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Background: Physical restraint is frequently used in intensive care units to prevent patients' life‐threatening removal of indwelling devices. In France, their use is poorly studied. Therefore, to evaluate the need for physical restraint, we have designed and implemented a decision support tool. Aims: Besides describing the prevalence of physical restraint use, this study aimed to assess whether the implementation of a nursing decision support tool had an impact on restraint use and to identify the factors associated with this use. Study Design: A large observational, multicentre study with a repeated one‐day point prevalence design was conducted. All adult patients hospitalized in intensive care units were eligible for this study. Two study periods were planned: before (control period) and after (intervention period) the deployment of the decision support tool and staff training. A multilevel model was performed to consider the centre effect. Results: During the control period, 786 patients were included, and 510 were in the intervention period. The prevalence of physical restraint was 28% (95% CI: 25.1%–31.4%) and 25% (95% CI: 21.5%–29.1%) respectively (χ2 = 1.35; p =.24). Restraint was applied by the nurse and/or nurse assistant in 96% of cases in both periods, mainly to wrists (89% vs. 83%, p =.14). The patient‐to‐nurse ratio was significantly lower in the intervention period (1:3.0 ± 1 vs. 1:2.7 ± 0.7, p <.001). In multivariable analysis, mechanical ventilation was associated with physical restraint (aOR [95% CI] = 6.0 [3.5–10.2]). Conclusion: The prevalence of physical restraint use in France was lower than expected. In our study, the decision support tool did not substantially impact physical restraint use. Hence, the decision support tool would deserve to be assessed in a randomized controlled trial. Relevance to Clinical Practice: The decision to physically restrain a patient could be protocolised and managed by critical care nurses. A regular evaluation of the level of sedation could allow the most deeply sedated patients to be exempted from physical restraint. [ABSTRACT FROM AUTHOR]

Objectives: While clinical guidelines exist for the management of bipolar disorder (BD), there are significant challenges to their widespread dissemination and implementation in clinical practice. The Canadian Network of Mood and Anxiety Treatment Improving Patient Care and Outcomes in the Treatment of Bipolar Disorder (C‐IMPACT BD) web‐based application was developed for use at the point‐of‐care to improve adherence to guidelines for evidence‐based pharmacological management of BD. Methods: C‐IMPACT BD uses a point‐of‐care practice assessment which, via adaptive questioning of patient‐specific information, text/video descriptions of the guidelines, and pop‐up prompts delivers personalized, evidence‐based treatment recommendations for patients with BD. In order to inform quality improvement of the newly developed tool, a sample of Canadian physicians were invited to use the application and record its influence on their prescribing behavior. Results: Of 375 patients with bipolar I (BD‐I) or bipolar II (BD‐II) disorder for whom a point‐of‐care practice assessment was completed, a change in therapy was considered for 225 (60.0%). Prior to completing the assessment, 59.6% of these patients were receiving first‐line therapy recommended for their phase of illness. Following the assessment, the overall number of patients for whom a first‐line recommended therapy was being considered increased significantly to 76.9% (p = 0.0001). Conclusions: Outcomes suggest that the C‐IMPACT BD web‐based application has the potential to improve physician adherence to clinical treatment guidelines. Formal research investigations are warranted to explore the impact of this tool on physician prescribing behavior and patient outcomes. [ABSTRACT FROM AUTHOR]

Objectives: The 2018 Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) guidelines provided clinicians with pragmatic treatment recommendations for bipolar disorder (BD). While these guidelines included commentary on how mixed features may direct treatment selection, specific recommendations were not provided—a critical gap which the current update aims to address. Method: Overview of research regarding mixed presentations in BD, with treatment recommendations developed using a modified CANMAT/ISBD rating methodology. Limitations are discussed, including the dearth of high‐quality data and reliance on expert opinion. Results: No agents met threshold for first‐line treatment of DSM‐5 manic or depressive episodes with mixed features. For mania + mixed features second‐line treatment options include asenapine, cariprazine, divalproex, and aripiprazole. In depression + mixed features, cariprazine and lurasidone are recommended as second‐line options. For DSM‐IV defined mixed episodes, with a longer history of research, asenapine and aripiprazole are first‐line, and olanzapine (monotherapy or combination), carbamazepine, and divalproex are second‐line. Research on maintenance treatments following a DSM‐5 mixed presentation is extremely limited, with third‐line recommendations based on expert opinion. For maintenance treatment following a DSM‐IV mixed episode, quetiapine (monotherapy or combination) is first‐line, and lithium and olanzapine identified as second‐line options. Conclusion: The CANMAT and ISBD groups hope these guidelines provide valuable support for clinicians providing care to patients experiencing mixed presentations, as well as further influence investment in research to improve diagnosis and treatment of this common and complex clinical state. [ABSTRACT FROM AUTHOR]

