Objective and behavioural assessment of the emergence from post-traumatic amnesia (PTA)

Primary objective: To determine the profile of resolution of typical PTA behaviours and describe new learning and improvements in self-care during PTA. Research design: Prospective longitudinal study monitoring PTA status, functional learning and behaviours on a daily basis. Methods and procedures: Participants were 69 inpatients with traumatic brain injury who were in PTA. PTA was assessed using the Westmead or Oxford PTA assessments. Functional learning capability was assessed using a routine set of daily tasks and behaviour was assessed using an observational checklist. Data was analysed using descriptive statistics. Main outcomes and results: Challenging behaviours that are typically associated with PTA, such as agitation, aggression and wandering resolved in the early stages of PTA and incidence rates of these behaviours were less than 20%. Independence in self-care and bowel and bladder continence emerged later during resolution of PTA. New learning in functional situations was demonstrated by patients in PTA. Conclusions: It is feasible to begin active rehabilitation focused on functional skills-based learning with patients in the later stages of PTA. Formal assessment of typically observed behaviours during PTA may complement memory-based PTA assessments in determining emergence from PTA.

Psychotropic medication utilization in a child and adolescent mental health service

Objectives: This study aimed to identify rates and correlates of psychotropic drug utilization in children and adolescents in inpatient and outpatient settings. Methods: A retrospective chart review examined 122 inpatient and 126 outpatient charts from a metropolitan child and youth mental health service in Brisbane, Australia. Results: Inpatients received more psychotropic medication than outpatients (71% vs. 25%; p < 0.01). Patients receiving medication were older, had longer hospital admissions, and more complex presentations, including history of abuse or suicide attempts and more diagnoses (all p < 0.01). Selective serotonin reuptake inhibitors (SSRIs) were the most frequently used drug class (44% inpatients; 14% outpatients), primarily indicated for mood disorders (31%). SSRIs and newer antidepressants (ADs) were used more frequently in patients with a high suicide risk (p < 0.01). Atypical antipsychotics (APs) were also used (inpatients 23%; outpatients 3%), primarily for behavioral disturbances. Half of those receiving medication (51%) received polypharmacy (> 1 concurrent drug), with up to four drugs used at one time. Rates of polypharmacy were highest among patients receiving antipsychotics. Conclusions: Use of psychotropic medication is frequent in this population. Future research should initially focus on inpatients and intensive treatment settings and examine both safety and efficacy of interventions for depression in young people, atypical antipsychotics for behavioral disturbances, and polypharmacy.

Medication errors in older people with mental health problems:a review

Objective - To review and summarise published data on medication errors in older people with mental health problems. Methods - A systematic review was conducted to identify studies that investigated medication errors in older people with mental health problems. MEDLINE, EMBASE, PHARMLINE, COCHRANE COLLABORATION and PsycINFO were searched electronically. Any studies identified were scrutinized for further references. The title, abstract or full text was systematically reviewed for relevance. Results - Data were extracted from eight studies. In total, information about 728 errors (459 administration, 248 prescribing, 7 dispensing, 12 transcribing, 2 unclassified) was available. The dataset related almost exclusively to inpatients, frequently involved non-psychotropics, and the majority of the errors were not serious. Conclusions - Due to methodology issues it was impossible to calculate overall error rates. Future research should concentrate on serious errors within community settings, and clarify potential risk factors.

Medication errors in mental healthcare:a systematic review

Methods: It has been estimated that medication error harms 1-2% of patients admitted to general hospitals. There has been no previous systematic review of the incidence, cause or type of medication error in mental healthcare services. Methods: A systematic literature search for studies that examined the incidence or cause of medication error in one or more stage(s) of the medication-management process in the setting of a community or hospital-based mental healthcare service was undertaken. The results in the context of the design of the study and the denominator used were examined. Results: All studies examined medication management processes, as opposed to outcomes. The reported rate of error was highest in studies that retrospectively examined drug charts, intermediate in those that relied on reporting by pharmacists to identify error and lowest in those that relied on organisational incident reporting systems. Only a few of the errors identified by the studies caused actual harm, mostly because they were detected and remedial action was taken before the patient received the drug. The focus of the research was on inpatients and prescriptions dispensed by mental health pharmacists. Conclusion: Research about medication error in mental healthcare is limited. In particular, very little is known about the incidence of error in non-hospital settings or about the harm caused by it. Evidence is available from other sources that a substantial number of adverse drug events are caused by psychotropic drugs. Some of these are preventable and might probably, therefore, be due to medication error. On the basis of this and features of the organisation of mental healthcare that might predispose to medication error, priorities for future research are suggested.

