Approach to acute agitation in the pediatric emergency department

PURPOSE OF REVIEW

The complexity of pediatric mental and behavioral health (MBH) complaints presenting to emergency departments (EDs) is increasing at an alarming rate. Children may present with agitation or develop agitation during the ED visit. This causes significant distress and may lead to injury of the child, caregivers, or medical staff. This review will focus on providing safe, patient-centered care to children with acute agitation in the ED.

RECENT FINDINGS

Approaching a child with acute agitation in the ED requires elucidation on the cause and potential triggers of agitation for optimal management. The first step in a patient-centered approach is to use the least restrictive means with behavioral and environmental strategies. Restraint use (pharmacologic or physical restraint) should be reserved where these modifications do not result in adequate de-escalation. The provider should proceed with medications first, using the child's medication history as a guide. The use of physical restraint is a last resort to assure the safety concerns of the child, family, or staff, with a goal of minimizing restraint time.

SUMMARY

Children are increasingly presenting to EDs with acute agitation. By focusing primarily on behavioral de-escalation and medication strategies, clinicians can provide safe, patient-centered care around these events.

Code De-Escalation: Decreasing restraint use during agitation management in a community hospital emergency department

INTRODUCTION

Restraint use in the emergency department (ED) can pose significant risks to patients and health care workers. We evaluate the effectiveness of Code De-escalation- a standardized, team-based approach for management and assessment of threatening behaviors- in reducing physical restraint use and workplace violence in a community ED.

METHODS

A retrospective observational study of a pathway on physical restraint use among patients placed on an involuntary psychiatric hold in a community ED. This pathway includes a built-in step for the team members to systematically assess perceptions of threats from the patient behavior and threats perceived by the patient. Our primary outcome was the change in the rate of physical restraint use among patients on an involuntary psychiatric hold. Our secondary outcome was the change in the rate of workplace violence events involving all ED encounters. We evaluated our outcomes by comparing all encounters in a ten-month period before and after implementation, and compared our results to rates at neighboring community hospitals within the same hospital network.

RESULTS

Pre intervention there were 434 ED encounters involving a psychiatric hold, post-intervention there were 535. We observed a significant decrease in physical restraint use, from 7.4% to 3.7% (ARR 0.028 [95% CI 0.002-0.055], p < 0.05). This was not seen at the control sites.

CONCLUSIONS

A standardized de-escalation algorithm can be effective in helping ED's decrease their use of physical restraints in management of psychiatric patients experiencing agitation.

Patterns of change in restrictive measures in residential care: Trauma-informed staff training benefits children and youth who need it the Most

BACKGROUND

Implementation of trauma-informed staff training is promising to reduce restrictive measures (restraints, seclusions, and time-outs) used to address problem behaviors in youth in residential care. Previous mixed results may be explained in part by the heterogeneity in the use of restrictive measures among youth.

OBJECTIVE

The objective was twofold: (1) to examine whether heterogeneity in the initial number of restrictive measures experienced by youth, before implementing trauma-informed staff training, moderates the effect of the training and (2) to explore whether children and youth's characteristics are associated with the number of restrictive measures.

PARTICIPANTS AND SETTING

A trauma-informed staff training was implemented in 44 residential care units in Quebec, Canada.

METHODS

This study used administrative data. The sample (n = 297 youth) was divided into three subgroups based on the number of restrictive measures experienced in the six-month period prior to the training: 1) absence or low (52 % of the sample); 2) moderate (23 %); 3) high (25 %).

RESULTS

The use of restrictive measures was compared between the subgroups. Main and interaction effects were all significant. None of the slopes for groups 1 and 2 were significant. In contrast, significant decreases from T1 were observed at T2 (-0.18 (0.02), p < .000) and T3 (-0.22 (0.02), p < .000) in group 3. Several children and youth's characteristics distinguished groups.

CONCLUSIONS

Implementation was more beneficial to youth who experienced a high number of restrictive measures. Training opportunities can lead to positive changes in measures used to address problem behaviors in youth.

Relationship between perceived coercion and perceived justification of coercive measures - secondary analysis of a randomized-controlled trial

BACKGROUND

Subjective perception of coercion has gained attention as an important outcome. However, little is known about its relation to patients' appraisal of the justification of coercive measures. The present study aims to analyze the relationship between patients' appraisal of the justification of coercive measures and their level of perceived coercion.

METHODS

This study presents a secondary analysis of the results of a multi-center RCT conducted to evaluate the effects of post-coercion review. Patients who experienced at least one coercive measure during their hospital stay were included in the trial. Participants' appraisal of the justification of coercive measures was categorized into patient-related and staff-related justifications. Subjective coercion was assessed using the Coercion Experience Scale (CES) and used as dependent variable in a multivariate regression model.

RESULTS

97 participants who completed the CES were included in the analysis. CES scores were significantly associated with the perception of the coercive measure as justified by staff-related factors (B = 0,540, p < 0,001), as well as with higher level of negative symptoms (B = 0,265, p = 0,011), and with mechanical restraint compared to seclusion (B=-0,343, p = 0,017).

CONCLUSIONS

Patients' perceptions of coercive measures as justified by staff-related factors such as arbitrariness or incompetence of staff are related to higher levels of perceived coercion. Multiprofessional efforts must be made to restrict the use of coercive measures and to ensure a transparent and sustainable decision-making process, particularly with patients showing high levels of negative symptoms. Such key elements should be part of all coercion reduction programs.

Prenatal stress and KCl-induced depolarization modulate cell death, hypothalamic-pituitary-adrenal axis genes, oxidative and inflammatory response in primary cortical neurons

Maternal stress has been described as an important component in the offspring's cerebral development, altering the susceptibility to diseases in later life. Moreover, the postnatal period is essential for the development and integration of several peripheral and central systems related to the control of homeostasis. Thus, this study aimed to evaluate the effects of prenatal stress on the activation of cortical neurons, by performing experiments both under basal conditions and after KCl-induced depolarization. Female mice were divided in two groups: control and prenatal restraint stress. Cortical neurons from the offspring were obtained at gestational day 18. The effects of prenatal stress and KCl stimulations on cellular mortality, autophagy, gene expression, oxidative stress, and inflammation were evaluated. We found that neurons from PNS mice have decreased necrosis and autophagy after depolarization. Moreover, prenatal stress modulated the HPA axis, as observed by the increased GR and decreased 5HTr1 mRNA expression. The BDNF is an important factor for neuronal function and results demonstrated that KCl-induced depolarization increased the gene expression of BDNF I, BDNF IV, and TRκB. Furthermore, prenatal stress and KCl treatment induced significant alterations in oxidative and inflammatory markers. In conclusion, prenatal stress and stimulation with KCl may influence several markers related to neurodevelopment in cortical neurons from neonate mice, supporting the well-known long-term effects of maternal stress.

