Acute disturbance is a broad term referring to escalating behaviors secondary to a change in mental state, such as agitation, aggression, and violence. Available management options include de-escalation techniques and rapid tranquilization, mostly via parenteral formulations of medication. While the intramuscular route has been extensively studied in a range of clinical settings, the same cannot be said for intravenous (IV); this is despite potential benefits, including rapid absorption and complete bioavailability. This systematic review analyzed existing evidence for effectiveness and safety of IV medication for management of acute disturbances. It followed a preregistered protocol (PROSPERO identification CRD42020216456) and is reported following the guidelines set by Preferred Reporting Items for Systematic Review and Meta-Analysis. APA PsycINFO, MEDLINE, and EMBASE databases were searched for eligible interventional studies up until May 30th, 2023. Data analysis was limited to narrative synthesis since primary outcome measures varied significantly. Results showed mixed but positive results for the effectiveness of IV dexmedetomidine, lorazepam, droperidol, and olanzapine. Evidence was more limited for IV haloperidol, ketamine, midazolam, chlorpromazine, and valproate. There was no eligible data on the use of IV clonazepam, clonidine, diazepam, diphenhydramine, propranolol, ziprasidone, fluphenazine, carbamazepine, or promethazine. Most studies reported favorable adverse event profiles, though they are unlikely to have been sufficiently powered to pick up rare serious events. In most cases, evidence was of low or mixed quality, accentuating the need for further standardized, large-scale, multi-arm randomized controlled trials with homogeneous outcome measures. Overall, this review suggests that IV medications may offer an effective alternative parenteral route of administration in acute disturbance, particularly in general hospital settings.
Posttraumatic stress symptoms (PTSS) may adversely affect glycemic control. Yet no studies have focused on trauma and PTSS induced by diabetes-related events in adolescents and young adults (AYA) with type 1 diabetes.
This study explores PTSS arising from diabetes-related events (e.g., severe symptoms or emergency room visits due to complications) among AYA with type 1 diabetes.
In this cross-sectional pilot study, self-reported measures (Posttraumatic Diagnostic Scale for DSM-5, Child Posttraumatic Stress Disorder Symptom Scale 5) were employed to assess trauma experiences and PTSS in AYA with type 1 diabetes at a pediatric diabetes clinic within a large hospital/academic medical center.
Fifty AYA with type 1 diabetes completed questionnaires assessing trauma and PTSS. Of the sample, 82% (n = 41) reported experiencing at least one form of general trauma (e.g., physical abuse, witnessing violence, or serious injuries). Among those who reported trauma, 22% (n = 9) indicated that the most distressing event was specifically diabetes-related. Over a quarter of participants exhibited clinically relevant levels of PTSS related to diabetes events. Females assigned at birth and those with a higher frequency of emergency room visits due to diabetes had an elevated risk of developing clinically relevant levels of diabetes-related PTSS.
Our results suggest that diabetes itself can serve as a traumatic stressor for some individuals. Therefore, interventions should be designed to prevent or mitigate PTSS starting from the time of diagnosis.
Collaborative care (CC) is an evidence-based model of care for treating behavioral health conditions in primary care settings. The CC team consists of a primary care provider, behavioral health care manager (CM), and a consultant psychiatrist who collaborate to create treatment plans. To date, there is limited data on factors associated with meaningful engagement in CC programs.
To identify the proportion of patients who were meaningfully engaged and to investigate the factors associated with meaningful engagement in a CC program.
Data was collected from a CC program implemented across 27 adult primary care clinics in a Midwestern, U.S. academic medical system. Logistic regression (n = 5218) was used to estimate the odds of receiving meaningful engagement.
Data was collected from 6437 individuals with 68% being female and a mean age of 45 years old (standard deviation 17.6). Overall, 57% of patients were meaningfully engaged; however, this proportion differed based on demographic and clinical factors. Among modifiable clinical factors, systematic case reviews between the CM and psychiatrist (odds ratio: 10.2, 95% confidence interval: 8.6–12.1) and warm handoffs (odds ratio: 1.3, 95% confidence interval: 1.1–1.5) were associated with a higher likelihood of receiving meaningful engagement.
The presence of systematic case reviews between the behavioral health CM and the consultant psychiatrist was highly associated with meaningful engagement. When implementing such programs, high fidelity to the core principles including regularly scheduled systematic case reviews should be pursued.
Post-acute sequelae of COVID-19 may include physical, psychiatric, and neurocognitive symptoms. Few studies of cognitive symptoms have been longitudinal, with many following participants briefly after infection and relying on subjective complaints, screening instruments, or computerized testing. This group previously reported diminished neuropsychological (NP) test performance in over half of 60 individuals tested in-person 7 months post-COVID-19, particularly those seeking care for cognitive complaints. The current study describes the initial and 6-month follow-up results of an expanded cohort of 75 participants.
To measure longitudinal changes in neuropsychological test performance, as well as medical and psychiatric changes, post-COVID-19.
Participants underwent NP, psychiatric, and medical assessments approximately 7 months after acute COVID-19 infection. Sixty-three (84%) returned approximately 6 months later for repeat evaluation.
At the initial visit, 29 (38.7%) met criteria for low NP performance, and 16 (21.3%) met criteria for extremely low NP performance. At 6-month follow-up, several NP domains that were significantly below normative values at the initial visit were no longer abnormal, with the exception of language. Only measures of delayed memory and fatigue showed significant improvements between the 2 time points.
A substantial proportion of individuals recovered from acute COVID-19 infection have persistent neuropsychiatric symptoms over 1 year after infection. While the overall sample in this study showed some improvement in NP test performance relative to norms, only fatigue and delayed memory improved significantly between times 1 and 2. No individual declined in NP test performance, though relatively few individuals made significant clinical improvement, indicating the need for serial neuropsychiatric assessment and treatment supports. Longitudinal follow-up of this cohort is in progress.
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