Aglomeração urbana descontínua: o exemplo de Araguari e Uberlândia/MG

The analysis of urban conurbations demands the understanding regarding the difference between urban territorial continuity and spatial continuity. While the spatial continuity is understood due to its interrelations and established fluxes, in other words, through the spatial integration, the territorial continuity is related to the urban tissue. Therefore, the spatial continuity can manifest in a simultaneous way or associated to the territorial discontinuity. From this perspective, the main objective of this research consists on identifying and dimensioning the spatial interactions that are driven to a urban conurbation process between the municipalities of Araguari and Uberlândia/MG, besides the not continuity of the territorial urban area. The intensity of these interactions was identified from the displacements by the dwellers from both municipalities in search of job occupations, education and health assistance. So it would be able to reach the proposed objectives we used several methodological procedures, such as a bibliographic and documental researches. In order to identify the education and work fluxes we analyzed the micro data from the Demographic Census 2010. For the educational sector it was also accomplished a research, in Araguari, the place of residence of students enrolled at Instituto Master de Ensino Presidente Antônio Carlos (IMEPAC) and, in Uberlândia, the place of residence of students enrolled at Universidade Federal de Uberlândia (UFU). The identification of health fluxes was done through a research, in Uberlândia, of the inpatients' origin at Hospital de Clínicas de Uberlândia of the Universidade Federal de Uberlândia (HCU/UFU) and, in Araguari, of the origin of patients that are attended at the Pronto-Socorro Municipal. Semi structured interviews were also accomplished with different social actors. Another important step was the use of questionnaires with the inter-municipal public transportation users at their boarding place in Araguari and Uberlândia. This paper was organized in five chapters, while in the first one we accomplished a theoretical discussion over the concept of urban conurbation, in order to presenting the identification and classification criteria and the urban conurbation of non metropolitan criteria. The second chapter analyses the differentiation process between Araguari and Uberlândia, which is a result of the distinct territorial formation of the municipalities. The third chapter analyses the intensity and degree of the spatial interactions between the two municipalities, having as a focus the established fluxes in the work sector. The fourth chapter, on the other hand, focuses on the education and health sectors, while the last chapter accomplishes a discussion to investigate if the analyzed fluxes in the previous chapters make it able to identify if the spatial interactions established between Araguari and Uberlândia are measured through complementarities or dependence. As a result it was possible to identify that, due to the expressiveness of the established fluxes between the two municipalities, beyond the further ones of Triângulo Mineiro and Alto Paranaíba in the three selected sectors, there is a configuration of a discontinuous urban conurbation process. It was also possible to conclude that, despite the fluxes between Araguari and Uberlândia being more representative than the other way around there's a coexistence dependence relationship and complementarity between the two municipalities.

What is the current practice of medicines reconciliation in children nationally in the UK?

INTRODUCTION: The National Institute for Health and Clinical Excellence/National Patient Safety Agency (NICE/NPSA) guidelines for medicines reconciliation (MR) on admission to hospital in adult inpatients were introduced in 2007, but they excluded children less than 16 years of age. METHOD: We conducted a survey of 98 paediatric pharmacists (each from a different hospital) to find out what the current practice of MR in children is in the UK. KEY FINDINGS: Responses showed that 67% (43/64) of pharmacists surveyed carried out MR in all children at admission and only a third 34% (22/64) had policies for MR in children. Of the respondents who did not carry out MR in all children, 80% (4/5) responded that they did so in selected children. Pharmacists considered themselves the most appropriate profession for carrying out MR. When asked whether the NICE guidance should be expanded to include children, 98% (54/55) of the respondents answered 'yes'. CONCLUSION: In conclusion, the findings suggest that MR is being conducted inconsistently in children and most paediatric pharmacists would like national guidance to be expanded to include children.

Guideline-based decision support has a small, non-sustained effect on transthoracic echocardiography ordering frequency.

BACKGROUND: Guidance for appropriate utilisation of transthoracic echocardiograms (TTEs) can be incorporated into ordering prompts, potentially affecting the number of requests. METHODS: We incorporated data from the 2011 Appropriate Use Criteria for Echocardiography, the 2010 National Institute for Clinical Excellence Guideline on Chronic Heart Failure, and American College of Cardiology Choosing Wisely list on TTE use for dyspnoea, oedema and valvular disease into electronic ordering systems at Durham Veterans Affairs Medical Center. Our primary outcome was TTE orders per month. Secondary outcomes included rates of outpatient TTE ordering per 100 visits and frequency of brain natriuretic peptide (BNP) ordering prior to TTE. Outcomes were measured for 20 months before and 12 months after the intervention. RESULTS: The number of TTEs ordered did not decrease (338±32 TTEs/month prior vs 320±33 afterwards, p=0.12). Rates of outpatient TTE ordering decreased minimally post intervention (2.28 per 100 primary care/cardiology visits prior vs 1.99 afterwards, p<0.01). Effects on TTE ordering and ordering rate significantly interacted with time from intervention (p<0.02 for both), as the small initial effects waned after 6 months. The percentage of TTE orders with preceding BNP increased (36.5% prior vs 42.2% after for inpatients, p=0.01; 10.8% prior vs 14.5% after for outpatients, p<0.01). CONCLUSIONS: Ordering prompts for TTEs initially minimally reduced the number of TTEs ordered and increased BNP measurement at a single institution, but the effect on TTEs ordered was likely insignificant from a utilisation standpoint and decayed over time.

