The Latest Review of the Potential Benefits of Animal-assisted Therapy

Eur J Integr Med. 2016 Oct; 8(5): 695–706.

Animal assisted intervention: A systematic review of benefits and risks

Received 2016 Mar 4; Revised 2016 May nineteen; Accepted 2016 May 19.

Abstruse

Introduction

The therapeutic use of animals has been debated for decades, and its use explored in a variety of settings and populations. However, there is no uniformity on naming these interventions. Evidence based knowledge is essential to implement constructive strategies in hospital. This review focused on the use of animal programs for hospitalized patients, and considered the potential risks.

Methods

The following databases were searched: PubMed, Scopus, PsychInfo, Ebsco Animals, PROQUEST, Web of Scientific discipline, CINAHL, and MEDLINE, and PRISMA guidelines were adhered to.

Results

Out of 432 manufactures were identified 36 manufactures suitable for inclusion into the review. Information was heterogeneous in terms of age of patient, health effect, animals used and the length of interactions, which made comparison problematic. Studies on children, psychiatric and elderly patients were the most mutual. The animal-intervention programs suggested diverse benefits such as reducing stress, pain and anxiety. Other outcomes considered were changes in vital signs, and nutritional intake. Nigh studies used dogs, but other animals were effectively employed. The major risks outlined were allergies, infections and beast-related accidents. Zoonosis was a possible risk, as well every bit mutual infections equally Methicillin-resistant Staphylococcus Aureus. The implementation of simple hygiene protocols was effective at minimizing run a risk. The literature suggested that the benefits outweighed by far the risks.

Conclusion

The human relationship with animals tin be useful and relatively safe for inpatients with various problems. Moreover, the implementation of security precautions and the conscientious selection of patients should minimize the risks, particularly those infection-related. Many aspects remain unclear, farther studies are required.

Keywords: Animal-assisted activity, Animate being-assisted therapy, Animal-assisted intervention, Pet-therapy, Hospital, Systematic review, Risks & benefits, Benefits, Clinical guidelines

ane. Introduction

The Animal Assisted Therapy (AAT) is a wellness intervention, meant to meliorate concrete, social, emotional or cognitive functioning, with animals equally integral part of the treatment [ane]. The therapeutic utilize of animals was argued for decades and many associations use this intervention in order to improve care.

The interest shown by the scientific community is proven not only by the amount of articles published, but likewise by the specific trainings offered by many universities and in particular past the inception of specific law to regulate this practice [2].

The "Pet Partners" (an organization dedicated to improve people'due south health through the interaction with animals) pointed out the differences betwixt AAT and Animal Assisted Action (AAA), less structured and mainly composed by pet visitation) [3]. The AAA, equally described above, is slightly structured and it includes, primarily, pet-visitation. These kind of activities are in general spontaneous, group several patients, and poorly standardized with regard to duration and type of activities. On the contrary, the AAT sessions are strictly organized considering both the activity blazon and the duration. Indeed, each AAT session presents individualized goals and is conducted past specifically trained couples (handler and animal) [3]. Unfortunately, there is no uniformity on naming these interventions and AAT, AAA and other names are used, often, in a confusing way. To make even harder to compare the studies dissimilar animals were used. Although dog is the most common, by and large every species can be employed.

Brute interventions have been studied for unlike pathologies including mental disorders [4] and cancer [5]. In item, some interventions focused on frail patients every bit elderly [6], [vii] or children [5], [8]. Furthermore, AAT and AAA are implemented in different settings like hospitals, nursing homes and schools [iv], [5]. The employment of Animal-Assisted Interventions (AAI) resulted increasingly popular, specially among pediatric patients. Chur-Hansen et al. conducted a critical review regarding AAI for children inpatients. This review focused primarily on the methodology of the retrieved studies. Precisely, the authors concluded that the evidences regarding AAI are scant, and more standardized studies (in particular RCTs) about this topic are required [9]. Another recent review considered only the available RCTs regarding AAT, retrieving overall eleven studies (published from 1990 to 2012). The authors outlined a relatively depression quality of the recovered papers. However, the written report highlighted some benefits of the AAT, especially in case of psychiatric disorders. The animals employed in these interventions were disparate, from dogs to dolphins or ferrets. The authors identified some areas requiring further insights such as costs, reasons to refuse the intervention and potential adverse effects. Moreover, the authors highlighted how the clarification of the intervention in terms of length, activities and settings, in the studies included in the review, was not always obvious [4].

The outcomes considered, in society to ascertain the AAI benefits, are heterogeneous, incorporating subjective outcomes every bit the quality of life [10], [eleven], just also objective parameters as vital signs [12], hemodynamic measures [13] and nutritional intake [14]. A 2007 review and meta-analysis, firstly, assessed the quantitative effects of AAT. The meta-analysis included 49 studies, and suggested a pregnant improvement in the following examined areas: autism-spectrum symptoms, behavioral issues, and emotional well-being. The authors described the AAT as a worthy intervention, necessitating, notwithstanding, further insights [fifteen].

Furthermore, the risks of implementing animal therapeutic interventions peculiarly in hospitals are not negligible, and these hazards must be considered [16], [17].

An accurate cognition of the effectiveness and risks of beast use in hospital is essential to implement effective strategies in this setting. Withal, data because beast interventions are often heterogeneous. To our knowledge, no previous reviews estimated the evidence on the utilise of animal-interventions for inpatients. The aim of this review was to focus on Animal Assisted Therapy/Action for hospitalized patients, to provide a clearer view on the status of the evidence supporting this practise, likewise as the potential risks.

ii. Methods

This review followed the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statements [18].

Multiple search strategies were employed to summarize the existing evidence relating to brute assisted therapy or animal assisted activeness for inpatients. Searches for papers reporting data about the effectiveness or the risks of beast use in hospitals were carried out using the following databases: PubMed, Scopus, PsychInfo, Ebsco Animals, PROQUEST, Web of Science, CINAHL and MEDLINE.

Iii researchers (EC, GP and GV) independently performed a systematic search using the following strings: "Animal assisted activity" AND infirmary, "Animal assisted therapy" AND infirmary, "Beast assisted intervention" AND hospital, "Pet therapy" AND hospital, "Animal assisted activity" AND hospitalization, "Fauna assisted therapy" AND hospitalization, "Beast assisted intervention" AND hospital, "pet therapy" AND hospitalization.