Decline in Physical Restraint Use Following Implementation of Institutional Guidelines

OBJECTIVE

To investigate the strategies implemented at our institution to reduce medical restraint use.

BACKGROUND

Restraints have been utilized to prevent agitation, self-extubations, and falls, although they are often associated with negative repercussions for nurses and patients.

METHODS

The restraint data at our institution were compared with the National Database of Nursing Quality Indicators (NDNQI) benchmark. We also described the measures taken to improve restraint documentation.

RESULTS

The number of patients in medical restraints, medical restraint hours, medical restraints/patient-days, and deaths in restraints at our institution all significantly decreased (P < 0.00001). There were 27 self-extubations of restrained patients compared with 11 self-extubations of nonrestrained patients. The percentage of inpatients with restraints in critical care and step-down areas declined and remained below the NDNQI benchmark.

CONCLUSIONS

This study reports the processes implemented to reduce restraint use through enhanced communication and increased documentation. Further exploration into factors that may attain a restraint-free environment is warranted.

Exercise and crocin prevent adolescent-stress induced impairment of spatial navigation and dendritic retraction in the hippocampal CA3 area in adult male rats

Adolescent chronic stress has been shown to induce functional, biochemical and morphological modifications of the hippocampus, leading to stress-related disorders in adulthood. The present study investigated the effects of exercise, crocin and their combination on spatial learning and memory impairment and dendritic retraction of the CA3 pyramidal neurons induced by chronic adolescent stress in adult male rats. Rats were exposed to restraint stress 2 h/day for 10 days during postnatal days (PNDs) 30-40. Following this period, separate groups of animals were treated with crocin (25 and 50 mg/kg), exposed to running wheel, and or received the combined treatment during PNDs 41-55. Following the interventions, plasma levels of corticosterone, spatial learning and memory, apical dendritic length of CA3 pyramidal neurons and BDNF levels in the CA3 area were assessed. Findings showed that adolescent stress significantly increased corticosterone levels and caused a tendency to reduce CA3 BDNF levels. Adolescent stress also impaired spatial learning and memory, and retracted apical dendritic length of CA3 pyramidal neurons. Crocin, voluntary exercise, and their combination recovered stress-induced spatial learning and impairment and CA3 pyramidal neurons dendritic length retraction. All treatments also reduced significantly corticosterone levels and enhanced CA3 BDNF levels in the stress groups. Finally, these treatments even increased apical dendritic length of CA3 pyramidal neurons in the non-stress groups. These findings indicate that detrimental effects of adolescent stress on cognitive function and hippocampal morphology in adulthood could be restored by early interventions with physical activity and crocin treatment during adolescent period.

Restraint, seclusion and time-out among children and youth in group homes and residential treatment centers: a latent profile analysis

BACKGROUND

Many children and youth living in residential units have experienced multiple traumas that may result in challenging behaviors. Among a range of professional responses, staff may use restraint, seclusion and time-out to manage these behaviors.

OBJECTIVE

To enhance our understanding of these restrictive interventions in residential units as a means of improving professional practices involving children and youth in out-of-home care.

PARTICIPANTS AND SETTING

Administrative data were used. Restrictive intervention data for 324 children and youth (29 units) over a 6-month period were extracted.

METHODS

Latent profile analysis was used to identify subgroups of children and youth with distinct restrictive intervention profiles. Children and youth in these profiles were compared on individual (age, sex, ethnic group, length of stay in unit, reasons for services) and environmental characteristics (unit type, type of services, specialized designation).

RESULTS

Restrictive interventions, especially time-outs, were frequent (5136 interventions; 69% time-outs), yet approximately half of the sample did not experience any. Restraints, seclusions and time-outs differed in frequency, duration and reason for use. A two-profile model was favored for children and youth who were subjected to restrictive interventions (classification accuracy = 94%). Children and youth in these two profiles differed from each other, and from those not subjected to restrictive interventions, on numerous individual and environmental characteristics.

CONCLUSION

The use of restrictive interventions is frequent, and attention should be paid to individual and environmental risk factors identified in this study (i.e., being a boy, non-Caucasian, taken into care for neglect, and having a longer stay in unit).

Physical and Mental Health-Related Quality of Life Changes Among Insurer Subgroups Following Bariatric Surgery

OBJECTIVE

This study sought to determine improvements in mental and physical health-related quality of life (HRQOL) following bariatric surgery in Medicaid and commercially insured patients.

METHODS

Using data from the Longitudinal Assessment of Bariatric Surgery, an observational cohort study of adults undergoing bariatric surgery (2006-2009), changes in Short Form 36 mental component summary (MCS) and physical component summary (PCS) scores were examined in 1,529 patients who underwent Roux-en-Y gastric bypass, laparoscopic adjustable band, or sleeve gastrectomy and were followed for 5 years. Piecewise linear mixed-effects models estimated MCS and PCS scores as a function of insurance group (Medicaid, N = 177; commercial, N = 1,352) from 0 to 1 year and from 1 to 5 years after surgery, with interactions between insurance group and surgery type.

RESULTS

Patients with Medicaid had lower PCS and MCS scores at baseline. At 1 year after surgery, patients with Medicaid and commercial insurance experienced similar improvement in PCS scores (commercial-Medicaid difference in PCS change [95% CI]: Roux-en-Y gastric bypass, 1.5 [-0.2, 3.3]; laparoscopic adjustable band, 1.9 [-2.2, 6.0]; sleeve gastrectomy, 6.4 [0.0, 12.8]). One-year MCS score improvement was minimal and similar between insurance groups. In years 1 to 5, PCS and MCS scores were stable in all groups.

CONCLUSIONS

Both insurance groups experienced improvements in physical HRQOL and minimal changes in mental HRQOL.