A study protocol of a randomised controlled trial to measure the effects of an augmented prescribed exercise programme (APEP) for frail older medical patients in the acute setting

Background: Older adults experience functional decline in hospital leading to increased healthcare burden and morbidity. The benefits of augmented exercise in hospital remain uncertain. The aim of this trial is to measure the short and longer-term effects of augmented exercise for older medical in-patients on their physical performance, quality of life and health care utilisation. Design and Methods: Two hundred and twenty older medical patients will be blindly randomly allocated to the intervention or sham groups. Both groups will receive usual care (including routine physiotherapy care) augmented by two daily exercise sessions. The sham group will receive stretching and relaxation exercises while the intervention group will receive tailored strengthening and balance exercises. Differences between groups will be measured at baseline, discharge, and three months. The primary outcome measure will be length of stay. The secondary outcome measures will be healthcare utilisation, activity (accelerometry), physical performance (Short Physical Performance Battery), falls history in hospital and quality of life (EQ-5D-5 L). Discussion: This simple intervention has the potential to transform the outcomes of the older patient in the acute setting.

Duelo, ansiedad y depresión en familiares de pacientes en una unidad de cuidados paliativos a los dos meses de la pérdida

Aim: This study is going to assess the prevalance of prolonged grief diagnoses and it will evaluate the severity of the symptoms of depression, anxiety and complicated grief two months after a loved one is lost. We also intend to study which variables associated with the risk of grief could be more decisive when diagnosing it, its symptoms and the consequent emotional distress.Method: A total of 66 families of patients in the Palliative Care Unit (PCU) at Hospital San Cecilio in Granada have been evaluated. Measurements were taken two months after the death. This investigation has explored the existing emotional distress using the following questionnaires: Beck Depression Inventory (BDI-II), Beck Anxiety Inventory (BAI), Inventory of Complicated Grief (ICG) and Prolongued Grief Disorder (PG-12).Results: The results show that 33.3% and 21.21% of the sufferers had high levels of depression and clinical anxiety two months after the death. The prevalence of prolongued grief diagnoses, according to the PG-12, is 10.6% and 53.03% of the participants showed symptoms of complicated grief according to the ICG. Additionally, statistically significant differences are found in the sufferers with and without a prolongued grief diagnosis and scores in the ICG and BDI-II. The family’s financial situation is linked to the presence of symptoms of anxiety and depression and complicated grief, with the most determining variable being the risk of grief. Finally, the greater the age of the deceased and the longer the time spent in the PCU is linked to fewer symptoms of grief. However, important links have been found between the sufferers who have experienced stressful critical events prior to losing their loved one, with symptoms of depression, anxiety and complicated grief.Conclusions: The high numbers of cases of symptoms of complicated grief and levels of anxiety and clinical depression two months after a death suggests that early interventions should be carried out in those individuals with greater vulnerability.

The Antibiotic Resistance and Prescribing in European Children Project: A Neonatal and Pediatric Antimicrobial Web-based Point Prevalence Survey in 73 Hospitals Worldwide

BACKGROUND: The neonatal and pediatric antimicrobial point prevalence survey (PPS) of the Antibiotic Resistance and Prescribing in European Children project (http://www.arpecproject.eu/) aims to standardize a method for surveillance of antimicrobial use in children and neonates admitted to the hospital within Europe. This article describes the audit criteria used and reports overall country-specific proportions of antimicrobial use. An analytical review presents methodologies on antimicrobial use.

METHODS: A 1-day PPS on antimicrobial use in hospitalized children was organized in September 2011, using a previously validated and standardized method. The survey included all inpatient pediatric and neonatal beds and identified all children receiving an antimicrobial treatment on the day of survey. Mandatory data were age, gender, (birth) weight, underlying diagnosis, antimicrobial agent, dose and indication for treatment. Data were entered through a web-based system for data-entry and reporting, based on the WebPPS program developed for the European Surveillance of Antimicrobial Consumption project.