Studies were considered eligible for inclusion if they:

• were conducted in hospitals or in long-term care facilities
• were written in English, Spanish or Portuguese
• considered interventions of "Animal Assisted Therapy", "Creature Assisted Action" or "Fauna Assisted Intervention"

No restriction was performed based on inpatient age, pathology, or type of animal used. All types of papers were included, since RCTs were few and did not give a complete overview of the topic.

Articles were excluded if they:

• were conducted exterior the hospital
• were published earlier 2000
• used robotic animals
• were example reports or messages to the editor

3 investigators (EC, GP and GV) independently conducted a first literature search, sorting sources by title and abstract. Then, the eligible studies for full text review were selected. During the first screening, the irrelevant or duplicated papers were excluded. The search was completed through a reference list screening. Finally, the researchers independently assessed the manufactures considering the criteria enunciated in a higher place.

two.i. Data extraction

The investigators, solving any discrepancies by consensus, independently extracted data from the selected studies, collecting information about the country, the report blueprint, the setting, the sample characteristics, the blazon of intervention, the outcomes, the results and the potential risks.

3. Results

The search returned 432 results. Afterwards removing the duplicates and irrelevant results, 64 manufactures for full text review were obtained. The final selection obtained 36 sources (see Fig. 1 ). Eight studies were conducted on children, five referred to psychiatric population, six considered elderly patients, six were performed in the Emergency Department, Orthopedics, Internal Medicine or other wards, and eleven focused primarily on the intervention risks.

Flowchart—the effigy summarizes the choice procedures of our review.

3.1. Psychiatric settings

Five studies focused on the AAT for psychiatric inpatients (See Table one ) [10], [xi], [nineteen], [20], [21]. All studies were published between 2009 [twenty], [21] and 2015[eleven], [19]. Virtually all the studies considered a dog-AAT (northward = 4), with the exception of a written report comparing iv interventions: equine-assisted psychotherapy (EAP), canine-assisted psychotherapy (CAP), enhanced social skills psychotherapy, and regular hospital care [19]. 4 studies were RCTs [10], [11], [19], [21] and one a controlled crossover study [20]. The full sample size ranged from 12 [20] to 90 [19].

Table 1

Characteristics of the retrieved studies regarding animal interventions for psychiatric inpatients. The table reported information about the report pattern, the participant characteristics (sample size, disease, setting), the intervention type (including length and beast used), the considered outcomes and the main results.

Authors and Yr	Study Pattern	Sample	Disease/setting	Intervention Type	Length	Animals	Outcomes	Findings
Stefanini, 2015	RCT	34 children	Acute psychiatric diagnosis	Intervention group: structured AAT Control groups: standard therapeutic protocol	Weekly sessions (45 min each) for 3 months	Dogs	Global functioning Format of hospital care (assessing clinical severity) Ordinary schoolhouse omnipresence Observation of AAT (participation, socialization with peers and adults, withdrawal behaviors)	Pre- and post-exam analysis outlined an comeback in hospital care (p = 0.02), school omnipresence (p < 0.03) and global performance (p < 0.0001) in the handling group vs. control. Patients in the AAT-grouping showed higher participation and socialized behaviors with adults and peers (all p < 0.01), and a reduction in withdrawal behaviors (p < 0.04)
Nurenberg, 2015	RCT	90 inpatients	Psychiatric inpatients with ambitious or regressed behaviors	Equine-assisted psychotherapy (EAP) Canine-assisted psychotherapy (CAP) Environmentally enhanced social skills grouping psychotherapy (SSP) Regular hospital care	10 weekly group sessions (40–lx min each)	Dogs Horses	Assailment-related consequence measures Brief Psychiatric Rating Calibration Life Skills Profile Greystone Intrusiveness Mensurate Staff expectations about AAT Pet Attitude Calibration–Modified Visual Analog Scale	Violent incident reports showed a significant subtract for EAP patients compared to other groups (p < 0.035), showing differences in aggressions both towards objects (p = 0.05) and persons (p = 0.053).
Chu, 2009	RCT	thirty inpatients	Chronic schizophrenia	Intervention grouping: AAA sessions Control grouping: standard therapy	AAA sessions (50 min) once a week for 2-months	Dogs	A questionnaire exploring: Self-esteem, Self-determination, Extent of social support and Adverse psychiatric symptoms	There were significant improvements (p < 0.05) in self-esteem, self-determination, positive psychiatric symptoms, and emotional symptoms. The scores regarding social support and negative psychiatric symptoms did non significantly improve.
Hoffmann 2009	Cantankerous-over study	12 inpatients	Unipolar major depression	Intervention group: interaction with a domestic dog and a inquiry assistant. Command group: xxx-min talk with the researcher	Two AAA 30 min sessions	Dogs	Country-Trait Feet Inventory (STAI)	The STAI score significantly decreased after the dog-session (p = 0.016). In the control group STAI score did not significantly differ (p = 0.327)
Villalta 2009	RCT	21 patients in long-term care facilities	Chronic schizophrenia	Intervention group: AAT Control group: no AAT	25 sessions of 45 min each	Dogs	Symptoms (Positive and Negative Syndrome Scale PANSS) Social competence (Living Skills Profile) Quality of Life Satisfaction with Treatment	Patients in the intervention group presented significant improvements in social contact score (p = 0.04), in positive (p = 0.005) and negative symptoms (p = 0.005), in quality of life (p = 0.02). Patients in control group showed improvements in positive (p = 0.03) and general symptoms (p = 0.046).

Chu and Villalta specifically focused on canine-assisted therapy for chronic schizophrenic inpatients (>10 years since onset) [10], [21]. Both studies underlined some positive effects of these interventions. In detail, the study of Chu, highlighted an increase in self-esteem, self-determination, and a decrease in positive psychiatric symptoms and emotional symptoms after 8 weeks of AAA (p < 0.05) [10]. The study past Villalta showed a pregnant improvement from baseline later on a canis familiaris-program in social contact score, in positive and negative symptom dimensions and in quality of life [21]. Nevertheless, no meaning difference was assessed between the group experiencing AAT and the control group [21]. Nurenberg et al. considered the effectiveness of the AAT in reducing aggressiveness in chronic psychiatric inpatients, including various psychiatric diagnosis (76% presented schizophrenia or schizoaffective disorder). The authors compared two different AAT, the first using dogs and the 2d horses. Certified pet therapists, following the "Pet-Partners guidelines", conducted both these interventions. The reduction of violent incidents was significantly greater in the EAP group (p < 0.035), while other generic benefits were assessed for both the AAT interventions. These positive furnishings were maintained for several months [19].