The Adverse Effects of Physical Restraint Use among Older Adult Patients Admitted to the Internal Medicine Wards: A Hospital-Based Retrospective Cohort Study

OBJECTIVES

To evaluate the negative effect of physical restraint use on the hospital outcomes of older patients.

DESIGN

A retrospective cohort study.

SETTING

Internal medicine wards of a tertiary medical center in Taiwan.

PARTICIPANTS

Subjects aged 65 years and over who were admitted during April to Dec 2017 were recruited for study.

MEASUREMENTS

Demographic data, geriatric assessments (polypharmacy, visual impairment, hearing impairment, activities of daily living before and after admission, risk of pressure sores, change in consciousness level, mood condition, history of falls in the previous year, risk of malnutrition and pain) and hospital conditions (admission route, department of admission, length of hospital stay and mortality) were collected for analysis.

RESULTS

Overall, 4,352 participants (mean age 78.7±8.7 years, 60.2% = male) were enrolled and 8.3% had physical restraint. Results of multivariate logistic regression showed that subjects with physical restraints were at greater risk of functional decline (adjusted odds ratio 2.136, 95% confidence interval 1.322-3.451, p=0.002), longer hospital stays (adjusted odds ratio 5.360, 95% confidence interval 3.627-7.923, p<0.001) and mortality (adjusted odds ratio 4.472, 95% confidence interval 2.794-7.160, p<0.001) after adjustment for covariates.

CONCLUSION

The use of physical restraints during hospitalization increased the risk of adverse hospital outcomes, such as functional decline, longer length of hospital stay and mortality.

The Effects of Two Methods on Venipuncture Pain in Children: Procedural Restraint and Cognitive-Behavioral Intervention Package

BACKGROUND

Invasive interventions can produce fear, anxiety, and pain in children. This may negatively affect the children's treatment and care.

AIM

This study was conducted to determine the effects of procedural restraint (PR) and cognitive-behavioral intervention package (CBIP) on venipuncture pain in children between 6-12 years of age.

DESIGN

Quasi-experimental study.

SETTINGS

The study was conducted in the pediatric blood collection service of the hospital in Turkey between October 1, 2015, and April 1, 2016.

PARTICIPANTS/SUBJECTS

The population of the study consisted of children admitted to the blood collection service during the study period who met the inclusion criteria.

METHODS

The children included in the study were divided into two groups. Group 1 (n = 31) received PR in accordance with routine clinical practice. Group 2 (n = 30) received the CBIP. The data were collected by the researchers using a questionnaire, the visual analog scale (VAS), and the Wong-Baker FACES (WB-FACES) Pain Rating Scale.

RESULTS

The children in the PR group had a mean VAS score of 5.90 ± 3.22 and a mean WB-FACES score of 8.70 ± 2.22. The children in the CBIP group had a mean VAS score of 2.43 ± 2.02 and a mean WB-FACES score of 2.80 ± 2.49. A statistically significant difference was found between the mean VAS and WB-FACES pain scores of the groups (p < .05).

CONCLUSIONS

The results of this study showed that the children in the CBIP group had a lower pain level during venipuncture compared to those restrained for the procedure.

Radiologic Imaging in Trauma Patients with Cervical Spine Immobilization at a Pediatric Trauma Center

BACKGROUND

Pediatric trauma patients with cervical spine (CS) immobilization using a cervical collar often require procedural sedation (PS) for radiologic imaging. The limited ability to perform airway maneuvers while CS immobilized with a cervical collar is a concern for emergency department (ED) staff providing PS.

OBJECTIVE

To describe the use of PS and analgesia for radiologic imaging acquisition in pediatric trauma patients with CS immobilization.

METHODS

Retrospective medical record review of all trauma patients with CS immobilization at a high-volume pediatric trauma center was performed. Patient demographics, imaging modality, PS success, sedative and analgesia medications, and adverse events were analyzed. Patients intubated prior to arrival to the ED were excluded.

RESULTS

A total of 1417 patients with 1898 imaging encounters met our inclusion criteria. A total of 398 patients required more than one radiographic imaging procedure. The median age was 8 years (range 3.8-12.75 years). Computed tomography of the head was used in 974 of the 1898 patients (51.3%). A total of 956 of the 1898 patients (50.4%) required sedatives or analgesics for their radiographic imaging, with 875 (91.5%) requiring a single sedative or analgesic agent, and 81 (8.5%) requiring more than one medication. Airway obstruction was the most common adverse event, occurring in 5 of 956 patients (0.3%). All imaging procedures were successfully completed.

CONCLUSION

Only 50% of CS immobilized, nonintubated patients required a single sedative or analgesic medication for their radiologic imaging. Procedural success was high, with few adverse events.

Seating configuration and position preferences in fully automated vehicles

Objective: This study aimed to understand seating configuration and position preferences in a fully automated vehicle (FAV) across 7 hypothetical traveling scenarios.Methods: Participants completed an online survey in which they were asked to imagine traveling in an FAV across 7 hypothetical traveling scenarios and asked to select 1 of 5 seating configurations and 1 of 4 seating positions for themselves and for any additional occupants. Furthermore, participants were asked to indicate any activities that they and any additional occupants would engage in and whether they would be willing to wear a different seat belt in an FAV while seated in a non-forward-facing mode or while reclined.Results: Five hundred and fifty-two participants (male = 50.5%; mean = 36.6 years, SD = 14.0 years) completed the online survey. Most participants resided in Australia (40.9%), Spain (16.5%), Sweden (15.6%), or Lebanon (19.4%). Most participants drove on a daily basis (60.0%), had driven between 5,000 and 15,000 km in the previous year (33.2%), and reported that they always or almost always wear a seat belt while traveling in a motor vehicle (98.2%). Across all scenarios, participants were most likely to prefer a conventional seating configuration (i.e., all seats facing forward; between 40.0 and 76.3%). In terms of seating position preferences, participants preferred seating position A (i.e., the conventional driver's seat; between 54.6 and 68.3%), regardless of with whom they were traveling. The most common activity while traveling alone was reading (25.0%). However, when traveling with other occupants, talking was the most common activity (41.0-63.0%), even with someone they did not know (31.0%). Most participants predicted that they would always or almost always wear a seat belt when traveling in an FAV (95.9%). Most participants also reported that they would be very willing or willing to wear a different seat belt configuration in an FAV while seated in a non-forward-facing mode or while reclined (73.8 and 80.7%, respectively).Conclusions: This study has provided valuable insight regarding seating configuration and position preferences in an FAV, as well as predicted activities and restraint use. Future research will use this information to simulate likely injury outcomes of these preferences in the event of a motor vehicle crash and provide a basis for the design of occupant protection systems for FAVs.

