Experiences of nursing home staff using the targeted interdisciplinary model for evaluation and treatment of neuropsychiatric symptoms (TIME) – a qualitative study

Background/Aims: Neuropsychiatric symptoms (NPS) in dementia pose great challenges for residents and staff in nursing homes. The Targeted Interdisciplinary Model for Evaluation and Treatment of Neuropsychiatric Symptoms (TIME) has recently in a randomized controlled trial demonstrated reductions in NPS. We explored the participating staff's experiences with the model and how it meets the challenges when dealing with the complexity of NPS.

Methods: Three to six months after the end of the intervention, we interviewed 32 of the caregivers, leaders, and physicians participating in the trial, in five focus groups. We used thematic content analysis.

Results: The analysis yielded two main themes: (1) a systematic reflection method enhanced learning at work; (2) the structure of the approach helped staff to cope with NPS in residents with dementia.

Conclusion: TIME shifts the way of learning for the staff from a traditional to a more innovative and reflection-based learning through a process of learning how to learn at work. The staff's experienced increased coping in their approach to complex problems. Our results emphasise the importance of a structured and biopsychosocial approach to NPS in clinical practice. Future research should explore models for integrating situated learning in daily routines in nursing homes.     

The emergence of human Powassan virus infection in North America

Powassan virus (POWV) is a tickborne flavivirus discovered in Ontario, Canada in 1958 that causes long-term neurological sequelae in about half the reported cases and death in a little more than 10 % of cases. The incidence of POWV disease is rising in the United States but there is limited understanding of the scope and causes of recent changes in POWV epidemiology. We focus on quantifying the increase in human POWV disease incidence and infection prevalence in the United States. We also examine differences in the frequency of symptomatic cases and asymptomatic or mildly symptomatic cases, as well as limitations in national and state surveillance for POWV infection. We searched SCOPUS for all articles containing original POWV prevalence research, case studies, or literature reviews published in English. Case studies were supplemented by Morbidity and Mortality Weekly Report POWV data from the Centers for Disease Control and Prevention (CDC) and surveillance information from state health department websites. An increase in the number of POWV cases has been reported in the United States over the past 50 yr, and the geographic range of human POWV cases has expanded. The age distribution of symptomatic POWV cases has shifted, with significantly more individuals over 40 yr old being diagnosed after 1998. The emergence of POWV is due in large part to: (i) a change in transmission of POWV from a vector that rarely bites people (Ixodes cookei) to a new vector that often bites people (Ixodes scapularis) and has expanded its geographic range, (ii) enhanced surveillance efforts for arboviruses, and (iii) a greater awareness of POWV infection.     

家长陪同对口腔门诊患儿七氟烷全身麻醉苏醒期躁动的影响研究

 目的　研究家长陪同对口腔门诊患儿七氟烷全身麻醉苏醒期躁动的影响。方法　选取2017年6—12月于重庆医科大学附属口腔医院行七氟烷全身麻醉口腔治疗患儿120例，随机分为陪同组和未陪同组，每组60例。陪同组患儿在治疗前麻醉诱导期及治疗后苏醒期均有家长陪同，未陪同组患儿在麻醉诱导期及苏醒期均无家长陪同。采用小儿麻醉苏醒期躁动量化评分表（pediatric anesthesia emergence delirium scale，PAED）对患儿麻醉苏醒期躁动情况进行评分，并计算躁动发生率。结果　陪同组PAED评分为（9.18 ± 3.41）分，未陪同组PAED评分为（10.57 ± 3.62）分，两组PAED评分比较，差异有统计学意义（t = 2.04，P = 0.03）。陪同组躁动发生率（26.67%）明显低于非陪同组（50.00%），差异有统计学意义（χ2 = 6.91，P = 0.01）。结论　治疗前麻醉诱导期及治疗后苏醒期有家长陪同，可减少患儿躁动的发生，提高家长对口腔治疗的满意度，促进良好的医患关系。     

Cost-Effectiveness of Midazolam Versus Haloperidol Versus Olanzapine for the Management of Acute Agitation in the Accident and Emergency Department

ObjectivesA multicenter randomized clinical trial in Hong Kong Accident and Emergency (A&E) departments concluded that intramuscular (IM) olanzapine is noninferior to haloperidol and midazolam, in terms of efficacy and safety, for the management of acutely agitated patients in A&E setting. Determining their comparative cost-effectiveness will further provide an economic perspective to inform the choice of sedative in this setting.MethodsThis analysis used data from a randomized clinical trial conducted in Hong Kong A&E departments between December 2014 and September 2019. A within-trial cost-effectiveness analysis comparing the 3 sedatives was conducted, from the A&E perspective and a within-trial time horizon, using a decision-analytic model. Sensitivity analyses were also undertaken.ResultsIn the base-case analysis, median total management costs associated with IM midazolam, haloperidol, and olanzapine were Hong Kong dollar (HKD) 1958.9 (US dollar [USD] 251.1), HKD 2504.5 (USD 321.1), and HKD 2467.6 (USD 316.4), respectively. Agitation management labor cost was the main cost driver, whereas drug costs contributed the least. Midazolam dominated over haloperidol and olanzapine. Probabilistic sensitivity analyses supported that midazolam remains dominant > 95% of the time and revealed no clear difference in the cost-effectiveness of IM olanzapine versus haloperidol (incremental cost-effectiveness ratio 667.16; 95% confidence interval ?770.89, 685.90).ConclusionsIM midazolam is the dominant cost-effective treatment for the management of acute agitation in the A&E setting. IM olanzapine could be considered as an alternative to IM haloperidol given that there is no clear difference in cost-effectiveness, and their adverse effect profile should be considered when choosing between them.     