The effects of AAT were studied also in other psychiatric diseases equally major depression (inpatients with suicidality tendencies). In this study, a dog-assisted intervention (two sessions of dog-AAA) effectively reduced anxiety (p = 0.016), as measured employing the Country-Trait Anxiety Inventory (STAI). This improvement was contained from age, gender or pet possession [xx].

Finally, an Italian study considered children experiencing acute psychiatric disorders. The master diagnosis were eating disorders (64.7%) and mood disorders (20.half-dozen%). In this population, the implementation of a domestic dog-AAT program once a calendar week resulted, compared to the control grouping, in an improvement of clinical severity (p = 0.02), ordinary school attendance (p < 0.03), and global functioning (p < 0.0001). In particular, the intervention group showed an improvement in socialized behaviors with adults and peers (p < 0.04). The authors adhered, for the protocol implementation, to the "Pet Partners guidelines", and all the animals employed in the study followed strictly veterinarian sanitary protocols [11].

iii.2. Childrens' hospitals

8 papers referred to pet therapy in pediatric hospitals (See Table 2 ) [8], [22], [23], [24], [25], [26], [27], [28]. The articles were published between 2002 [22], [28] and 2015 [23]. Two were descriptive studies [24], [25] and half-dozen trials [8], [22], [23], [26], [27], [28]. Two studies had a special focus on oncological patients [24], [25], while the others referred to full general pediatric inpatients. In item, two interested children with acute diseases [23], [26]. All papers used dogs, ranging from simple pet visitation [22], [28] to structured AAT [23], [26], [27]. The number of children involved ranged from 15 [27] to almost 150 [eight].

Tabular array 2

Characteristics of the retrieved studies regarding creature interventions for inpatient children. The table reported information well-nigh the report design, the participant characteristics (sample size, disease, and setting), the intervention blazon (including length and animal used), the considered outcomes and the primary results.

Authors and Year	Study Design	Sample	Illness/setting	Intervention Type	Length	Animals	Effect	Findings
Barker, 2015	RCT	40 hospitalized children	Children admitted to Hospital of Richmond except Pediatric Intensive Intendance Units	Intervention group: AAI Agile control group: jigsaw puzzle	10 min sessions	Dogs	Hurting and Anxiety ratings Attachments Questionnaire for Children Family unit life-space Diagrams	The AAI-group experienced lower post-intervention anxiety scores (p < 0.05). No meaning inside- or between-group pre-post changes in either pain or anxiety were detected.
Tsai, 2010	Quasi-experimental blueprint	15 hospitalized children	Acute or chronic weather condition	AAT (taking place in patient room) Command group: puzzle (each kid did both the interventions)	6–x min sessions	Dogs	Blood force per unit area and heart rate Child Medical Fear Scale State-Trait Anxiety Inventory for Children (STAI-C)	Systolic Blood Pressure (SBP) decreased from before, during and after AAT (p = 0.008). Children'due south feet and medical fear did not differ after the AAT visit compared with the comparing intervention.
Braun 2009	Quasi-experimental intervention written report	57 children	Acute care settings	Intervention group: AAT Control group: children sat quietly for 15 min	fifteen–twenty min sessions	Dogs	Blood pressure, pulse charge per unit, respiratory rate Pain level (Confront hurting scale)	The grouping experiencing AAT had a significantly lower mail service-examination pain score compared to the control group (p = 0.006). Even parents perception of pain reduction was college for the intervention group (p = 0.008). AAT group presented college respiratory rate (p = 0.011), no differences were found in blood pressure and pulse
Caprilli 2006	RCT	138 children	Unlike hospital wards	AAA	In one case a calendar week for 2-h sessions	Dogs	Children participation Infection charge per unit in the infirmary Children pleasure Parents and staff level of satisfaction	No increase in infection or in contagious illness transmitted by dogs were institute. The children pleasure evaluation showed significant improvement. Parents and staff satisfaction rate was high.
Gagnon 2004	Descriptive report	16 parents and 12 nurses	Pediatric oncology wards	Dog-AAT	Each session lasted a whole solar day	Dogs	Satisfaction with the program and of quality of intendance	Benign office of animal therapy was underlined for physical, social, emotional, coping and cocky-esteem dimension
Bouchard 2004	Airplane pilot project	27 children	Pediatric oncology wards	AAT with a dog at bed-side	/	Dogs	Customer satisfaction Touch on on nursing work Appropriateness of prevention measures	Parents outlined positive aspects of the feel (as increasing children confidence, mood improvement). According to nurses, the program was well structured. They used the children's human relationship with dogs every bit a therapeutic tool during the intervention process.
Kaminski 2002	Clinical trial on a convenience sample	70 hospitalized children	General inpatients	Intervention group: dog-facilitated therapy Command group: Kid Life group	Ane session per week	Dogs	Self-reported mood, and parents and caregiver reports Clinical assessment Physiological indicators: heart charge per unit, claret pressure, salivary cortisol	Parents and caregivers rated their children every bit happier after intervention in both groups (p < 0.001). Heart rate was significantly higher in the pet therapy group (99.27 ± 16.38) than in control grouping (88.44 ± 12.68).
Moody et al. 2002	2 cross-sectional surveys	Staff Questionnaire: 115 pre-programme and 45 after	Pediatric Medical wards	Pet-visitation program	/	Dogs	Hospital staff perception (questionnaire to administrators, doctors, nursing staff and therapists; half-dozen weeks before and 12 weeks afterward the introduction of the program)	Prior to the introduction of the dog visitation, there were loftier staff expectations regarding the programme. Healthcare workers outlined the relaxation effect, the mood comeback. Staff fellow member mostly accustomed dogs.

Four studies evaluated the satisfaction later on the intervention and the effects on psychosocial behaviors [8], [22], [24], [25], instead four considered likewise physiological phenomena [23], [26], [27], [28]. Two studies were conducted through a survey amidst parents and caregivers [22], [24], while in two these information were integrated with children self-reports [viii], [25]. Many unlike physiological parameters similar pain [23], [26] or cardiovascular response [27], [28] were evaluated.

The studies involving oncological patients showed physiological benefits, like pain reduction [26], and psychological benefits like decreased loneliness, increased relaxation, socialization and cocky-esteem [8]. These benefits were perceived also by parents and caregivers [24], [28]. These findings are consequent with a written report conducted in acute pediatric care [22].