Effective chair training methods for neuroscience research involving rhesus macaques (Macaca mulatta)

BACKGROUND

Neuroscience research using macaques remains fundamental in our endeavours to understand how the human brain functions. Applying the refinement principle of the 3Rs is essential to optimise the monkeys' welfare and still produces high quality science.

NEW METHOD

Here we document refinements in our training methods for acclimation to transport devices (i.e. primate chair or transport box) while working with 46 male rhesus macaques. Our training methods always used positive reinforcement training (PRT). However, PRT was sometimes combined with negative reinforcement training (NRT), but not pole and collar techniques, to successfully transfer each monkey from its home enclosure to its transport device.

RESULTS AND COMPARISON WITH EXISTING METHODS

Training monkeys in pairs or groups, and starting their PRT training upon arrival within the unit reduced the days required to acclimate them. While the use of PRT is essential to establish a positive relationship with monkeys, NRT techniques are sometimes necessary, and are most effective when withdrawn immediately once the monkey makes the desired response, to reduce the days of acclimation. Once acclimatised to their chair, monkeys succeeded within 10 days to present their head voluntarily for neck-plating using PRT. Space reducers inside the chairs also facilitated head presentations for some monkeys.

CONCLUSIONS

Acclimating (shaping) the monkeys to transport devices can be a stressful experience for monkeys and trainers. The adaptations to our training substantially reduced the days spent on this stage. We view this reduction in days as an effective implementation of the 3Rs (refinement) in monkey neuroscience research.

The Virtual-Environment-Foraging Task enables rapid training and single-trial metrics of rule acquisition and reversal in head-fixed mice

Behavioural flexibility is an essential survival skill, yet our understanding of its neuronal substrates is still limited. While mouse research offers unique tools to dissect the neuronal circuits involved, the measurement of flexible behaviour in mice often suffers from long training times, poor experimental control, and temporally imprecise binary (hit/miss) performance readouts. Here we present a virtual-environment task for mice that tackles these limitations. It offers fast training of vision-based rule reversals (~100 trials per reversal) with full stimulus control and continuous behavioural readouts. By generating multiple non-binary performance metrics per trial, it provides single-trial estimates not only of response accuracy and speed, but also of underlying processes like choice certainty and alertness (discussed in detail in a companion paper). Based on these metrics, we show that mice can predict new task rules long before they are able to execute them, and that this delay varies across animals. We also provide and validate single-trial estimates of whether an error was committed with or without awareness of the task rule. By tracking in unprecedented detail the cognitive dynamics underlying flexible behaviour, this task enables new investigations into the neuronal interactions that shape behavioural flexibility moment by moment.

Pelvic and lower extremity immobilization for cloacal exstrophy bladder and abdominal closure in neonates and older children

INTRODUCTION

Successful bladder closure in cloacal exstrophy (CE) is best accomplished through a multidisciplinary team and attention to pre- and postoperative technique. This study from a high volume exstrophy center investigates outcomes and complications of primary and reoperative bladder closures in patients immobilized with spica cast or patients with external fixation (EF) and skin traction.

METHODS

The authors reviewed an institutionally approved and daily updated database of 1311 patients with exstrophy-epispadias complex and identified patients with cloacal exstrophy born between 1975 and 2015 who had undergone primary or reoperative bladder closures. Only the closures that used spica casting or external fixation were included for analysis. Demographic, operative, and outcomes data were compared between patients with spica cast only and patients with external fixation and skin traction.

RESULTS

Out of 140 patients with CE or a CE variant, a total of 71 patients with 94 bladder closures (66 primary and 28 reoperative) met inclusion criteria. Median follow-up time was 8.8 years (range 1.5-29.1). There were 37 closures performed at the authors' institution and 58 from outside hospitals. Pelvic osteotomy was undertaken in 66 (70.2%) of all closures, and in 36 (97.3%) of closures at the authors' institution. Postoperative immobilization was achieved with spica cast alone in 46 (48.9%) closures, external fixation and skin traction in 43 (45.7%), and spica cast and external fixation in 5 (5.3%) closures. For all closures, there were 33 failures (71.7%) among those immobilized with spica cast alone versus 4 failures (9.3%) for those immobilized with external fixation and skin traction (p<0.001). When restricted to closures performed with osteotomy, the failure rates were 50.0% and 9.3% respectively (p=0.002). There was minimal differences in complication rates between spica and external fixation groups (8.7% versus 23.3%, p=0.059).

CONCLUSION

Failure of CE closure can occur with any form of pelvic and lower extremity immobilization. This study, however, provides continued evidence that external fixation with skin traction is an optimal, secure technique (3.8% failure rate) for postoperative management in an older child (1-2 years).

LEVEL OF EVIDENCE

Level III, Retrospective comparative study STUDY TYPE: Therapeutic study.

The ties that bind: Cradling in Tajikistan

A traditional childrearing practice—“gahvora” cradling—in Tajikistan and other parts of Central Asia purportedly restricts movement of infants’ body and limbs. However, the practice has been documented only informally in anecdotal reports. Thus, this study had two research questions: (1) To what extent are infants’ movements restricted in the gahvora? (2) How is time in the gahvora distributed over a 24-hour day in infants from 1–24 months of age? To answer these questions, we video-recorded 146 mothers cradling their infants and interviewed them using 24-hour time diaries to determine the distribution of time infants spent in the gahvora within a day and across age. Infants’ movements were indeed severely restricted. Although mothers showed striking uniformity in how they restricted infants’ movements, they showed large individual differences in amount and distribution of daily use. Machine learning algorithms yielded three patterns of use: day and nighttime cradling, mostly nighttime cradling, and mostly daytime cradling, suggesting multiple functions of the cradling practice. Across age, time in the gahvora decreased, yet 20% of 12- to 24-month-olds spent more than 15 hours bound in the gahvora. We discuss the challenges and benefits of cultural research, and how the discovery of new phenomena may defy Western assumptions about childrearing and development. Future work will determine whether the extent and timing of restriction impacts infants’ physical and psychological development.

