nurse develops therapeutic contact that helps the patient to feel safe and positively react for the introduced treatment.

Causal analysis of the impact of homecare services on patient discharge disposition.

This study uses observational causal inference to evaluate the impact of different combinations of home care services (nursing, therapies, social work, home aides) on end-of-episode disposition for individuals with chronic diseases associated with the circulatory, endocrine, and musculoskeletal systems. The potential to generate actionable recommendations for personalizing home care services, or treatment plans, from limited clinical and care needs data is demonstrated. For patients with chronic disease in the circulatory or musculoskeletal systems, a 2.91% and 3.38% decrease, respectively, in acute care hospitalization rates could be obtained by providing patients with therapy and nursing services, rather than therapy services alone.

Estudio descriptivo sobre las condiciones de trabajo y los trastornos musculo esqueléticos en el personal de enfermería (enfermeras y AAEE) de la Unidad de Cuidados Intensivos Pediátricos y Neonatales en el Hospital Clínico Universitario de Valladolid / Descriptive Study on the Working Conditions and Musculoskeletal Disorders in the Nursing Staff (Nurses and Auxiliary of Nursing) of the Pediatric and Neonatal Intensive Care Unit at the University Clinical Hospital of Valladolid

Introducción: Los trastornos musculoesqueléticos (TME) son lesiones del aparato locomotor que pueden tener un origen laboral. Afectan principalmente a la espalda, cuello, hombros y extremidades superiores. Es uno de los problemas más importantes de salud en el trabajo con elevados costes económicos. Entre las profesiones sanitarias, la enfermería es la principal afectada, en relación con la manipulación de enfermos. Desde los servicios de prevención se ha objetivado un aumento de las consultas en relación con TME por parte del personal de enfermería de la UCI pediátrica que podría estar relacionado con el aumento de la demanda asistencial. Objetivo: Estimar la prevalencia de TME del personal de enfermería de la UCI Pediátrica y Neonatal (UCIP) del Hospital Clínico Universitario de Valladolid (HCUV) durante el primer semestre del año 2016. Metodología: Estudio observacional transversal, en el que se registran los síntomas musculoesqueléticos referidos en los últimos 12 meses previos a la cumplimentación del cuestionario y se identifica la exposición a riesgos ergonómicos mediante la aplicación del método REBA por tareas. Resultados: Se obtuvieron datos de 17 trabajadoras con una edad entre 25 y 32 años. El 100% de trabajadoras ha presentado molestias musculoesqueléticas. La prevalencia de TME de cuello es del 94,1%, en hombros es de 64,7%, en zona dorso lumbar del 88,2%, en codo o antebrazo del 18,8% y en muñeca o manos del 18,8%. El análisis Inferencial en base a la edad, categoría ocupacional, puesto actual y variables ergonómicas no arroja relación significativamente estadística entre las variables. Sólo encontramos significación estadística entre las molestias musculoesqueléticas a nivel dorsal o lumbar y la antigüedad en el servicio de UCI (p=0,051). El método REBA estima que el 11,8% de las trabajadoras realizan tareas de riesgo «ALTO» y el 88,2% realizan tareas de riesgo «MEDIO». Conclusiones: Los resultados ponen de manifiesto que existe una alta prevalencia de TME en el personal de enfermería de la UCIP del HCUV, siendo el cuello y la zona dorsal o lumbar las más afectadas. No hemos podido encontrar una relación causal entre los TME y factores como la edad, categoría ocupacional, puesto actual y variables ergonómicas