Barker et al., in a RCT on generic pediatric inpatients, showed the consistency of these results in unlike diseases [23]. This study evaluated the AAI impact on anxiety and pain in acute intendance. A pregnant difference was found for feet, with the AAI-group experiencing lower anxiety score [23]. However, no pregnant differences inside- or between-groups or pre-postal service intervention were assessed in nor hurting or anxiety [23]. For the implementation of this protocol, all the infirmary policies were followed, including those regarding safeguard for the dogs.

On the other hand, no differences in anxiety and medical fear were noticed in a study involving fifteen hospitalized children [27]. In this study, a reduction in the systolic claret pressure (p = 0.008) was recorded and this reduction continued even later on the intervention was over.

3.iii. Elderly patients

Half-dozen articles evaluated the affect of the AAT in elderly inpatients (Come across Table three ) [6], [7], [thirteen], [14], [29], [xxx]. These manufactures were published between 2002 [fourteen] and 2012 [30]. Five studies were performed in hospitals [7], [13], [14], [29], [30], while one was conducted in a nursing home [6]. The samples ranged from twenty [30] to 76 [13] subjects.

Tabular array 3

Characteristics of the retrieved studies regarding animal interventions for elderly inpatients with various illness (including Alzheimer disease and heart failure). The table reported information about the report design, the participant characteristics (sample size, affliction, and setting), the intervention type (including length and brute used), the considered outcomes and the main results.

Authors and Year	Study Design	Sample	Disease/setting	Intervention Blazon	Length	Animals	Effect	Findings
Kumasaka, 2012	Pre-/Post- report	twenty inpatients	Oncologic patients in palliative care unit	AAA	Once per month for about 30 min	Dogs Cats Rabbits	Quality of Life (QOL) assessed through the Lorish's Confront Scale	The study outlined a beneficial effects of AAA considering the facial scale score. Mean score was 8.x ± three.48 before the session and two.66 ± 1.99 after the action (meaning decrease: p < 0.01)
Abate, 2011	Prospective study	69 inpatients	Heart failure	Intervention: Canine-assisted ambulation (CAA) Command: historical population	/	Dogs	Actual altitude walked Patient satisfaction	The experimental group receiving CAA walked significantly more steps than the historical group (p < 0.0001).
Falk et al. 2008	Qualitative study	35 Older people	Swedish hospital wards	Placing a bird cage in the ward lounge	September − November 2002	Birds	Participant ascertainment (three major themes: activity, mental experience and socializing)	The patients manifested attention and curiosity toward birds, expressing desire to have intendance of the birds. The birds became subject area of full general diversion.
Cole, 2007	RCT	76 inpatients	Avant-garde heart failure	Volunteer-dog team (visit from a volunteer with a therapy dog) Volunteer only Control: standard care	12-min visits	Dogs	Blood pressure level, Heart charge per unit Pulmonary pressure and pulmonary capillary wedge pressure Correct atrial pressure Epinephrine and norepinephrine Anxiety score	The dog intervention grouping had significantly greater decreases in systolic pulmonary artery force per unit area (p = 0.03), and in pulmonary capillary wedge pressure (p = 0.001). The volunteer-dog group had the greatest decrease in anxiety score compared with volunteer-simply (p = 0.02) and control group (p < 0.001).
Stasi, 2004	Case-control study	28 Subjects	Chronic age-related disabilities in a nursing home	Intervention group: true cat-therapy Command group: usual activity programs	3/week sessions of almost one-hour visit for 6 weeks	Cats	Blood pressure Cognitive damage by mini mental state examination (MMSE). Geriatric low scale (GDS) Self-assessment calibration-geriatric (SASG). Activities of daily living (ADL) Instrumental activities of daily living (IADL)	Patients in the intervention group presented improved depressive symptoms (not statistically meaning) Significant systolic blood pressure decrease was outlined in pet-therapy group compared to command group (p = 0.01).
Edwards et al. 2002	Time-series design	62 inpatients	Alzheimer affliction	Aquariums placed in the activity/dining surface area	10 weeks	Fishes	Nutritional intake Change in trunk weight	Following aquariums introduction, the nutritional intake significantly increased (p < 0.001) and continued to improve during follow-upwards. Patient weight increased significantly (p < 0.001) over the observational menstruum

Patients were hospitalized for different diseases including cancer [thirty], chronic centre failure [13], [29], Alzheimer disease [14] or chronic age-related illness [6], [7]. The animals used were dogs [13], [29], [30], cats [6], [30], rabbits [30], cage birds [7] and fishes [14].

Stasi used a cat-therapy (3 sessions per week) for 28 elderly patients in a long-term facility [six]. A pregnant reduction in depressive symptoms and systolic blood pressure (p = 0.01) was measured in the intervention group [6]. Similarly, a domestic dog therapy was compared to volunteer visit and usual care in 76 patients suffering acute heart failure [13]. Compared with controls, the volunteer-dog group experienced a significant decrease in systolic pulmonary avenue pressure and in pulmonary capillary wedge pressure [13]. Compared with the volunteer-only group, the volunteer-dog grouping presented a greater decrease in epinephrine and in norepinephrine levels during and subsequently the intervention. Finally, the dog-group showed a greater decrease in the state feet score compared to both volunteer-but (p = 0.02) and control group (p < 0.001) [13].

Conversely, another written report analyzed the impact of dog-therapy on patients with chronic heart failure to determine the touch of Canine Assisted Ambulation (CAA) in encouraging ambulation [29]. Additionally, patient satisfaction was assessed. The experimental group receiving CAA walked significantly more steps (p < 0.0001) than the historical control grouping, and all patients responded positively to this feel [29].

The benefits of AAA were investigated in a palliative care unit of measurement of a Japanese hospital, considering twenty elderly users. The considered program included a 30-min session once a month using dogs, cats or rabbits, all previously tested for health and suitability. The authors considered the effects of this intervention upon the Quality of Life of the selected inpatients, employing a validated calibration (Lorish Face Scale) to assess mood changes. The study outlined the beneficial effect of similar interventions in the mood state before and after each session (p < 0.01). In item, the positive results were higher for those who claimed to like animals or that owned a pet (particularly dogs) [thirty].

Furthermore, we constitute studies using uncommon animals like fish [xiv] and caged birds [vii]. A kickoff report assessed the nutritional intake in individuals with Alzheimer after the introduction of an aquarium in the ward [fourteen]. The nutritional outcomes were recorded at baseline, and, and then, afterward 10 weeks following the aquariums introduction. The nutritional intake increased significantly (p < 0.001) after this intervention and connected increasing during follow-up. Moreover, also the weight increased significantly (p < 0.001) [14]. A 2d study assessed the interaction between caged-birds and older people in hospital [7]. This qualitative study investigated the patient's reactions succeeding the introduction of caged birds in a Swedish geriatric ward. Patients manifested attention and curiosity regarding the birds and expressed desire to take intendance of them [vii].