Food and water restriction lead to differential learning behaviors in a head-fixed two-choice visual discrimination task for mice

Head-fixed behavioral tasks can provide important insights into cognitive processes in rodents. Despite the widespread use of this experimental approach, there is only limited knowledge of how differences in task parameters, such as motivational incentives, affect overall task performance. Here, we provide a detailed methodological description of the setup and procedures for training mice efficiently on a two-choice lick left/lick right visual discrimination task. We characterize the effects of two distinct restriction regimens, i.e. food and water restriction, on animal wellbeing, activity patterns, task acquisition, and performance. While we observed reduced behavioral activity during the period of food and water restriction, the average animal discomfort scores remained in the 'sub-threshold' and 'mild' categories throughout the experiment, irrespective of the restriction regimen. We found that the type of restriction significantly influenced specific aspects of task acquisition and engagement, i.e. the number of sessions until the learning criterion was reached and the number of trials performed per session, but it did not affect maximum learning curve performance. These results indicate that the choice of restriction paradigm does not strongly affect animal wellbeing, but it can have a significant effect on how mice perform in a task.

Mechanical restraint in an emergency department: a consecutive series of 593 cases

The objective is to describe the characteristics of mechanically restrained patients in the emergency department (ED) of a university hospital and to evaluate the quality of restraint documentation that was filled out according to the dedicated protocol with respect to the law on restraint. All adult patients (≥16 years) who were admitted to the ED from January 2009 to December 2010 and were mechanically restrained were included. We assessed medical and demographic characteristics, the completeness of the dedicated protocol, and the concomitant use of chemical sedation. 72,844 patients were admitted to the ED. Of these, 593 (0.81%) were mechanically restrained. Two types of patients were restrained: young patients under the influence of psychoactive substances who were usually discharged home, and confused older patients who were hospitalized. 186 dedicated protocols were missing (31.4%). From the 407 filled-out protocols, only 119 (29.2%) were complete. Of the mechanically restrained patients, 215 (36.2%) received additional chemical sedation. Even though restraint is strictly regulated by law, many protocols justifying the privation of liberty were not filled out. This emphasizes the need for strict respect of the dedicated protocol and the use of guidelines and training sessions for nursing and medical staff that address specific procedures for the two categories of patients needing to be restrained.

Prolonged restraint stressor exposure in outbred CD-1 mice impacts microbiota, colonic inflammation, and short chain fatty acids

Stressor-exposure has been shown to exacerbate inflammation and change the composition of the gastrointestinal microbiota; however stressor-induced effects on microbiota-derived metabolites and their receptors are unknown. Thus, bacterial-produced short chain fatty acids (SCFAs), as well as microbial community composition, were assessed in the colons of mice exposed to stress during infection with Citrobacter rodentium. Mice were exposed to overnight restraint on 7 consecutive nights, or left undisturbed as a control. After the first exposure of restraint, mice were orally challenged with C. rodentium or with vehicle. Microbial community composition was assessed using 16S rRNA gene sequencing and SCFA levels measured using gas chromatography-mass spectrometry (GC-MS). Pathogen levels and colonic inflammation were also assessed 6 days post-infection. Results demonstrated that the microbial community structure and SCFA production were significantly affected by both stressor exposure and C. rodentium-infection. Exposure to prolonged restraint in the absence of infection significantly reduced SCFAs (acetic acid, butyric acid, and propionic acid). Multiple bacterial taxa were affected by stressor exposure, with the relative abundance of Lactobacillus being significantly reduced and directly correlated with propionic acid. Lactobacillus abundances were inversely correlated with colonic inflammation, supporting the contention that Lactobacillus helps to regulate mucosal inflammatory responses. Our data indicates that restraint stressor can have significant effects on pathogen-induced colonic inflammation and suggest that stressor-induced changes in the microbiota, microbial-produced SCFAs and their receptors may be involved.

Combined corticosterone treatment and chronic restraint stress lead to depression associated with early cognitive deficits in mice

Many models, such as chronic mild stress, chronic stress or chronic corticosterone injections are used to induce depression associated with cognitive deficits. However, the induction period in these different models is still long and face constraints when it is short such as in the chronic mild stress done in a minimum period of 21 days. This study aimed to characterize a model of depression with early onset cognitive deficit. 14 days combined chronic injection of corticosterone followed by 2 h restraint stress using a restrainer was used to induce depression with early cognitive deficit onset. The forced swim test, sucrose test and plasma corticosterone concentration were used to assess depression-like characteristics. The Morris water maze, novel object recognition task, as well as hippocampal acetylcholinesterase activity were used to assess cognitive deficit. The combined corticosterone injection + chronic restraint stress group presented with marked depression-like behaviour and a higher plasma corticosterone concentration compared to corticosterone injection alone and restraint stress alone. It also showed an alteration in the learning process, memory deficit as well as increased acetylcholinesterase activity compared to corticosterone injection and restraint stress alone groups. These findings suggest that the combined corticosterone administration and chronic restraint stress can be used not only as an animal model for severe depression, but also for depression with early onset cognitive deficit.

The patient/significant other experience of physical restraint in acute care settings: a qualitative systematic review protocol

REVIEW QUESTION

The overarching question for this qualitative systematic review is: What meanings are attributed to the experience of physical restraint among adult patients or their significant others in acute care hospitals? Specifically the review will seek to answer two questions.

Occupant kinematics of the Hybrid III, THOR-M, and postmortem human surrogates under various restraint conditions in full-scale frontal sled tests

OBJECTIVE

The objective of this research was to compare the occupant kinematics of the Hybrid III (HIII), THOR-M, and postmortem human surrogates (PMHS) during full-scale frontal sled tests under 3 safety restraint conditions: knee bolster (KB), knee bolster and steering wheel airbag (KB/SWAB), and knee bolster airbag and steering wheel airbag (KBAB/SWAB).

METHODS

A total of 20 frontal sled tests were performed with at least 2 tests performed per restraint condition per surrogate. The tests were designed to match the 2012 Toyota Camry New Car Assessment Program (NCAP) full-scale crash test. Rigid polyurethane foam surrogates with compressive strength ratings of 65 and 19 psi were used to simulate the KB and KBAB, respectively. The excursions of the head, shoulders, hips, knees, and ankles were collected using motion capture. Linear acceleration and angular velocity data were also collected from the head, thorax, and pelvis of each surrogate. Time histories were compared between surrogates and restraint conditions using ISO/TS 18571.

