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Objectives: To update the 2017 European Alliance of Associations for Rheumatology (EULAR) recommendations for treatment of systemic sclerosis (SSc), incorporating new evidence and therapies., Methods: An international task force was convened in line with EULAR standard operating procedures. A nominal group technique exercise was performed in two rounds to define questions underpinning a subsequent systematic literature review. The evidence derived was discussed and overarching principles, recommendations and future research agenda were iteratively developed with voting rounds., Results: The task force agreed on 22 recommendations covering 8 clinical/organ domains including Raynaud's phenomenon, digital ulcers, pulmonary arterial hypertension, scleroderma renal crisis, skin fibrosis, interstitial lung disease (ILD), gastrointestinal manifestations and arthritis. Most new recommendations are related to skin fibrosis and ILD. These included novel recommendations for the use of mycophenolate mofetil, nintedanib, rituximab and tocilizumab for the treatment of these crucial disease manifestations. The recommendations also included first-line and second-line interventions, providing increased utility for rheumatology practitioners. Important additions to the future research agenda included consideration of novel interventions for the management of vascular, musculoskeletal and gastrointestinal manifestations and calcinosis, as well as for the local management of digital ulcers., Conclusion: These updated recommendations include the first set of synthetic and biological targeted therapies recommended for key fibrotic manifestations of SSc as well as first-line combination treatment for newly diagnosed pulmonary artery hypertension and prioritise a new research agenda for the coming years., Competing Interests: Competing interests: Each author has signed a detailed ICMJE sent as online supplemental file 2., (© European Alliance of Associations for Rheumatology, EULAR 2024. Re-use permitted under CC BY-NC-ND. No commercial re-use. No derivatives. See rights and permissions. Published by BMJ on behalf of EULAR.)

Gastrointestinal involvement (GI) is a frequent and troublesome complication of systemic sclerosis (SSc), whose etiology is poorly understood, though it is hypothesized that autoimmunity and progressive vasculopathy may play a role. Vasculopathy is considered one of the main pathogenetic pathways responsible for many of the clinical manifestations of SSc, and, therefore, studying the principal splanchnic vessels (i.e., superior mesenteric artery-SMA and inferior mesenteric artery-IMA) with Doppler Ultrasound (DUS) may provide further insights into measuring the progression of vasculopathy, evaluating its possible association with SSc GI symptoms, and determining whether it plays a role in the development or severity of SSc GI disease. A cohort of SSc patients consecutively recruited underwent DUS examination, and associations with GI (UCLA-GIT 2.0 questionnaire) and extraintestinal SSc characteristics were evaluated. Semiquantitative DUS parameters (resistive index-RI and pulsatility index-PI), were applied for splanchnic vessel assessment in SSc patients and healthy subjects (HS). Moreover, a review and meta-analysis of the literature to understand which the values of the main semiquantitative DUS parameters (RI and PI) are both in SSc patients and HS has been conducted. Seventy-eight patients completed DUS examinations and clinical assessments. 30 (39%) were classified as diffuse cutaneous SSc (dcSSC), 35 (45%) as limited cutaneous SSc (lcSSc) and 13 (17%) as sine scleroderma. A significant difference was found both for SMA RI (p for trend = 0.032) and SMA PI (p for trend = 0.004) between patients with sine scleroderma, lcSSc and dcSSc, with lower values observed in the sine scleroderma and lcSSc groups. IMA RI and PI were significantly correlated with GI symptoms such as fecal incontinence (ῥ - 0.33, p = 0.008 and ῥ - 0.30, p = 0.021, respectively). By multivariate analysis, significant associations were confirmed between SMA RI and SMA PI and mRSS (β 0.248, p = 0.030 and β 2.995, p = 0.004, respectively) and with bosentan (β 0.400, p = 0.003 and β 3.508, p = 0.001, respectively), but not with anticentromere antibody (ACA). No significant differences were found between the weighted median values of SMA RI and SMA PI of SSc patients compared to those of HS that were derived from the meta-analysis of the literature (p = 0.72 and p = 0.64, respectively). This cross-sectional study confirms that the splanchnic vasculature of SSc patients can noninvasively been studied with DUS. Vascular splanchnic involvement correlates with the presence and/or severity of specific clinical features in SSc, including GI. Larger and prospective studies are needed to confirm these preliminary observations and to examine the role of DUS in SSc-risk stratification and GI progression and to obtain definitive data regarding both HS and SSc patients splanchnic DUS parameters., (© 2024. The Author(s).)