3.4. Emergency department, orthopedics, internal medicine and other wards

Vi studies evaluated the touch of pet therapy on adult inpatients with different pathologies (Run across Tables 4 ) [31], [32], [33], [34], [35], [36]. Ii studies investigated the dog-AAT effectiveness for orthopedic inpatients after a full joint arthroplasty intervention [31], [32]. Both studies considered the impact of this intervention on pain [31], [32]. Harper et al. inquired the subjective level of hurting, using the Visual Analogue Scale (VAS) [31], while Havey et al. assessed the apply of oral pain medications [32]. Harper et al. considered a dog-visitation session prior each physical session, and outlined lower VAS score in the intervention grouping (p < 0.001) [31]. Furthermore, the use of hurting medications appeared significantly lower among the AAT grouping (p = 0.007) [32]. Harper investigated also the patient satisfaction regarding the hospital stay [31]. The treatment group reported a college level of appreciation compared to the control group (p < 0.05). Moreover, the groups did non differ nor in the cleanliness items nor in quietness of hospital environs [31].

Table 4

Characteristics of the retrieved studies regarding creature interventions for adult inpatients with various illness (including orthopedic patients, and high-risk pregnancy). The table reported information about the written report design, the participant characteristics (sample size, disease, and setting), the intervention type (including length and animal used), the considered outcomes and the main results.

Authors and Year	Study Blueprint	Sample	Affliction/setting	Intervention Blazon	Length	Animals	Upshot	Findings
Harper, 2014	RCT	72 patients	Orthopedic patients after Total Joint Arthroplasty intervention	Intervention Group: therapy canis familiaris and handler visitation Control group: standard concrete therapy	30 min earlier each physical therapy session	Dogs	Pain (VAS calibration) Hospital Consumer Cess of Healthcare Providers and Systems survey (HCAHPS)	Patients in the intervention grouping had lower VAS scores after each session compared to standard intendance (p < 0.001). The intervention group presented college scores regarding nursing communication (p = 0.035), hurting management (p = 0.024) and overall hospital rating (p < 0.001) compared to command group.
Havey et al. 2014	Retrospective written report	297 hospitalized patients	Joint replacement intervention	Infirmary A: no AAT program Hospital B: AAT program (canis familiaris + handler visits)	Visits of 5–15 minutes	Dogs	Analysis of oral pain medications usage	The cohort receiving at least ane session of animal assisted therapy presented lower rate of oral pain medication use (p = 0.007)
Lynch et al. 2014	Airplane pilot written report	82 Hospitalized women	High-risk pregnancies	Non-structured session of dog in-room contact	Sessions of xv–20 min	Dogs	Land-Trait Anxiety Inventory Beck Depression Inventory	Both depression (p < 0.0001) and feet (p < 0.0001) significantly improved post-obit canis familiaris contact
Nahm, 2012	Survey	125 patients, 105 staff members	Emergency Department (ED)	Therapy dogs visited the ED	6 visits during the observation menses	Dogs	Acceptance of a therapy canis familiaris amidst staff and patients	Well-nigh patients (93%) and staff (95%) thought that therapeutic dogs should visit the ED. But 3.3% of patients and one% of staff considered canis familiaris presence every bit a danger, while 8.6% of the staff and 4.2% of patients thought that dogs could interfered with ED work.
Coakley 2009	Pre-/post quasi-experimental design	61 inpatients	Medical 52.six% or surgical 47.4% diagnosis	Individualized pet therapy intervention based on patient preference	Session of on boilerplate ten min	Dogs	Vital signs (blood pressure, pulse and respiratory rate) Visual Analog Calibration (VAS) for pain Profile of Mood States survey (POMS)	After pet therapy sessions, patients experienced a pregnant subtract in respiratory rate (p < 0.001) and pain score (p = 0.001), associated with increased free energy levels (p = 0.001). Total mood disturbance scores improved significantly (p < 0.001), in particular, in feet (p < 0.001), acrimony (p = 0.001) and fatigue (p < 0.001) items.
Hastings et al. 2008	Survey	614 patients or visitors	Burn down Intensive Care Unit and Fire Acute Care Unit	Domestic dog-AAT	Bi-weekly visitation	Dogs	Total number of AAT visits Questionnaire with visitation assessments Observational summaries from patients, their families, and staff.	Number of canis familiaris-visits increased from 2002 to 2005 (respectively 39 vs. >300). Merely 3 patients (0.5%) refused canis familiaris visitation, reporting fear. Observations of patients, families, and staff were about all positive

Lynch et al. studied the implementation of a canis familiaris-AAI in antepartum wards for women with complicated pregnancies [33]. The program consisted of non-structured canis familiaris-contact sessions. The authors assessed depression and anxiety symptoms prior and afterward each session [33]. The women recruited presented heterogeneous complications, including pre-term labor, pre-eclampsia and diabetes. Despite the lack of a control group, the results indicated that both depression and feet improved subsequently the intervention (p < 0.01) [33].

Two studies considered the implementation of a domestic dog-AAT in hospital wards [34], [35]. Nahm considered the development of similar programs in an Emergency Section, because the opinion of patients, staff and visitors [34]. The intervention was successful amongst both patients and visitors ( < v% of the patients expressed negative opinions). Furthermore, the staff appreciated the intervention (over ninety% did not considered dogs as an obstacle to routine activities) [34]. Coakley et al., instead, focused on the implementation of a canis familiaris-visitation plan in twelve different departments, collecting patients' opinions [35]. The authors considered the furnishings on vital signs, pain perception (VAS-scale), and mood-state (exploring feet, depression, hostility, vigor, fatigue and defoliation). The subjects participating presented a wide range of diseases. Later on the intervention the participants experienced a slightly, merely significant, decrease in respiratory charge per unit (p < 0.001) and in pain score (p = 0.001). The mood scale outlined a significant improvement in nigh all the items (p < 0.001), except vigor and confusion [35].

Finally, Hastings et al. investigated the employ of a bi-weekly dog-visitation in a Burn down Intensive Care Unit and a Burn Astute Intendance Unit [36]. In lodge to guarantee the security of these patients, all the Protection Equipment guidelines were respected. The authors collected patients, staff and visitor opinions. Virtually all comments were positive and but three patients (0.5%) refused the proposed sessions, reporting fear. The number of dog-visits significantly increased during the observation, and no infection nor issues animal-related were reported [36].