RESULTS

All surrogates showed some degree of sensitivity to changes in restraint condition. For example, the use of a KBAB decreased the pelvis accelerations and the forward excursions of the knees and hips for all surrogates. However, these trends were not observed for the thorax, shoulders, and head, which showed more sensitivity to the presence of a SWAB. The average scores computed using ISO/TS 18571 for the HIII/PMHS and THOR-M/PMHS comparisons were 0.527 and 0.518, respectively. The HIII had slightly higher scores than the THOR-M for the excursions (HIII average = 0.574; THOR average = 0.520). However, the THOR-M had slightly higher scores for the accelerations and angular rates (HIII average = 0.471; THOR average = 0.516).

CONCLUSIONS

The data from the current study showed that both KBABs and SWABs affected the kinematics of all surrogates during frontal sled tests. The results of the objective rating analysis indicated that the HIII and THOR-M had comparable overall biofidelity scores. The THOR-M slightly outperformed the HIII for the acceleration and angular velocity data. However, the HIII scored slightly better than the THOR-M for the excursion data. The most notable difference in biofidelity was for the knee excursions, where the HIII had a much higher average ISO score. Only the biofidelity of the HIII and THOR-M with regard to occupant kinematics was evaluated in this study; therefore, future work will evaluate the biofidelity of the ATDs in terms of lower extremity loading, thoracic response, and neck loading.

Prehospital Extrication Techniques: Neurological Outcomes Associated with the Rapid Extrication Method and the Kendrick Extrication Device

Most emergency medical service personnel rely on one of two techniques to extricate motor vehicle crash victims; the Rapid Extrication Maneuver (REM) or the Kendrick Extrication Device (KED). The purpose of this study was to compare pre- and postextrication neurological outcomes between these two techniques. A retrospective review was conducted of all adult patients with a vertebral column injury resulting from motor vehicle collision and admitted to a Level I trauma center between January 1, 2003 and December 31, 2010. Standardized pre- and postextrication neurological examinations were reviewed for all patients. More than half of patients (N = 81) were extricated using the KED (53.1%, n = 43) and 46.9 per cent (n = 38) were extricated with the REM. Except for the thoracic Abbreviated Injury Score, no differences between groups emerged related to the Glasgow Coma Scale score, Injury Severity Score or Abbreviated Injury Score. There were no pre- and postextrication changes for motor to all extremities and sensation to all extremities using either method. The results of this study suggest that the REM and the KED are equivalent in protecting the patient from neurologic injury after motor vehicle collision.

Where Does Your State Stand on Shackling of Pregnant Incarcerated Women?

Pregnant incarcerated women have been identified as a particularly high-risk group and among the most vulnerable women in the United States. The use of shackling or restraints poses health risks to pregnant women and their fetuses. Currently, only 22 states have legislation prohibiting or limiting the shackling of pregnant women. Here we provide an overview of the potential negative health outcomes that can result from shackling pregnant women, especially during labor and birth, and suggest strategies for nurses who wish to promote optimal health care for incarcerated women and to advocate for anti-shackling legislation in their states.

Approach to the Agitated Emergency Department Patient

BACKGROUND

Acute agitation is a common occurrence in the emergency department (ED) that requires rapid assessment and management.

OBJECTIVE

This review provides an evidence-based summary of the current ED evaluation and management of acute agitation.

DISCUSSION

Acute agitation is an increasingly common presentation to the ED and has a broad differential diagnosis including metabolic, neurologic, infectious, toxicologic, and psychiatric etiologies. Missed diagnosis of a dangerous etiology of the patient's agitation may result in severe morbidity and mortality. Assessment and management of the agitated patient should occur concurrently. Focused history and physical examination are recommended, though control of the patient's agitation may be required. All patients should receive a point-of-care glucose test, with additional testing depending upon the specific patient presentation. Initial management should involve verbal de-escalation techniques, followed by pharmacologic interventions, with physical restraints reserved as a last resort. Pharmacologic options include first-generation antipsychotics, second-generation antipsychotics, benzodiazepines, and ketamine. Finally, the management of pediatric, pregnant, and elderly patients warrants special consideration.

CONCLUSION

Acute agitation is an important presentation that requires prompt recognition and treatment. A focused and thorough examination coupled with appropriate management strategies can assist emergency clinicians to safely and effectively manage these patients.

Indian nurses' Knowledge, Attitude and Practice towards use of physical restraints in psychiatric patients

OBJECTIVES

To assess nurses' knowledge, attitude and practice towards using physical restraints among psychiatric patients.

METHODS

A descriptive cross sectional survey was carried out among conveniently selected sample of nurses working in psychiatry departments at a tertiary care center. The data was collected using self reported questionnaires of Suen.

RESULTS

The findings revealed that nurses had good knowledge (7.2±1.7, maximum posible=11), favorable attitudes 30.8± 3.3 (maximum posible=48) and good practice 31.2±6.2 (maximun posible=42) about use of physical restraints in psychiatric patients. Females had better knowledge (p<0.001), attitudes (p<0.05) than males towards use of physical restraints. Nurses those had more than ten years of experience found to have more favorable attitudes towards using physical restraints than nurses with less experience (p<0.05) and nurses with higher education differed significantly on practice score than nurses with basic education in nursing (p<0.05).

CONCLUSIONS

This study revealed good knowledge, positive attitudes and good practices among nurses about using physical restraints in mental health services. However there is need to improve even more nurses practice through continuing education programs on this topic.