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The article offers information on the role of medical students as a public health emergency resource during the COVID-19 pandemic. Topics include the support of medical students to medical teams in monitoring symptoms of people who were infected with COVID-19, the feasibility of medical students conducting surveillance of outpatients who may develop symptoms requiring hospitalisation, and key lessons learned in implementing the pilot project.

Background Prescribers at a 400-bed metropolitan teaching hospital applied for approval to prescribe restricted antimicrobials using Guidance DS® ( GDS), an electronic antimicrobial approval system ( EAAS). The implementation of Cerner Millennium® ( CM), a computerised physician order entry system ( CPOE), necessitated a new but cumbersome workflow for prescribers. This prompted an evaluation of the value of a stand-alone EAAS, which has no interface with a CPOE, for antimicrobial stewardship. Aim This study compares the performance of an EAAS and CPOE, used alone and in combination, for surveillance of restricted antimicrobials and compliance with antimicrobial restriction policy. Method General medical and surgical patients prescribed restricted antimicrobials over three defined periods were retrospectively recruited; period one (P1) used GDS plus National Inpatient Medication Chart, period two (P2), GDS plus CM, and period three (P3), CM alone. For each period, 100 medical and 100 surgical restricted antimicrobial orders were collected. Data collection included prescribing date, indication, approvals obtained, and time to approval. Surveillance rate and compliance was compared. Results The introduction of CM improved surveillance from 10.5% (P1) to 65% (P2) and 100% (P3) via a CM reporting module (p < 0.0001). Compliance improved from 6% (P1), to 55% (P2) and 76% (P3) (p < 0.0001). Documentation of a clear/complete indication improved from 10% (P1) to 56.5% (P2) and 76.5% (P3) (p < 0.0001). Approvals obtained within 24 h of prescribing improved from 61.9% (P1), to 96.9% (P2), and 100% (P3). Conclusion Cerner Millennium®, with customisation, optimises surveillance and significantly improves compliance with policy, negating the need for a stand-alone EAAS. [ABSTRACT FROM AUTHOR]

Objectives Bipolar I disorder ( BD-I) is associated with gray matter volume ( GMV) alterations in neural regions important for emotional regulation. Reductions found in patients with multiple episodes are not seen at illness onset, suggesting that changes occur with illness progression, although no prospective studies to date have examined this. In the present study, we assessed GMV at baseline and one year following a first manic episode, examining the impact of episode recurrence on the trajectory of change. Methods A total of 41 recently remitted first manic episode patients with BD-I and 25 healthy subjects ( HS) underwent 3T magnetic resonance imaging at baseline and one year later. Using voxel-based morphometry, we compared GMV change between HS, patients who experienced a recurrence of a mood episode ( BDrecurr), and patients in sustained remission ( BDwell). Results The GMV change from baseline to one year did not differ significantly between HS and the full BD-I group or BDwell and HS. However, the BDrecurr group had greater GMV loss than HS in left frontal and bilateral temporal regions, and BDwell patients involving bilateral frontal, temporal and left parietal regions. Conclusions GMV change early in the course of BD-I is associated with clinical outcome, such that neuroprogression found in patients who experience a recurrence of a mood episode is not seen in those with sustained remission. These findings have important implications for the treatment of BD-I as they suggest that prevention of recurrence might minimize neuroprogression of the disease, possibly requiring a multipronged early intervention approach to achieve this goal. [ABSTRACT FROM AUTHOR]