3.5. Risks and threats of animal-intervention in healthcare settings

Eleven articles focused explicitly on the risks of animate being utilise in hospitals (run into Table five ) [16], [17], [37], [38], [39], [twoscore], [41], [42], [43], [44], [45]. These papers ranged from 2000 [37] to 2013 [38], and included guidelines, recommendations, clinical trials, cantankerous-exclusive surveys and reviews. Two studies investigated the prevalence of infective agents in pet-visitation animals in hospitals or in long-term care facilities [17], [44]. The first investigation is a broader survey that considered all the hospitals located in the Ontario region with a pet visitation program. In particular, this investigation analyzed audible, nasal, oral, pharyngeal and rectal swabs of over 100 visitation dogs, identifying Clostridium Difficile as the virtually common isolated organism [17]. Moreover, 17% of these isolates were duplicate from the toxigenic microorganisms responsible of the homo disease. In the carrion samples, the authors retrieved also Salmonella and Escherichia Coli (partly in antibody-resistant forms). Furthermore, some samples were positive to parasitology and mycology analysis. These microorganisms were carried asymptomatically by dogs, only tin be dangerous peculiarly for immunocompromised patients [17]. Coughlan et al. focused on Methicillin-resistant Staphylococcus Aureus (MRSA) colonization among residents animals (one domestic dog and eleven cats) in a long-term intendance facility [44]. The authors considered a large long-term intendance facility with over 100 beds, characterized by the presence of resident animals. The researchers collected nasal swabs from the animals for overall eight weeks. Two cats presented MRSA positive swabs and the test positivity was confirmed in subsequent tests. In the concurrently, human MRSA infections occurred in the facility [44].

Table 5

Characteristics of the retrieved studies regarding animal interventions risks in healthcare settings. The tabular array reported information about the study pattern, the setting, the type of intervention considered (including the assessed animals), the major risks identified and the findings.

Authors and Year	Written report blueprint	Setting	Considered intervention	Animals	Risk considered	Findings
Sehr, 2013	Guidelines	Memorial Hospital in Belleville, Illinois	Pet visitation	Private pets	Infection risks Nurse evaluation	The authors considered every bit eligible all inpatients, excluding those in operating room, mail-anesthesia care unit and newborn nursery. Besides, immunocompromised patients were excluded. The pet was not allowed to stay in the room alone with the patient. The nurses did cleanliness check after each visitation. The authors assessed overall positive nurses' evaluations
Silveira, 2011	Protocol of AAT	A Brazilian Academy hospital	AAA	Dogs Cats Fish Rabbits Reptiles Rodents	Infection risks Allergy	Animals must exist evaluated by veterinary before the access to the programme, and all the animals employed followed a specific train. Then, animals are evaluated annually. Animal's hygiene protocols should be implemented in the 24 h prior each session. Hygiene protocols for all the surfaces after each session. Exclusion criteria for patients are postal service-operative, recent splenectomy, known allergy, phobia, immunocompromised oncologic patients and HIV infection in concluding stage.
Coughlan, 2010	Prevalence study	I long-term care facility with 108 patients	Resident animals in long-term care facility	eleven cats 1 dogs	Infection adventure, focusing on Methicillin-resistant Staphylococcus aureus. The animals were sampled weekly for 8 weeks (total: 87 cultures) in the time period July 2006–Baronial 2006	Ii of xi cats were colonized with MRSA; positivity was confirmed in repeated samples. The isolated strains were classified as healthcare-associated strains. In the meantime, human MRSA infections occurred in the facility.
Kobayashi, 2009	Written report	San Paolo Hospital	AAT	Potential animals employed in AAT	Infection risks Allergy Accidents related to animals	The animals involved must follow repeated veterinary visits, presenting a health certificate. Both therapist and animate being followed a specific train. Animals should be bathed the solar day before each session. Exclusion criteria for the patients included splenectomy, immunosuppression, neutropenia, allergy or respiratory problems. Each incident should exist recorded and reported to a specific hospital Committee.
Di Salvo, 2006	Guidelines	Infirmary with specialized units	Service dogs AAT Pet visitation	Dogs	Infection risks Accidents related to animals	Therapy and visitation dogs are more restricted than service dogs. Health certification is required for all animals entering hospitals. Dogs are excluded to certain areas as Intensive Intendance Unit and isolation rooms. Adopting current regulations, risks can be minimized. A proper instruction to all the staff is recommended.
Lefebvre, 2006	Cantankerous-sectional study	Hospitals in Ontario (northward = 231) Dog Owners (due north = 90)	AAA and Canine visitation	Dogs	Survey regarding potential risks and adherence to guidelines	Dogs were admitted in ninety% of the considered hospitals. The Acute Care Hospital were more than likely to disallow dogs (p < 0.001). The sanitary protocols to avoid infections resulted variable. 20% of the possessor declared no infection control. 73% owners consented dogs to get on the patient's bed and 79% let dogs lick patients. Simply 14% received zoonosis information from their veterinary. 40% of the owners did non know any potential zoonosis transmitted past dogs.
Jofrè, 2005	Review of Guidelines	Healthcare facilities	AAT	Dogs Cats Rabbits Birds	Infection risks Allergy Accidents related to animals	Animals must undergo periodic veterinary controls, avoiding the apply of puppies. It is important to careful evaluate which patients to include in the interventions (exclusion in instance of phobia, allergy, splenectomy, and immunocompromised patients) Rigorous mitt-hygiene for patients and healthcare personnel, fugitive, every bit possible, any contact with animal actual fluids. Rigorous control of the AAT sessions by trained therapists. The animal should be bathed earlier each session, to minimize the allergy take a chance.
Lefebvre, 2005	Prevalence study	Hospitals in Ontario	Pet-visitation programs	Dogs (n = 102)	Zoonosis Investigated through aural, nasal, oral, pharyngeal and rectal swabs.	58% of the samples were positive to Clostridium Difficile (41/58 isolates were toxigenic). 3 dogs were positive to Salmonella. Other samples resulted positive to Toxocara Canis, Ancylostoma Caninum, Giardia, Escherichia Choli, Malassezia Pachydermatis, Pasteurella and Trichophyton Mentagrophytes
Sehulster, 2003	CDC Guidelines	Health-care facilities	AAA and Resident animals programs	All potential animals	Infection risk Animal-related accidents Allergies	Specific guidelines to avoid the potential risks. In item, minimize contact with animal actual fluids, and implement hand hygiene later each contact. Avoid option of dangerous animals for AA as primates and reptiles. Careful selection of specifically trained animals. Provide prompt response in case of animal-related accidents. Minimize allergic risks bathing and training the animal in the 24 h prior the visit. Employ routine cleaning protocols afterward each session. Use all the protective measure for immunocompromised patients.
Brodie, 2002	Review	Healthcare environment in Europe or Due north America	Pet-therapy	Dogs Cats Birds Other animals	Infection risk Beast-related accidents Allergies	The review ended that infectious hazards are minimal The animate being-related accidents, as bites and scratches, can be minimized following rigorous train and protocols It is recommended to incorporate intensive veterinarian care.
Khan, 2000	Review	Healthcare settings	AAA or AAT	All potential creature employed in AAI, especially dogs	Animal bites or accidents Zoonosis Allergies	Infection command policies must be implemented and followed. Careful selection and suitability of the animals employed. Conscientious pick of eligible patients. The authors suggested to exclude: patients with splenectomy, canis familiaris allergies, positive to Mycobacterium Tuberculosis, with pyrexia of unknown origin or infected past MRSA