Telemedicine and digital health represent alternative approaches for clinical practice; indeed, its potential in healthcare services for prevention, diagnosis, treatment, rehabilitation, and disease monitoring is widely acknowledged. These are all crucial issues to consider when dealing with chronic Rheumatic and Musculoskeletal Diseases (RMDs). The aim was to determine the current state of telemedicine in the field of rheumatology, considering the tools and devices in use as well as the Patient Reported Outcomes. A scoping review was performed following the PRISMA-ScR, retrieving articles through five databases from 1990 to 2022. Inclusion criteria were as follows: (I) adult patients with RMDs, (II) original research papers in the English language with available abstracts, and (III) telehealth and telemedicine are provided as healthcare services. Within the 62 included studies, multiple tools of telemedicine were used: 21/62 websites/online platforms, 18/62 mobile applications, 16/62 telephone contacts, 5/62 video-consultations, and 1/62 wearable devices. Outcomes were classified based on the economic, clinical, and humanistic framework. Clinical outcomes assessed through digital tools were pain, disease activity, and serum uric acid levels. Humanistic outcomes have been grouped according to four categories (e.g., mental and physical function, health management, and health perception). The heterogeneity of digital tools in the field of rheumatology highlights the challenge of implementing reliable research into clinical practice. Effective telerehabilitation models have been presented, and the use of a tight control strategy has also been mentioned. Future research should focus on establishing studies on other RMDs as well as summarizing and formulating clinical guidelines for RMDs. Key Points • Evidence for the usefulness of telemedicine and digital health for managing and monitoring rheumatic and musculoskeletal diseases is progressively increasing. • Several digital tools effectively measure clinical and humanistic and patient reported outcomes in rheumatic and musculoskeletal diseases. • Integrating diverse digital tools in rheumatology is challenging yet promising. • Future research should focus on developing standardized recommendations for practical use of telemedicine in daily practice., (© 2024. The Author(s).)

Background: To meet the population's needs, community care should be customized and continuous, adequately equipped, and monitored., Introduction: Considering their fragmented and heterogeneous nature, a summary of community healthcare services described in European literature is needed. The aim of this study was to summarize their organizational models, outcomes, nursing contribution to care, and nursing-related determinants of outcomes., Methods: A systematic review was performed by searching PubMed, CINAHL, Scopus, and Embase in October 2022 and October 2023 (for updated results). Quantitative studies investigating the effects of community care, including nursing contribution, on patient outcomes were included and summarized. Reporting followed the PRISMA checklist. The review protocol was registered on PROSPERO (CRD42022383856)., Results: Twenty-three studies describing six types of community care services were included, which are heterogeneous in terms of target population, country, interventions, organizational characteristics, and investigated outcomes. Heterogeneous services' effects were observed for access to emergency services, satisfaction, and compliance with treatment. Services revealed a potential to reduce rehospitalizations of people with long-term conditions, frail or older persons, children, and heart failure patients. Models are mainly multidisciplinary and, although staffing and workload may also have an impact on provided care, this was not enough investigated., Discussion: Community health services described in European literature in the last decade are in line with population needs and suggest different suitable models and settings according to different care needs. Community care should be strengthened in health systems, although the influence of staffing, workload, and work environment on nursing care should be investigated by developing new management models., Conclusions and Implications for Health Policy: Community care models are heterogeneous across Europe, and the optimum organizational structure is not clear yet. Future policies should consider the impact of community care on both health and economic outcomes and enhance nursing contributions to care., (© 2024 The Author(s). International Nursing Review published by John Wiley & Sons Ltd on behalf of International Council of Nurses.)

Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Objective: Proton pump inhibitors (PPIs) are widely prescribed to treat gastroesophageal reflux disease (GERD) in Systemic Sclerosis (SSc). However, not all patients adequately respond to the treatment, and there are frequent concerns about the safety of long-term use of PPIs. Our aim was to identify the main problems/complaints of SSc patients on PPIs, as well as understand their unmet needs., Methods: SSc patients treated with PPIs were invited through international patient associations and social media to participate in an online survey., Results: We gathered 301 valid responses from 14 countries (United Kingdom 19.3% and United States 70.4%). Multiple PPIs use (two: 30% and three: 21% in series) was common. The majority (89%) reported improvement in gastrointestinal symptoms from receiving PPIs. Side effects attributed to receiving PPIs were uncommon (19%); however, most (79%) were potentially concerned. Around half (58%) had received lifestyle information, and most (85%) had searched online for information about PPIs. Only in the minority (12%) had a surgical approach been discussed; however, half (46%) indicated that they would be willing to undergo surgery to resolve their GERD symptoms but had important concerns., Conclusion: Despite the frequent use of PPIs in patients with SSc, there is significant heterogeneity in prescription, and combination therapy (PPIs plus other medication for acid reflux) is not uncommon (approximately 40%). Patients have significant concerns about PPIs side effects. Education about PPIs is often neglected, and patients very frequently use online sources to obtain information on drug treatment. A surgical approach is infrequently discussed, and patients fear this potential therapeutic approach., (© 2023 American College of Rheumatology.)