Repetitive restraint stress changes spleen immune cell subsets through glucocorticoid receptor or β-adrenergic receptor in a stage dependent manner

Immune system is sensitive to stress. Spleen is the largest peripheral immune organ innervated with sympathetic nerves and controlled by adrenomedullary system in the body. However, the alterations and mechanism of spleen immune cell subsets caused by repetitive restraint stress (RRS) is poorly understood. In this study, we found that RRS reduced spleen index in mice, and induced an expansion of white pulp and involution of the red pulp. Meanwhile, the percentage of CD3⁺CD8⁺ T lymphocytes, CD11b⁺F4/80⁺ macrophages, CD11b⁺Ly-6G^-Ly-6C^hi monocytic myeloid derived suppressor cells (mMDSCs) and CD11b⁺Ly-6G⁺Ly-6C^int granulocytic myeloid derived suppressor cells (gMDSCs) in spleen were significantly changed by RRS. Mechanistically, we found that the expression of norepinephrine (NE) and β-adrenergic receptor (β-AR) in spleen were up-regulated after 21 days of RRS, but not 7 days. The expression of corticosterone (CORT) and glucocorticoid receptor (GR) in spleen were up-regulated after 7 days of RRS but were lower after 21 days of RRS, even though they were still higher than that in mice without stress. By treating the stressed mice with RU486 (antagonist of GR) or propranolol (antagonist of β-AR), we demonstrated that GR was responsible for the changes of spleen induced by 7 days of RRS and β-AR was for 21 days of RRS. Our data suggest that RRS changes spleen immune cell subsets through GR or β-AR in a stage dependent manner.

Feasibility of transthoracic echocardiographic imaging in non-sedated ovine subjects using a commercial restraint device

Transthoracic echocardiography (TTE) is a valuable non-invasive imaging research technique. In ovine models of cardiac disease, restraint for TTE often involves sedation even with currently available restraint equipment; our goal was to determine the feasibility of using a commercial restraint device, commonly known as the sheep chair, in minimizing animal stress and the need for sedation while achieving a complete TTE examination. A total of 10 healthy adult Dorset sheep were restrained in a sheep chair for TTE and observed for signs of stress. No animals displayed overt evidence of stress and none required sedation. While individual anatomic variation existed, image quality was sufficient to determine cardiac function. These observations suggest that a sheep chair is a useful aid in minimizing the need for sedation to acquire a full TTE study in ovine subjects.

Characterization and minimization of the stress response to trapping in free-ranging wolves (Canis lupus): insights from physiology and behavior

OBJECTIVES

Wildlife capture is an essential management tool that induces a reactive homeostasis response in the captured animals. The aim of this study was to characterize the reactive homeostatic response to trapping in free-ranging wolves and assess the mitigation achieved by reducing the duration of restraint.

MATERIALS AND METHODS

Making use of wolves captured for ecological research as a model for wildlife acute stress, we characterize 25 reactive homeostasis mediators and we assess the effect on these mediators of reducing the duration of restraint in trap by using remote trap activation alarms.

RESULTS

Free-ranging wolves trapped by leg-hold snares (n = 15) showed higher stress leukogram, tissue injury and hematocrit; while lower glucose, ions and cardiac rate compared with captive wolves. They also showed higher leukocyte count and creatine kinase; but lower hematocrit, cardiac rate and rectal body temperature compared to wolves captured by darting from a helicopter. Daily distance travelled was significantly lower up to day 12 post-capture compared to the remainder of the telemetry follow-up and this effect was more noticeable on the nocturnal distance travelled. Reducing the duration of restraint on trap significantly lowered the stress leukogram and dehydration. Daily distance travelled during the night by wolves captured using trap-alarms was significantly lower only up to day 4 post-capture compared to up to day 28 for wolves captured without trap-alarms.

DISCUSSION

The capture method and duration of restraint influence the reactive homeostasis response of free-ranging wolves. Technological solutions that reduce the duration of restraint on trap significantly dampen this influence.

CONCLUSIONS

Wildlife trapping actions should strive to minimize the delay from capture to manipulation.

Clinical parameters and adrenocortical activity to assess stress responses of alpacas using different methods of restraint either alone or with shearing

Shearing of alpacas is stressful and is undertaken by restraint in the standing position, cast on the floor or on a tilt table. The objectives of the study were to evaluate and compare the stress responses between different methods. The study consisted of two parts. In part one, 15 animals were restrained applying all three methods but without shearing. In part two, 45 animals in three groups of 15 were shorn using one of the three procedures. Body temperature, heart rate, respiratory rate, salivary cortisol and faecal cortisol metabolites (FCM) were measured. Part 1: restraint in a standing position was less stressful than other procedures. Part 2: the classic clinical parameters changed significantly over time but without significant differences between the methods. The number of injuries did not differ. Saliva cortisol and FCM concentrations varied in wide ranges between animals. An increase in FCM concentrations occurred in all groups but saliva cortisol concentration increased only after shearing on the ground. The recommendations of the study are to shear calm alpacas in the standing position but animals showing severe defence reactions should be shorn either cast on the ground or on a table to decrease the risk of injuries.

Elbow splinting as a method to increase patching compliance in amblyopia therapy

PurposeThe purpose of the study was to evaluate the feasibility and acceptability of utilizing elbow splints as a method of increasing amblyopic patching compliance in pediatric ophthalmology patients who fail to comply with prescribed patching regimens.Patients and methodsPatients <6 years of age who were not adhering to pre-specified patching guidelines were prescribed elbow splints in order to increase patching compliance at the discretion of a pediatric ophthalmologist. If the child was non-compliant (patching <50% of specified time or consistently removing patch), parents were asked to try using the elbow splints until patching compliance was achieved. Non-parametric Wilcoxon signed-rank tests were used to compare patching time pre- and post-splints.Results41/48 children who were prescribed elbow splints to increase patching compliance for amblyopia were included for analysis. Seven children were excluded due to patching and splints being prescribed at the outset (n=4), and for not using the splinting intervention (n=3). Median age at being prescribed elbow splints was 37 (12-68) months. Mean daily patching prior to splints was 1.5±1.7 h, whereas mean prescribed daily patching was 4.95±1.5 h. Following splinting, 34/41 (83%) became compliant with patch alone, and visual acuity increased in 39/41 (95%) patients, with no patients developing amblyopia in the fellow eye. Median amount of time splints was required to improve compliance was 7 (1-240) days.ConclusionElbow splinting seems to be a viable alternative method to increase pediatric amblyopic patching compliance when patching alone fails to achieve satisfactory compliance.