Lefebvre et al. conducted a cross-sectional survey in the Ontario hospitals in gild to appraise the presence and characteristics of Canine Visitation Programs for inpatients. Moreover, the authors interviewed the canis familiaris handlers regarding the health protocols for AAA. Virtually all the hospitals surveyed (ninety%) consented the access to dogs in their facilities. Two of the selected hospitals interrupted the AAA program, during 2003, due to the onset of severe acute respiratory syndrome. The screening protocols resulted extremely variable, and xviii domestic dog-owners (xx%) declared that they did not follow whatsoever infection command. Furthermore, over 70% of the interviewed handlers allowed the dog both to climb on patient's bed and to lick patients. Finally, the domestic dog owners were not aware of the potential zoonosis risks [45].

Two reviews [37], [39] considered the potential risks of animal use in healthcare settings, considering infections, allergies and bites. Precisely, Khan et al. considered the AAA or AAT implementation in healthcare settings, especially in hospitals [37]. The second review focused specifically on the healthcare environment of Europe and Northward America [39]. The zoonosis can be a risk especially for very immature, erstwhile or immunosuppressed patients [37], [39]. All the animals by and large used in AAI can act as a source of infections. Non only zoonosis could be a chance, only also other common infections equally MRSA. However, the awarding of hygiene protocols consented an effective risk minimization [39]. Moreover, the repeated wellness screenings for the animals and the careful selection of patients, using special precautions in example of open wounds and immunosuppression tin can help to control the risks [37]. Another gamble is allergy; anyhow, the reasoned selection of patients and animals can effectively reduce this take a chance. Finally, animal-related accidents can be practically canceled following appropriate guidelines [39]. Therefore, the reviews concluded that the benefits overhang risks. In particular, Khan et al. recommended a careful choice of the patients, excluding patients with splenectomy, dog allergy, positive to Mycobacterium Tuberculosis, with pyrexia of unknown origin or infected with MRSA [37].

The guidelines nigh AAI and pet-visitation agreed over the main central points, suggesting manus hygiene after all fauna contacts and avoiding as possible contacts with animal actual fluids [16], [38], [39], [40], [41]. All animals used for AAT must exist selected carefully, avoiding the most dangerous species as reptiles and primates [16]. Moreover, animals must follow strictly veterinarian health screenings, vaccine programs, and be specifically trained for these activities. To minimize the allergic risk, bathing and grooming animals prior each session could be useful. After each session, routine cleaning protocols should be implemented. Finally, inclusion of patients with severe immunosuppression, known allergy or brute phobia should exist advisedly considered, assessing benefits and risks [16], [38], [39], [40], [41]. In detail, Sehulster et al. reported the CDC guidelines for ecology infection control in wellness-care facilities, including a department regarding the rubber of AAA and resident animals programs in healthcare settings. On the reverse, in their guidelines [16], Sehr et al. considered exclusively a program of private pet-visitation in infirmary. In this case, the authors excluded immunocompromised patients, newborns and patients in post-anesthesia care units. Moreover, the authors registered overall positive evaluations of the nurses regarding the guidelines implementation [38]. The piece of work of Jofrè et al. consisted in a review of guidelines, in order to achieve a consensus regarding beast use in healthcare settings. Besides as underlining the importance of regular veterinary checks and strict germ-free protocols, the authors recommended to avert the utilise of puppies in lodge to minimize the infection risk [41]. Like guidelines are adopted also in hospital implementation protocols [42], [43]. In particular, these programs excluded all patients in mail service-operative period, with contempo splenectomy or severe immunosuppression [42]. Silveira et al. reported the implementation protocol of an AAA program in a Brazilian Academy infirmary. This protocol included a wide range of potential employed animals, including dogs, cats, fishes, rabbits, reptiles and other rodents [42]. Similarly, Kobayashi et al. reported the Lath of Nursery feel concerning the implementation of an AAT project in a University infirmary. In particular, the authors adapted the CDC guidelines to their specific setting [43].

iv. Give-and-take

Our review investigated the effectiveness and risks of beast assisted therapies in hospitals. Our search revealed extremely heterogeneous results, in terms of settings, target population, blazon of intervention and considered outcomes. Still, most studies focused on particularly frail population groups as children [8], [22], [23], [24], [25], [26], [27], [28], psychiatric inpatients [10], [eleven], [19], [20], [21] and elderly patients [vi], [7], [13], [14], [29]. The human relationship with the animals can be extremely useful for these patients peculiarly focusing on communication and social behaviours [7], [11], [28]. In item, considering psychiatric diseases, schizophrenic inpatients would do good from animate being contact considering schizophrenic symptoms, social relationships and aggressiveness [10], [nineteen], [21]. The reduction in aggressive behaviors was outlined, not merely in psychiatric inpatients, but also considering general inpatients [35]. The studies regarding adults were rare, but they considered unlike diseases including orthopaedic surgery and loftier-gamble pregnancies [31], [32], [33], [34], [35], [36].