喹硫平联合氟哌啶醇对精神分裂症患者激越行为的影响

目的 探讨喹硫平联合氟哌啶醇治疗对精神分裂症患者激越行为的影响。方法 采用回顾性研究方法,2015年1月-2016年9月选择在新乡医学院第二附属医院诊治的精神分裂症患者115例,根据治疗方法的不同分为观察组60例与对照组55例,对照组给予喹硫平治疗,观察组给予喹硫平联合氟哌啶醇治疗,比较两组的治疗效果、不良反应、血脂改变及激越行为评分情况。结果 观察组的总有效率96.7%（58/60）高于对照组87.3%（48/55）,差异有统计学意义（P<0.05）。观察组的不良反应发生率为21.7%（13/60）,对照组为21.8%（12/55）,且两组的不良反应都为轻中度。治疗后两组血清低密度脂蛋白胆固醇（LDL-C）、总胆固醇（TC）、三酰甘油（TG）、高密度脂蛋白胆固醇（HDL-C）含量对比无差异。治疗后观察组与对照组的激越行为评分分别为（8.14±6.33）分和（13.01±6.10）分,显著低于治疗前的（22.22±5.33）分和（22.09±4.82）分（P<0.05）,同组治疗前后比较差异有统计学意义（P<0.05）;且观察组明显低于对照组,差异有统计学意义（P<0.05）。结论 喹硫平联合氟哌啶醇治疗精神分裂症患者能有效控制激越行为,提高治疗效果,且不会增加不良反应的发生,也不会影响患者的血脂水平,有很好的应用价值。     

全麻患者苏醒期躁动影响因素的Meta分析

目的探讨全麻患者苏醒期躁动(EA)发生的相关影响因素。方法检索CNKI、Wanfang、VIP、PubMed、Cochrane Library、Embase等数据库,收集建库至2020年1月19日有关EA影响因素的文献。根据纳入及排除标准筛选文献,并对纳入文献进行质量评价,采用RevMan5.3软件进行Meta分析。结果共纳入26篇文献,共计21 179例观察对象,其中病例组3182例,对照组17 997例。Meta分析结果显示,两组男性、吸烟史、合并高血压、脑外伤或脑梗死病史、合并糖尿病、术前焦虑、气管插管、留置导尿管、手术时间、麻醉时间、药物催醒、术后疼痛、低氧(SpO_290%)、麻醉恢复室停留时间等因素与全麻术后EA的发生有关,差异有统计学意义(P0.05);亚组分析显示,吸入麻醉、麻醉诱导后留置尿管、开胸手术、普外科手术、ASAⅡ级、ASAⅢ级、术中开放性补液等因素是EA的危险因素,差异有统计学意义(P0.05)。结论在临床治疗过程中应充分了解患者的个体情况,整体预测和识别高危患者,制订针对性措施预防苏醒期躁动的发生。     

Occupation and communication programs for post-coma persons with or without consciousness disorders who show extensive motor impairment and lack of speech

These two studies were aimed at extending the assessment of technology-aided programs for post-coma persons with extensive motor impairment and lack of speech. Specifically, Study I assessed a new program arrangement, in which stimulation access and caregiver attention could be obtained with variations of the same response (i.e., single- versus double-hand closure) by three participants who were diagnosed at the upper level of the minimally conscious state at the start of the study. Study II was aimed at enabling two persons who had emerged from a minimally conscious state to engage in leisure activities, listen to audio-recordings of family members, and send and receive messages. The responses selected for these participants were hand pressure and eyelid closure, respectively. The results of both studies were positive. The participants of Study I increased their responding to increase their stimulation input and caregiver interaction. The participants of Study II managed to successfully select all the options the program included (i.e., the leisure options, as well as the family and communication options). General implications of the programs and the related technology packages for intervention with post-coma persons with multiple disabilities are discussed.     

曲马多不同静脉给药方案对小儿扁桃体切除术后躁动的影响

目的观察曲马多不同静脉给药方案对小儿扁桃体切除术后躁动的影响。方法择期扁桃体切除术患儿240例,年龄3~6岁,采用随机数字表法分为六组:A组诱导时给予曲马多2mg/kg,手术结束时给予生理盐水;B组诱导时给予生理盐水,手术结束时给予曲马多2mg/kg;C组诱导时给予曲马多1mg/kg,手术结束时给予生理盐水;D组诱导时给予生理盐水,手术结束时给予曲马多1mg/kg;E组诱导时给予曲马多1mg/kg,手术结束时给予曲马多1mg/kg;F组诱导时与手术结束时均给予生理盐水。记录拔管时间,清醒时间,清醒后10、20、30、40、50、60min的Ramsay镇静评分、躁动评分、FLACC评分及恶心呕吐发生率。结果清醒后10~50min B组镇静躁动评分、FLACC评分均明显低于其他五组(P0.05),而F组明显高于其他五组(P0.05)。清醒后10~40min B组Ramsay镇静评分明显高于其他五组(P0.05)。结论曲马多在小儿扁桃体切除术结束时以2mg/kg静脉注射可以在手术后1h内提供较好的镇静与镇痛,不增加手术后恶心呕吐的发生率,不影响拔管时间与清醒时间。