Introduction: Musculoskeletal Disorders (MSDS) are injuries in the locomotor system that may have an occupational origin. Back, neck, shoulders and the upper extremities are mainly affected, making it one of the major health issues on the workplace with high economic costs. Among health professions, nursing staff is the main affected, regarding the care of the sick. From the prevention services it has been observed an increase of the consultations in connection with musculoskeletal disorders by the nursing staff of the pediatric Intensive Care Unit that could be related to the increase in the demand for care. Aim: To estimate the prevalence of MSDS among the nursing staff of the Neonatal and Pediatric Intensive Care Unit of the University Clinical Hospital of Valladolid (Hospital Clínico Universitario de Valladolid, HCUV). Methodology: A cross-sectional observational study, which analyzes the musculoskeletal symptoms referred in the last 12 months and identifies the exposure to ergonomic hazards applying the REBA method (Rapid Entire Body Assessment) depending on tasks. Results: Data was obtained from 17 women aged between 25 and 32 years. The 100% of female workers presented musculoskeletal discomfort. The prevalence of MSDS in neck is 94.1%, 64.7% in shoulders, and 88.2% in back lumbar region, 18.8% in the elbow or forearm and 18.8% in wrist or hands. The inferential analysis based on age, occupational category, current position and ergonomic variables does not reveal a statistically significant relationship between the variables. We only were able to find statistical significance between the musculoskeletal discomfort dorsal or lumbar level and length of service of Intensive Care Unit (p=0.051). The REBA method estimated that 11.8% of female workers perform tasks of «high-risk» and that the 88.2% perform tasks of «medium-risk». Conclusions: The results show that there is a high prevalence of MSDS in the nursing staff of the Pediatric Intensive Care Unit, being both the neck and the dorsal or lumbar area the most affected areas. We have not been able to find a causal relationship between MSDS and factors such as age, occupational category, current position and ergonomic variables

Recognition and nursing management of children with non-traumatic limp.

Children with acute onset non-traumatic limp often present to emergency departments (EDs). The limp can occasionally be associated with medical emergencies such as septic arthritis and slipped upper femoral epiphysis but is often due to less severe conditions. This article discusses the common and self-limiting causes of acute onset of non-traumatic limp in children, such as transient synovitis, reactive arthritis, and benign acute childhood myositis. It also discusses more severe conditions, including septic arthritis, osteomyelitis, slipped upper femoral epiphysis, Perthes disease, malignancies and non-accidental injury. Management and prognosis of these conditions are discussed in the context of guidance from the National Institute for Health and Care Excellence. The article includes two case studies that illustrate different presentations and the challenges that nurses who manage children in EDs are likely to come across in clinical practice.

Respite service use among caregivers of older people: comparative analysis of family dementia caregivers with musculoskeletal and circulatory system disorder caregivers.

OBJECTIVES: To identify the main drivers of the use of respite services and the need for respite services among caregivers of people experiencing dementia relative to family caregivers of people with other health conditions. METHOD: Based on nationally representative secondary data regression analysis was used to test the association between selected health conditions and the utilisation of and need for respite services. RESULTS: For a person living with dementia the odds of using respite care are higher than for a person with either a musculoskeletal or circulatory condition. Family caregivers of people living with dementia report the odds of the need for more respite as 5.3 times higher than for family caregivers of people with musculoskeletal conditions and 7.7 times higher than for family caregivers of people with circulatory conditions. The main reason for never using respite services is largely driven by the type of health condition, age of care recipient, existence of a spouse, and level of disability. CONCLUSIONS: Respite services that cater to the specific needs of families experiencing dementia at home should become a higher priority within the aged care sector. Alternative models of respite care that focus on prevention and early intervention would be cost effective.

Loneliness and psychological health of orthopaedic patients' caregivers: does gender make a difference?

Although research evidence indicates that loneliness is detrimental to mental health in diverse populations, impact of loneliness on psychological distress of orthopaedic patients' caregivers has been given little research attention. The present study examined the association of loneliness with psychological health, and explored gender differences in the loneliness and psychological health association among orthopaedic patients' caregivers. Participants were 250 patients' caregivers drawn from a national orthopaedic hospital in eastern Nigeria. Data was collected by means of self-report measures translated into the local dialect of the caregivers. Multiple regression results showed that loneliness positively predicted psychological distress in the total sample. Loneliness did not predict psychological distress of male caregivers, but it positively predicted psychological distress of female caregivers. In order to promote orthopaedic patients caregivers' mental health, gender-based differentials in the link between loneliness and psychological distress should be addressed by researchers and healthcare practitioners.

Impact of a transition nurse program on the prevention of thirty-day hospital readmissions of elderly patients discharged from short-stay units: study protocol of the PROUST stepped-wedge cluster randomised trial.