Self-care plays a critical role in symptom recognition, management, and risk factor modification for patients with chronic illnesses. Despite its significance, self-care levels in this population are generally poor. Health literacy (HL) is pivotal for promoting effective self-care, yet the association across specific chronic illnesses remains fragmented and conflicting. Therefore, a systematic review and meta-analysis will be conducted. Inclusion criteria encompass quantitative studies involving adult patients with at least one chronic illness reporting on the association between a measure of HL and one or more elements of self-care behaviors as outcomes. Databases to be searched include PubMed, CINAHL, APA PsycINFO, Embase, Web of Science, and Cochrane Central Register of Controlled Trials. The studies will undergo risk of bias and certainty of evidence assessment using ROBINS-E and GRADE. Extracted data will include authors, publication date, aim(s), study location, design, sample characteristics, chronic illness type, study length, HL, and self-care measures. Understanding the link between HL and self-care can aid healthcare providers in implementing strategies to enhance health-promoting behaviors, contributing valuable insights to the scientific community and fostering nuanced discussions. This protocol ensures methodological transparency, stimulates discourse, and paves the way for informed interventions to improve overall health outcomes.

Rationale and Aim: Health literacy (HL) is pivotal for the successful self-management of chronic diseases. Little HL information is currently available in SSc patients; therefore, the present study aims at evaluating the HL levels in an Italian cohort of SSc patients., Methods: SSc patients were enrolled with the support of Italian patient associations, from September 2022 to March 2023. Health literacy characteristics were derived from the Health Literacy Scale European Questionnaire-16 (HLS-EU-Q16), consisting of 16 items designed on a four-point Likert scale ranging from "very difficult" to "very easy", and three HL levels were identified: inadequate HL (0-8 score); problematic HL (9-12 score); and sufficient HL (13-16 score)., Results: Enrolled patients (n = 57, mean age = 59 years, SD = 13.2) were mostly female (98.2%), partnered (73.7%), and unemployed or retired (67.9%). Almost half of SSc patients were diagnosed more than 10 years ago, with first symptoms appearing on average 19 years ago (SD 10.5). In 63% of the participants, the overall health literacy skills were inadequate, or problematic, especially in the health care and disease prevention domains. Indeed, 49.2% of the patients declared difficulty in finding information on treatments for illnesses and where to get professional help (42.1%), 47.6% found difficulty in retrieving information on how to manage mental health problems, and 40.4% declared difficulties in judging whether the information on health risks in the media was reliable., Conclusions: Our findings show that SSc patients have inadequate or problematic levels of HL, suggesting the need for periodic screenings to uncover poor health literacy skills and to provide tailored and understandable educational material. This study was not registered.