RESULTS: There were 2760 and 1565 pediatric versus 1154 and 589 neonatal inpatients reported among 50 European (n = 14 countries) and 23 non-European hospitals (n = 9 countries), respectively. Overall, antibiotic pediatric and neonatal use was significantly higher in non-European (43.8%; 95% confidence interval [CI]: 41.3-46.3% and 39.4%; 95% CI: 35.5-43.4%) compared with that in European hospitals (35.4; 95% CI: 33.6-37.2% and 21.8%; 95% CI: 19.4-24.2%). Proportions of antibiotic use were highest in hematology/oncology wards (61.3%; 95% CI: 56.2-66.4%) and pediatric intensive care units (55.8%; 95% CI: 50.3-61.3%).

CONCLUSIONS: An Antibiotic Resistance and Prescribing in European Children standardized web-based method for a 1-day PPS was successfully developed and conducted in 73 hospitals worldwide. It offers a simple, feasible and sustainable way of data collection that can be used globally.

Efficacy and safety of lumacaftor/ivacaftor combination therapy in patients with cystic fibrosis homozygous for Phe508del CFTR by pulmonary function subgroup

Background Lumacaftor/ivacaftor combination therapy demonstrated clinical benefits inpatients with cystic fibrosis homozygous for the Phe508del CFTR mutation.Pretreatment lung function is a confounding factor that potentially impacts the efficacyand safety of lumacaftor/ivacaftor therapy. Methods Two multinational, randomised, double-blind, placebo-controlled, parallelgroupPhase 3 studies randomised patients to receive placebo or lumacaftor (600 mgonce daily [qd] or 400 mg every 12 hours [q12h]) in combination with ivacaftor (250 mgq12h) for 24 weeks. Prespecified analyses of pooled efficacy and safety data by lungfunction, as measured by percent predicted forced expiratory volume in 1 second(ppFEV1), were performed for patients with baseline ppFEV1 <40 (n=81) and ≥40(n=1016) and screening ppFEV1 <70 (n=730) and ≥70 (n=342). These studies wereregistered with ClinicalTrials.gov (NCT01807923 and NCT01807949). Findings The studies were conducted from April 2013 through April 2014.Improvements in the primary endpoint, absolute change from baseline at week 24 inppFEV1, were observed with both lumacaftor/ivacaftor doses in the subgroup withbaseline ppFEV1 <40 (least-squares mean difference versus placebo was 3∙7 and 3.3percentage points for lumacaftor 600 mg qd/ivacaftor 250 mg q12h and lumacaftor 400mg q12h/ivacaftor 250 mg q12h, respectively [p<0∙05] and in the subgroup with baselineppFEV1 ≥40 (3∙3 and 2∙8 percentage points, respectively [p<0∙001]). Similar absoluteimprovements versus placebo in ppFEV1 were observed in subgroups with screening 4ppFEV1 <70 (3∙3 and 3∙3 percentage points for lumacaftor 600 mg qd/ivacaftor 250 mgq12h and lumacaftor 400 mg q12h/ivacaftor 250 mg q12h, respectively [p<0∙001]) and≥70 (3∙3 and 1∙9 percentage points, respectively [p=0.002] and [p=0∙079]). Increases inBMI and reduction in number of pulmonary exacerbation events were observed in bothLUM/IVA dose groups vs placebo across all lung function subgroups. Treatment wasgenerally well tolerated, although the incidence of some respiratory adverse events washigher with active treatment than with placebo. Interpretation Lumacaftor/ivacaftor combination therapy benefits patients homozygousfor Phe508del CFTR who have varying degrees of lung function impairment. Funding Vertex Pharmaceuticals Incorporated.

Care planning for aggression management in a specialist secure mental health service: user involvement

This paper describes an audit of prevention and management of violence and aggression care plans and incident reporting forms which aimed to: (i) report the compliance rate of completion of care plans; (ii) identify the extent to which patients contribute to and agree with their care plan; (iii) describe de-escalation methods documented in care plans; and (iv) ascertain the extent to which the de-escalation methods described in the care plan are recorded as having been attempted in the event of an incident. Care plans and incident report forms were examined for all patients in men's and women's mental health care pathways who were involved in aggressive incidents between May and October 2012. In total, 539 incidents were examined, involving 147 patients and 121 care plans. There was no care plan in place at the time of 151 incidents giving a compliance rate of 72%. It was documented that 40% of patients had contributed to their care plans. Thematic analysis of de-escalation methods documented in the care plans revealed five de-escalation themes: staff interventions, interactions, space/quiet, activities and patient strategies/skills. A sixth category, coercive strategies, was also documented. Evidence of adherence to de-escalation elements of the care plan was documented in 58% of incidents. The reasons for the low compliance rate and very low documentation of patient involvement need further investigation. The inclusion of coercive strategies within de-escalation documentation suggests that some staff fundamentally misunderstand de-escalation.

An epidemiological surveillance network of lumbar disc surgery to help prevention of and compensation for low back pain

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