BACKGROUND: In France, for patients aged 75 or older, it has been estimated that the hospital readmission rate within 30 days is 14 %, a quarter being avoidable. Some evidence suggests that interventions "bridging" the transition from hospital to home and involving a designated professional (usually nurses) are the most effective in reducing the risk of readmission, but the level of evidence of current studies is low. Our study aims to assess the impact of a care transition program from hospital to home for elderly admitted to short-stay units. METHODS: This is a multicentre, stepped-wedge cluster randomised trial. The program will be implemented at three times of the transition: 1) during the patient's stay in hospital: development of a discharge plan, creation of a transitional care file, and notification of the primary care physician about inpatient care and hospital discharge by the transition nurse; 2) on the day of discharge: meeting between the transition nurse and the patient to review the follow-up recommendations; and 3) for 4 weeks after discharge: follow-up by the transition nurse. The primary outcome is the 30-day unscheduled hospital readmission or emergency visit rate after the index hospital discharge. The patients enrolled will be aged 75 or older, hospitalized in an acute care geriatric unit, and at risk of hospital readmission or an emergency visit after returning home. In all, 630 patients will be included over a 14-month period. Data analysis will be blinded to allocation, but due to the nature of the intervention, physicians and patients will not be blinded. DISCUSSION: Our study makes it possible to evaluate the specific effect of a bridging intervention involving a designated professional intervening before, during, and after hospital discharge. The strengths of the study design are methodological and practical. It permits the estimation of the intervention effect using between- and within-cluster comparisons; the study of the fluctuations in unscheduled hospital readmission or emergency visit rates; the participation of all clusters in the intervention condition; the implementation of the intervention in each cluster successively. TRIAL REGISTRATION: This study has been registered as a cRCT at clinicaltrials.gov (identifier: NCT02421133 ). Registered 9 March 2015.

Comparación de un programa de ejercicio intradiálisis frente a ejercicio domiciliario sobre capacidad física funcional y nivel de actividad física / Comparison of intradialysis exercise program versus home exercise on functional capacity and physical activity level

Introducción: El ejercicio durante la hemodiálisis es beneficioso, aunque son pocas las unidades de hemodiálisis que ofrecen un programa de ejercicio adaptado a estos pacientes. Por ello es necesario encontrar alternativas más económicas para realizar ejercicio. El objetivo es comparar los efectos de un programa de ejercicio intradiálisis frente a ejercicio domiciliario, sobre la adherencia al programa, la capacidad física funcional y el nivel de actividad física. Métodos: 17 pacientes en hemodiálisis de un centro de Valencia fueron aleatorizados dividiéndoles en un grupo de ejercicio intradiálisis (n=9) y un grupo domiciliario (n=8). Ambos programas incluían ejercicio aeróbico y de fuerza durante 4 meses. Se valoró una amplia batería de pruebas funcionales (Short Physical Performance Battery, equilibrio monopodal, Timed Up and Go, Sit To Stand to sit test 10 y 60, dinamometría de mano, fuerza de tríceps, 6 minutos marcha) y dos cuestionarios de nivel de actividad física (Human Activity Profile y Physical Activity Scale for Elderly). Resultados: 2 pacientes del grupo intradiálisis y 5 pacientes de ejercicio domiciliario finalizaron el programa y fueron analizados. Se observó un efecto significativo del factor tiempo en el caso del Human Activity Profile (P<.017). En las pruebas funcionales no se encontró ninguna diferencia significativa. En cuanto a la adherencia al ejercicio los pacientes del grupo intradiálisis cumplieron el 92.7% y el grupo domiciliario el 68.7% del total de las sesiones. Conclusiones: En ambos grupos se observa un aumento del nivel de actividad física. Sin embargo, es necesario modificar factores, tanto en el personal sanitario como en los propios pacientes, para conseguir mayor adherencia a los programas de ejercicio (AU)