Introduction: Digital ulcers (DUs) significantly impact on quality of life and function in patients with systemic sclerosis (SSc). The aim of our survey was to explore patients' perspectives and their unmet needs concerning SSc-DUs., Materials: SSc patients were invited through international patient associations and social media to participate in an online survey., Results: 358 responses were obtained from 34 countries: US (65.6%), UK (11.5%) and Canada (4.5%). Recurrent DUs are common: >10 DUs (46.1%), 5-10 DUs (21.5%), 1-5 DUs (28.5%), 1 DU (3.9%). Fingertip DUs were most frequent (84.9%), followed by those overlying the interphalangeal joints (50.8%). The impact of DUs in patients is broad, from broad-ranging emotional impacts to impact on activities of daily living, and personal relationships. Half (51.7%) of respondents reported that they received wound/ulcer care, most often provided by non-specialist wound care clinics (63.8%). There was significant variation in local (wound) DU care, in particular the use of debridement and pain management. DU-related education was only provided to one-third of patients. One-quarter (24.6%) were 'very satisfied' or 'satisfied' that the provided DU treatment(s) relieved their DU symptoms. Pain, limited hand function, and ulcer duration/chronicity were the main reasons for patients to consider changing DU treatment., Conclusions: Our data show that there is a large variation in DU treatment between countries. Patient access to specialist wound-care services is limited and only a small proportion of patients had their DU needs met. Moreover, patient education is often neglected. Evidence-based treatment pathways are urgently needed for DU management., (© The Author(s) 2024. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Objectives: We characterized the microbiota in SSc, focusing on the skin-oral-gut axis and the serum and faecal free fatty acid (FFA) profile., Methods: Twenty-five SSc patients with ACA or anti-Scl70 autoantibodies were enrolled. The microbiota of faecal, saliva and superficial epidermal samples was assessed through next-generation sequencing analysis. GC-MS was used to quantify faecal and serum FFAs. Gastrointestinal symptoms were investigated with the University of California Los Angeles Scleroderma Clinical Trial Consortium Gastrointestinal Tract Instrument (UCLA GIT-2.0) questionnaire., Results: The ACA+ and anti-Scl70+ groups displayed different cutaneous and faecal microbiota profiles. The classes of cutaneous Sphingobacteriia and Alphaproteobacteria, the faecal phylum Lentisphaerae, the levels of the classes Lentisphaeria and Opitutae, and the genus NA-Acidaminococcaceae were significantly higher in faecal samples from the ACA+ patients than in samples from the anti-Scl70+ patients. The cutaneous Sphingobacteria and the faecal Lentisphaerae were significantly correlated (rho = 0.42; P = 0.03). A significant increase in faecal propionic acid was observed in ACA+ patients. Moreover, all levels of faecal medium-chain FFAs and hexanoic acids were significantly higher in the ACA+ group than in the anti-Scl70+ group (P < 0.05 and P < 0.001, respectively). In the ACA+ group, the analysis of the serum FFA levels showed an increasing trend in valeric acid., Conclusion: Different microbiota signatures and FFA profiles were found for the two groups of patients. Despite being in different body districts, the cutaneous Sphingobacteria and faecal Lentisphaerae appear interdependent., (© The Author(s) 2023. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Introduction: Smartwatches, wrist-mounted devices with computing capacity able to connect with other devices via short-range wireless networking, are today commonly used by the general population to monitor their health status using specific applications. Currently, these devices offer new possibilities in remote health care monitoring and integration with other applications, through alert notifications, collection of personal data by a variety of sensors and the storage of these data. Several companies are introducing smartwatches with "health status" monitoring software with multiple functions, i.e. electrocardiogram (ECG) sensors. Recently, detection of atrial fibrillation based on heart rate monitoring by optical sensors resulted to be feasible and reliable when using the Apple Watch® and its corresponding application. Indeed, previous case reports highlighted its sensitivity in detecting morphological changes typical of the Acute Coronary Syndrome., Case Report: We report the case of a healthcare worker, who experienced chest pain and diffuse myalgia, detected ECG alterations in the ST segment, and reached the Emergency Department Myopericarditis was diagnosed and treated promptly to prevent complications., Discussion: Acute viral myocarditis and pericarditis are clinical conditions, usually characterized by 21 a benign course that does not require medical evaluation. However, ventricular arrhythmias are also common in viral myocarditis, and the latter is associated with a large proportion of sudden cardiac deaths in the young population without previous structural heart disease. In this case report, smartwatch technology allowed the preventive implementation of interventions against potentially life-threatening complications. Further developments in smartwatch technology could lead to more sensitive and specific diagnostic algorithms for conditions that require immediate medical intervention., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Introduction: The COVID-19 pandemic has had a considerable impact on the psychological and psychopathological status of the population and health care workers in terms of insomnia, anxiety, depression, and post-traumatic stress disorder. The primary aim of this study was to describe and evaluate the impact of the pandemic on insomnia levels of a cohort of Italian nurses, particularly those involved in the care of COVID-19 patients. The secondary aim was to identify the interaction between insomnia and hardiness, anxiety, and sleep disturbances., Materials and Methods: A descriptive-exploratory study was conducted using an online survey during the first wave of the COVID-19 pandemic (March to July 2020). The questionnaire consisted of multiple-choice, open-ended, closed, and semi-closed questions. The psychometric tools administered were the Dispositional Resilience Scale (DRS-15), the State-Trait Anxiety Inventory (STAI-Y), and the Insomnia Severity Index (ISI)., Results: a cohort of 1167 nurses fully completed the questionnaire (86.2% of total respondents). The insomnia scale survey showed an increase in post-pandemic scores compared to those before the pandemic, implying that insomnia levels increased after the first pandemic wave. Insomnia scores were directly correlated with anxiety levels (r = 0.571; p ≤ 0.05) and inversely correlated with hardiness levels (r = -0.324; p < 0.001). Multivariate analysis revealed the following protective factors: not having worked in COVID-19 wards, high levels of hardiness (commitment), and the presence of high pre-pandemic insomnia disorder. The main risk factor for insomnia reported in the analysis was a high anxiety score., Discussion and Conclusion: Anxiety represented the main risk factor for insomnia severity in our sample, while hardiness was confirmed as a protective factor. Thus, it is necessary to design further studies to identify additional risk factors for poor sleep quality and to develop educational courses and strategies aimed at enhancing rest and sleep quality, especially for frontline nurses.