Even if dogs are the almost studied animals [8], [10], [11], [xx], [21], [22], [23], [24], [25], [26], [27], [28], [31], [32], [33], [34], [35], [36], besides other species are considered as cats [half dozen], [44], fishes [14], cage birds [7] and horses [19]. The prevalent use of dogs is explained by the easier training for therapy; still, also other species can be potentially benign. Interestingly, the papers retrieved highlighted how "pet therapy" programs can be effectively implemented in a broad range of settings including Emergency Departments [34], long-term intendance facilities [6] and infirmary wards [35]. Although all the interventions retrieved took place in hospitals or in long-term intendance facilities, the specific location of the interventions differed. Indeed, some interventions took place in the hospital garden [xix] or in activity rooms specifically equipped [11], while others occurred directly in the ward [33], [34], or at bedside [25], [27]. As well considering the interventions' characteristics, the results appeared variegated. In as much, the length of the sessions ranged from 5 to 10 minutes [32], [35] to unlike hours [24]. Moreover, some programs required multiple sessions [6], [eight], [11], [21], while others included but a single session [thirteen], [34]. These important organizational differences make extremely hard to compare the retrieved intervention, and to depict articulate conclusions. Furthermore, not all the studies exactly described the specific train and formation of the couple animate being-therapist or handler. About this, some studies alleged to adhere and follow the "Pet Partners Guidelines" [eight], [19]. The AAT interventions resulted, in accord to their definition, more structured, organized in limited groups and conducted by certified therapists. On the contrary, the described AAA ranged from simple pet-visitation to spontaneous activities. In this case, the specific formation of the couple dog-handler is less described, and in one case, the dogs are accompanied only past the investigators, and not by the handler [x].

Despite the wide range of outcomes considered, the studies retrieved outlined general benefits of AAT or AAA in terms of psychological and physical effects. In detail, one common consequence explored was anxiety. Positive effects on anxiety, measured using the STAI scale or the Contour of Mood States survey, were detected for various pathologies every bit major depression [20], hospitalized children [23], elderly patients with acute centre failure [13], loftier-risk pregnancies [33] and adult inpatients in dissimilar infirmary departments [35]. The favorable consequence of AAT upon anxiety symptoms on children was confirmed by parents and staff [8]. In conclusion, the favorable affect on inpatient anxiety seemed assessed for a broad range of historic period and conditions.

Another frequently assessed outcome was depression. Significant amelioration in depressive symptomatology was highlighted in psychiatric inpatients [19] and hospitalized women with at take a chance pregnancy [33]. In addition, an improvement in depression symptoms, even if not statistically significant, was observed for elderly institutionalized patients with age-related diseases [6]. The impact on depression required more than in-depth analysis, particularly because the dissimilar scales used for its assessment.

Moreover, the pain (VAS scale, FACES scale or oral pain medication employ) seemed to accept reward of animal therapeutic use in diverse conditions as post-orthopedic surgery [31], [32], hospitalized children in acute setting [26] and adult inpatient in different section [35]. The effective function of canine assisted therapy on pain was outlined both in surgical and medical conditions. Even so, non all the studies were concordant regarding this issue. Indeed, Barker et al. did not find any difference in hurting between intervention and control group in children [23].

As well, the effects of AAI were assessed focusing on physiological parameters. The most assessed were claret pressure [half-dozen], [27], outlining a significant issue in decreasing this parameter, heart rate [13], [28], [35] and respiratory rate [13], [35]. However, the outcome on blood force per unit area was not concordant in all studies. Indeed, Cole et al. did non place any significant modify in this parameter [thirteen]. Another positive effect outlined was the actual distance walked in patients with chronic centre failure [29].

Therefore, the implementation of AAI tin can be interesting in a broad range of age and pathologies, just further and more standardized studies are required to exactly assess the pathologies mostly benefited from these interventions. The main limitations were linked to the heterogeneity of the retrieved studies because both the outcomes and the quality, making the comparison quite hard. Indeed, in accordance with previous reviews [4], [fifteen], the previous cited findings are limited by the overall low quality of the retrieved studies. Indeed, simply few works were RCTs. Moreover, most of the included papers presented limited samples that could affect the overall results. Therefore, more studies are required to completely depict the potential effects of AAI. In fact, some studies lacked of a control group [seven], [14], [20], [33], while others were pilot studies considering limited samples [ten], [xi], [21]. Moreover, some papers lacked details of randomization [26], [33] or considered merely parents or patients opinions [7], [8], [36]. Hospitals are particularly at risk settings, thus introducing animals has to exist carefully considered. Various studies explored these risks outlining infections, allergies and animal accidents as major issues [xvi], [37], [38], [39], [40]. The potential adventure of infections was outlined investigating the prevalence of infective agents in animals used for pet-visitation [17], [44]. These studies outlined the potential chance related not simply to typical zoonosis, just also to common human infections as MRSA [17], [44]. However, reviews and guidelines suggested that the implementation of all security precautions could finer minimize risks [xvi], [37], [38], [39], [40]. Therefore, the identification of patients receiving AAI should be advisedly conducted. Some studies described in item the sanitary protocols adopted for the animals involved, including regular veterinarian visits, vaccination documentation and assessments of controllability and temperament [11], [23], [26], [35], [36]. On the contrary, other works did not explicitly refer to whatever of these procedures. This matter represents another limitation of our review. Indeed, detailed information regarding the health surveillance protocols are desirable in lodge to correctly evaluate the considered interventions. The extensive Canadian survey regarding dog visitation highlighted how the infection control protocols result variable and occasionally potentially inadequate. In particular, the knowledge concerning the potential risks amongst the dog-handlers seemed insufficient [45]. Consequently, a closer cooperation between hospital staff, AAI-team, and veterinarians seems necessary. In addition, stricter controls about AAI safety in the hospital are desirable.

Furthermore, the data regarding beast welfare during the intervention lacked in well-nigh of the studies. Then, information technology would exist interesting to further deepen this topic, investigating, also, any adherence to specific guidelines. Another major concern was the acceptance of AAI programs among healthcare professional person. However, all studies considering this issue identified a general acceptance by the staff [22], [34], [36].

5. Conclusions

In conclusion, AAT or AAA for hospitalized patients seem useful and safety for a wide range of diseases. All the same, many aspects remained unclear, in particular regarding the type of intervention, condom, economical issues and diseases that would greatly benefit of these programs. Finally, given the paucity of high quality works almost this topic, information technology would be desirable to conduct more standardized studies considering in details outcomes and interventions in order to draw all the potential benefits and risks. Anyway, considering the intervention peculiarity, the reproducibility of randomized clinical trials could exist hard to achieve.

Upstanding statement

The authors declare that they have no conflicts of interest. This article does non incorporate whatever studies with human participants or animals performed by any of the authors.

Conflict of interests

None

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7185850/