Objectives Executive function impairments are a core feature of bipolar I disorder ( BD-I), not only present during acute episodes but also persisting following remission of mood symptoms. Despite advances in knowledge regarding the neural basis of executive functions in healthy subjects, research into morphological abnormalities underlying the deficits in BD-I is lacking. Methods Patients with BD-I within three months of sustained remission from their first manic episode (n = 41) underwent neuropsychological testing and a 3T magnetic resonance imaging scan and were compared to healthy subjects matched for age, sex, and premorbid IQ (n = 30). Group dorsolateral prefrontal cortex ( DLPFC; Brodmann areas 9 and 46) and caudate volumes were examined and analyzed for relationships with the average score from three computerized tests of executive function: Spatial Working Memory, Stockings of Cambridge, and Intradimensional/Extradimensional Shift. Results Right caudate volumes were enlarged in patients ( z = 3.57, p < 0.05 corrected). No differences in DLPFC volumes were found. Patients showed large deficits in executive function relative to healthy subjects ( d = −0.92, p < 0.001). While in healthy subjects, a larger right ( r = +0.39, p < 0.05) and left ( r = +0.44, p < 0.05) caudate was associated with better executive function score, in patients, larger right ( r = −0.36, p < 0.05) and left ( r = −0.34, p < 0.05) volumes correlated with poorer performance. Conclusions Although the etiology of gray matter changes is unknown, volume increases in the right caudate may be an important factor underlying executive function impairments during remission in patients with BD-I. [ABSTRACT FROM AUTHOR]

Research on social stigma and disadvantage has flourished in the past two decades. The authors highlight the theoretical and methodological advancements that have been made, such as how experience sampling procedures and neuroscience have shed light on processes associated with social stigma. Finally, the authors discuss policy implications of historical and contemporary research on social stigma and disadvantage, as well as address ideas for future research that may be useful in creating policies and programs that promote social equality. [ABSTRACT FROM AUTHOR]

Aim: To describe the implementation of pharmacist-initiated e-script transcription service (PETS) in a teaching hospital; to validate the service through process indicators; and to explore the views of stakeholders. Method: Following an initial trial, PETS was implemented in 7 medical and surgical units at Frankston Hospital. Data were collected on activities and discharge prescription errors. Stakeholders' satisfaction was measured using a Likert scale based survey and group interviews. Transcripts of group interviews were analysed by informal word-based techniques, noting words or synonyms used repeatedly to discover themes. Results: During the implementation phase (8 to 29 February 2008), a daily average of 15 prescriptions (112 items) were prepared by the PETS pharmacist, i.e 30 to 60% of weekday discharge prescriptions. The discharge prescription error/amendment rate was 0.06 per patient. 163 respondents (92%) were satisfied or very satisfied with PETS. As a result of 3 group interviews of 10 doctors, 10 nurses and 10 pharmacists, several areas for enhancement were identified and implemented. Conclusion: PETS has transitioned from trial to mainstream service, facilitating the discharge process and improving continuity of care. [ABSTRACT FROM AUTHOR]

Aim: To evaluate a pharmacist-initiated e-script transcription service for discharged patients. Method: A sequential prospective study of 2 groups of 40 eligible medical patients recruited from the neurology and respiratory wards. Pre-implementation of the service, baseline data were collected from 40 consecutive medical patients. After the new service was implemented and allowing for a 2 week run-in period, data were collected from a further 40 consecutive medical patients. The outcome indicators were the time taken to discharge patients and the number of prescribing errors. Results: The pharmacist-initiated e-script transcription service was successfully implemented. The discharge process was faster with the time taken from decision to discharge to actual discharge decreased by 34% (p = 0.02). The time spent by dispensing pharmacists in clarifying and amending discharge prescriptions decreased from 9.5 to 1.5 minutes per patient. The time spent by doctors in preparing discharge prescriptions fell from 15 to 2 minutes per patient. There were also fewer prescribing errors - number of errors decreased from 0.83 to 0.1 per patient (p = 0.0005) and from 0.0962 to 0.0137 per item (p = 0.011). Conclusion: Combining a prescribing role with the medication safety elements of electronic prescribing and medication reconciliation has resulted in significant improvements in the quality, accuracy and timeliness of discharge prescriptions. The centralised discharge transcription service is transferable to a wide variety of health settings. The principles of workforce substitution and process change is important as the health system struggles to meet ever increasing demands. [ABSTRACT FROM AUTHOR]

Congressional enactment of Federal Rules of Evidence 413–415 changed centuries of the law which had excluded evidence by the state that the defendant had committed other bad acts and was therefore the sort of person who would be more likely to commit the act charged. The passage of Rules 413–415 opens the door to this type of character evidence in sexual assault and child molestation cases and requires trial judges to assess the probative value of this propensity evidence offered. Yet, neither these rules nor their legislative history offer much guidance in this assessment. This article offers guidance to trial judges and lawyers to assess the probative value of propensity evidence offered under these rules. Copyright © 2000 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]