At present, only a few reports have addressed the possible contribution of the lymphatic vascular system to the pathogenesis of systemic sclerosis (SSc). Based on the evidence that blood vascular endothelial cells can undertake the endothelial-to-myofibroblast transition (EndMT) contributing to SSc-related skin fibrosis, we herein investigated whether the lymphatic endothelium might represent an additional source of profibrotic myofibroblasts through a lymphatic EndMT (Ly-EndMT) process. Skin sections from patients with SSc and healthy donors were immunostained for the lymphatic endothelial cell-specific marker lymphatic vessel endothelial hyaluronan receptor-1 (LYVE-1) in combination with α-smooth muscle actin (α-SMA) as the main marker of myofibroblasts. Commercial human adult dermal lymphatic microvascular endothelial cells (HdLy-MVECs) were challenged with recombinant human transforming growth factor-β1 (TGFβ1) or serum from SSc patients and healthy donors. The expression of lymphatic endothelial cell/myofibroblast markers was measured by quantitative real-time PCR, Western blotting and immunofluorescence. Collagen gel contraction assay was performed to assess myofibroblast-like cell contractile ability. Lymphatic endothelial cells in intermediate stages of the Ly-EndMT process (i.e., coexpressing LYVE-1 and α-SMA) were found exclusively in the fibrotic skin of SSc patients. The culturing of HdLy-MVECs with SSc serum or profibrotic TGFβ1 led to the acquisition of a myofibroblast-like morphofunctional phenotype, as well as the downregulation of lymphatic endothelial cell-specific markers and the parallel upregulation of myofibroblast markers. In SSc, the Ly-EndMT might represent a previously overlooked pathogenetic process bridging peripheral microlymphatic dysfunction and skin fibrosis development.

Nurses and paramedics play a pivotal role when mass casualty incidents (MCI) occur, yet they often feel unprepared for such events. Implementation strategies for training activities, including virtual reality (VR) and augmented reality (AR) simulations, offer realistic and immersive learning experiences, enhancing skills and competencies for nursing students. The aim of this work was to investigate the adopted tools in studies on VR and AR simulations for training nursing and paramedic students in managing MCI. A scoping review was performed following the PRISMA-ScR statement, and the search strategy was conducted through five electronic databases from December 2022 to March 2023. Of 162 records identified, 27 full texts were screened and, six studies were included in this review. These studies involved students who were assigned to different training methods, including immersive VR simulation, written instruction, and traditional lecture. VR and AR and immersive simulation generally show promising evidence in enhancing practical skills and knowledge in MCI management. VR and AR showed to be promising in disaster education and preparedness training, offering different levels of immersiveness and engagement, encouraging active and experiential learning. Further research is needed to determine their long-term effectiveness. The choice of training method should consider program goals, target population, and available resources.