Introduction: Although exercise training of patients undergoing hemodialysis is generally associated with positive outcomes, few hemodialysis units routinely offer intradialytic exercise therapy. This is often related to financial cost and/or staff limitations. Home-based. The aim of this study was to compare the effects of intradialytic versus home based exercise regarding adherence, functional capacity and physical activity level. Methods: 17 participants from hemodialysis unit from Valencia were randomized to either intradialytic exercise (n=9,) or home based exercise (n=8). Both programs consisted of a combination of strength training and aerobic exercise during 4 months. We assess functional capacity with different test (Short Physical Performance Battery, one leg stand, Timed Up and Go, Sit To Stand test 10 and 60,handgrip, one leg heel rise, 6 minutes walking test) and two questionnaires to asses physical activity level (Human Activity Profile and Physical Activity Scale for Elderly). Outcomes: 2 participant from the intradialysis exercise and 5 participants from de home based exercise were analysed. We observed a significant time effect in the Human Activity Profile (P<.017). In the functional capacity test there was not a significant difference. The subjects from the intradilysis exercise completed the 92.7% and the home based group the 68.7% of the total of the sessions. Conclusions: In both groups was an increment of the physical activity. Nevertheless, it is necessary to modify some factors, both in health professionals and patients, to achieve higher (AU)

The assessment and management of pain in an orthopaedic out-patient setting: A case study.

The management of pain is an important aspect of an orthopaedic nurse's role. The aim of this paper is to use an individual case study to demonstrate the role of an out-patient orthopaedic nurse in the identification, assessment and management of pain. This paper describes how pain was identified and managed for a patient in the orthopaedic outpatient department, highlighting that pain and its management are not isolated to the in-patient setting. The case study illustrates the importance of recognising pain and taking into account the numerous factors that can influence pain perception. The assessment of an individual patient's pain led to obtaining help from the Acute Pain Team which led to improvement in the patient's pain management and quality of life. The nursing team reflected and discussed the issues identified by this case study which led to changes in practice being introduced. This has resulted in an increased knowledge of and confidence in pain management within the nursing team and development and improvement of pain management practice within the orthopaedic out-patient department.

Caring for frail elders with musculoskeletal conditions and family caregivers' subjective well-being: The role of multidimensional caregiver burden.

OBJECTIVES: The present study examined the unique set of correlates of each dimension of the burden experienced by family caregivers of frail elders with musculoskeletal (MSK) conditions in China, and the role of caregiver burden in between caregiver stressors and subjective well-being. METHODS: The data was derived from a community sample of 494 elder-caregiver dyads from six urban districts of Shanghai (China). The elders were aged 75 or above, needed assistance in activities of daily living (ADL) and had MSK conditions. The family caregivers were these elders' primary caregivers and at the age of 18 or older. Path analysis was used to examine the proposed model. RESULTS: Care recipients' functional health, cognitive status and behavioral problems affected the multiple dimensions of caregiver burden differently. These three stressors also indirectly affected caregivers' subjective well-being through physical, social and developmental burden. CONCLUSIONS: The findings highlighted the mediator role of caregiver burden in between caregiver stressors and subjective well-being, which supported burden-as-mediator theory in understanding family caregiving for frail elders with musculoskeletal conditions in a Chinese context. The focus of intervention should be varied according to the levels of the primary stressors. Policy and intervention implications with regard to the ways of helping Chinese families care for their frail elders with MSK conditions were discussed.

Work-related musculoskeletal disorders in senior farmers: safety and health considerations.

Aging farmers are at high risk musculoskeletal disorders due to occupational exposures. The development of musculoskeletal conditions can increase older farmers' risk for additional injuries because many older farmers continue to work past typical retirement age. Occupational health nurses with agricultural expertise can assist farmers by evaluating their health and safety needs. Possible interventions include ergonomic improvements in farm equipment, safety improvements in farm environment, and referrals to programs that assist older farmers in modifying their farms to improve safety.

Work-related musculoskeletal disorders in nursing: current knowledge and ongoing challenges for occupational health.

Work-related Musculoskeletal Disorders (MSD) represent a major occupational health concern when considering the relationships between work and disease but associations between MSD and hospital work, especially in the nursing profession, aren't yet full understanded.QMSDuestions that still need to be answered include: Are nurses' work-related musculoskeletal symptoms and injuries dependent on the wards, the hospital organization and even the national occupational health policies that they originated from? Is their MSD related with workplaces demands, equipment, and nurse-patient ratios? Do these factors highlight different nursing occupational exposure to MSD hazards? What are the individual and psychosocial contributes to nurses WRMSDs in different nursing contexts? As such, a new approach which integrates more realistic working conditions, real hospital equipment, workplace features, and individual information would likely be a better way forwards in the addressing the current MSD epidemic among hospital nurses, worldwide......