Passive restraint reduces visually induced motion sickness in older adults

Virtual environments such as those used in video games and driving/flight simulators are used for entertainment and training, but are often associated with visually induced motion sickness (VIMS). In this study, we asked whether passive restraint of the head and torso could reduce VIMS in younger and older adults. Twenty-one younger (18-35 years) and 16 older (65 + years) healthy adults engaged in a simulated driving task using a console video game while seated. On different days, participants completed 2 conditions: (a) in the unrestrained condition, participants were seated in a chair without a backrest and were free to move and (b) in the restrained condition, participants' head and torso were passively restrained to the backrest and headrest of the seat using tense elastic strips. Before and after exposure to the driving game, we measured standing postural sway with eyes closed. VIMS severity was quantified using the Fast Motion Sickness Scale and the Simulator Sickness Questionnaire. Results showed that older (but not younger) participants who became sick in the unrestrained condition reported significantly less VIMS when they were passively restrained. The present findings suggest that passive restraint may be useful to reduce, but not fully prevent, VIMS, particularly in older adults. (PsycINFO Database Record

Infant constraint induced movement therapy: Lessons learned from clinical implementation

Current evidence supports the efficacy of pediatric constraint induced movement therapy (CIMT) for toddlers and children but little has been published about its use in early intervention with children eighteen months and younger. This paper and case report describes the clinical experience of developing and executing a modified pediatric CIMT intervention with infants under 18 months old. This is an emerging area of practice that is showing positive trends with initial cases.

The use of various models of chronic immobilization stress in experimental studies

INTRODUCTION

Stress is defined as a complex of protective and disturbing responses of the organism, generated in the process of the evolution, which occur as a result of neuroendocrine and metabolic alterations in response to the impact of emergency or pathological factors. Hence, stress is an important link of the adaptive mechanism; however, its adverse course can contribute to pathogenesis of many diseases. The problem of stress, which has been under study for years, is still a relevant topic to be investigated.

AIM

The paper was aimed at comparison of various models of chronic immobilization stress based on the published data and findings from our own research.

MATERIALS AND METHODS

The comparative analysis of the various techniques of chronic immobilization stress simulation in rats has been carried out on the basis of published data and findings of our own studies.

RESULTS

It has been shown that the model, proposed by the investigators from the Ukrainian Medical Stomatological Academy aids in reducing the time of experimental study, does not require sophisticated equipment and the use of additional stressors, at night time, in particular, as well as enables animals' restraint in the convenient morning time.

CONCLUSIONS

This technique is easy-to-use and can be applied while studying the influence of the immobilization stress on the body.

Hormonal and molecular effects of restraint stress on formalin-induced pain-like behavior in male and female mice

The evolutionary advantages to the suppression of pain during a stressful event (stress-induced analgesia (SIA)) are obvious, yet the reasoning behind sex-differences in the expression of this pain reduction are not. The different ways in which males and females integrate physiological stress responses and descending pain inhibition are unclear. A potential supraspinal modulator of stress-induced analgesia is the central nucleus of the amygdala (CeA). This limbic brain region is involved in both the processing of stress and pain; the CeA is anatomically and molecularly linked to regions of the hypothalamic pituitary adrenal (HPA) axis and descending pain network. The CeA exhibits sex-based differences in response to stress and pain that may differentially induce SIA in males and females. Here, sex-based differences in behavioral and molecular indices of SIA were examined following noxious stimulation. Acute restraint stress in male and female mice was performed prior to intraplantar injections of formalin, a noxious inflammatory agent. Spontaneous pain-like behaviors were measured for 60min following formalin injection and mechanical hypersensitivity was evaluated 120 and 180min post-injection. Restraint stress altered formalin-induced spontaneous behaviors in male and female mice and formalin-induced mechanical hypersensitivity in male mice. To assess molecular indices of SIA, tissue samples from the CeA and blood samples were collected at the 180min time point. Restraint stress prevented formalin-induced increases in extracellular signal regulated kinase 2 (ERK2) phosphorylation in the male CeA, but no changes associated with pERK2 were seen with formalin or restraint in females. Sex differences were also seen in plasma corticosterone concentrations 180min post injection. These results demonstrate sex-based differences in behavioral, molecular, and hormonal indices of acute stress in mice that extend for 180min after stress and noxious stimulation.

Physical Restraint during Procedures: Issues and Implications for Practice

Physical restraint or holding down a child or young person with cancer is generally accepted to ensure success in carrying out the various procedures involved throughout the disease trajectory. Over the past several years, health care staff have become more aware of the issues surrounding physical restraint. However, the research around the effects of being involved in physical restraint is extremely limited. Nurses continue to have little education in the pertinent issues, restraint techniques, and alternative strategies. This article aims to highlight areas that nurses caring for children and young people with cancer need to consider. Strategies for improving practice are also discussed with the thought that nurses will be stimulated to re-evaluate the use of physical restraint in this group of children and young people.

Novel restraint system for neuroendocrine studies of socially living common marmoset monkeys

We describe a novel soft jacket and sling-harness restraint that permits species-typical postures for small-bodied primates, such as the common marmoset ( Callithrix jacchus), during long-term (>6 h), continuous restraint. The restraint system is straightforward to use and manipulate, it is easily repaired, and the materials used are readily available. The soft jacket allows for increased versatility and longevity, and the sling-harness provides for greater movement and much longer duration of continuous restraint (up to 3 days) compared to a previously described, more conventional chair restraint for small-bodied primates. The new restraint system prevents the normal diurnal decrease in plasma cortisol levels across the daylight hours; however, it does not disrupt ovulatory cycles. Unlike the previously available techniques, therefore, this new restraint system is applicable to many neurobiological and neuroendocrine studies involving small-bodied, non-human primates and is especially suited to investigations requiring the maintenance of relationships within social groups.

A Modified Constraint-Induced Movement Therapy Regimen for Individuals with Upper Extremity Hemiplegia

Background. The Constraint-Induced Movement Therapy approach has been identified as a promising method to address deficits in upper limb function experienced by some stroke survivors. There is some question regarding whether the intervention administered in the research setting could be translated into clinical practice.Purpose. This paper describes the modified version of Constraint-Induced Movement Therapy developed at St. Boniface General Hospital, Winnipeg, Canada.Method. This modified regimen involves practice of upper limb tasks for four hours per day for 10 weekdays over two weeks, concurrent with participants attempting to wear a restraint mitten on the less involved hand for 90% of their waking hours.Results. The primary outcome measure was the Canadian Occupational Performance Measure. Two case reports illustrate how the regimen is administered.Implications. The need for further research of this regimen in terms of the selection of participants, the measurement tools, and the effectiveness is discussed.