Investigating unmet needs and identifying the necessary interventions for patients affected by rheumatic and musculoskeletal diseases (RMDs) may help significantly to ensure the continuity and quality of the chronic care pathway. To this aim, the contribution of rheumatology nurses requires further evidence. The aim of our systematic literature review (SLR) was to identify the nursing interventions directed towards patients with RMDs undergoing biological therapy. To retrieve data, a search was carried out in the MEDLINE database, the Cumulative Index to Nursing and Allied Health Literature (CINAHL database), the APA PsycINFO database and the Excerpta Medica Database (EMBASE) from 1990 to 2022. The systematic review was carried out in accordance with the relevant PRISMA guidelines. Inclusion criteria were as follows: (I) adult patients with RMDs, (II) undergoing therapy with Biological Disease-Modifying Anti-Rheumatic Drugs (bDMARDs), (III) original and quantitative research papers in English with available abstract, (IV) specific to nursing interventions and/or outcomes. Two independent reviewers screened the identified records for eligibility according to their title and abstract, full texts were subsequently assessed and, finally, data was extracted. Critical Appraisal Skills Programme (CASP) tools were used to evaluate the quality of the studies included. Among the 2348 records retrieved, 13 articles met the inclusion criteria. These consisted of six randomised controlled trials (RCTs), one pilot study and six observational studies on RMDs. In a total population of 2004 patients, 43% (862/2004) of the cases concerned rheumatoid arthritis (RA) and 56% (1122/2004) of the cases concerned spondyloarthritis (SpA). Three major nursing interventions were identified, namely education, patient-centred care and data collection/nurse monitoring, which were correlated with high satisfaction rates regarding care, increased self-care capacity and treatment adherence among patients. All interventions followed a protocol defined in collaboration with rheumatologists. The large degree of heterogeneity in the interventions did not allow the performance of a meta-analysis. Rheumatology nurses are part of a multidisciplinary team caring for patients with RMDs. Following an accurate initial nursing evaluation, rheumatology nurses can plan and standardise their interventions focusing primarily on patient education and personalised care based on actual needs, such as psychological well-being and disease control. However, the training for rheumatology nurses should define and standardise, as much as possible, the competencies required for the detection of disease parameters. Key Points • This SLR provides an overview of nursing interventions for patients with RMDs. • This SLR considers the specific population of patients on biological therapies. • Training for rheumatology nurses should standardise, as much as possible, the knowledge and methods required for detecting disease parameters. • This SLR highlights the various competencies of rheumatology nurses., (© 2023. The Author(s), under exclusive licence to International League of Associations for Rheumatology (ILAR).)

Background: Awake prone positioning research focuses primarily on improving oxygenation and reducing intubation and mortality rates. Secondary outcomes concerning patient safety have been poorly addressed., Objective: To summarize current evidence on the frequency of adverse events during awake prone positioning and the effects on patients' safety, comfort, and tolerance., Methods: This scoping review used the Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews. MEDLINE/PubMed and CINAHL databases were the primary sources for the systematic search., Results: The review included 19 original studies involving 949 patients who underwent awake prone positioning. No major complications such as death, severe respiratory compromise, or hemodynamic disease were reported. Ten studies reported the following secondary adverse events related to awake prone positioning: skin breakdown (1%-6% of patients), pain (12%-42%), discomfort (35%-43%), vomiting (2%-7%), intolerance (3%-47%), and vascular catheter dislodgment (5%). The duration of awake prone positioning sessions varied widely (0.3-19 hours). Seven studies reported that nurses helped patients during prone positioning maneuvers, including monitoring and surveillance, and 3 studies reported patients placing themselves in the prone position. In 6 studies light or moderate sedation was employed in the procedures., Conclusions: Awake prone positioning was not related to cardiorespiratory consequences but was associated with pain, intolerance, discomfort, and patients' refusal. Patients should receive education regarding awake prone positioning to improve their acceptance. Health care professionals should optimize pain control, communication, patient comfort, patient adherence, and correct positioning., (©2023 American Association of Critical-Care Nurses.)

Psychological concerns in Systemic Sclerosis (SSc) patients represent an important issue and should be addressed through non-pharmacological treatments. Thus, the aim of the present study was to assess the effects of the Mindfulness-Based Stress Reduction (MBSR) program on psychological variables and the perspectives and experiences of patients with an SSc diagnosis. Notably, 32 SSc patients were enrolled and assigned to either the intervention (MBSR) group or the waitlist group. Inclusion criteria were (i) age ≥ 18 years, SSc diagnosis according to EULAR/ACR diagnostic criteria and informed consent. Exclusion criteria were previous participation in any Mind-Body Therapy or psychiatric diagnosis. Quantitative and qualitative outcomes were investigated through clinometric questionnaires and individual interviews. MBSR did not significantly impact outcomes such as physical functionality, anxiety, hopelessness, depression, physical health status, perceived stress, mindfulness and mental health status. For the anger evaluation, statistically significant differences are found for both controlling and expressing anger, indicating that the MBSR program had a favorable impact. As for qualitative results, more awareness of daily activities, stress reduction in terms of recognizing the causes and implementing self-strategies to prevent them, adherence to therapy, and recognition of the effect of medication on their bodies were reported. In conclusion, it is important to highlight the absence of negative or side effects of the MBSR program and the positive impact on patients' experience and perspective; thus, we suggest this approach should be taken into account for SSc patients.