Aggressive incidents occur frequently in health care facilities, such as psychiatric care and forensic psychiatric hospitals. Previous research suggests that civil psychiatric inpatients may display more aggression than forensic inpatients. However, there is a lack of research comparing these groups on the incident severity, even though both frequency and severity of aggression influence the impact on staff members. The purpose of this study is to compare the frequency and severity of inpatient aggression caused by forensic and civil psychiatric inpatients in the same Dutch forensic psychiatric hospital. Data on aggressive incidents occurring between January 1, 2014, and December 31, 2017, were gathered from hospital files and analyzed using the Modified Overt Aggression Scale, including sexual aggression (MOAS+). Multilevel random intercept models were used to analyze differences between forensic and civil psychiatric patients in severity of aggressive incidents. In all, 3,603 aggressive incidents were recorded, caused by 344 different patients. Civil psychiatric patients caused more aggressive incidents than forensic patients and female patients caused more inpatient aggression compared with male patients. Female forensic patients were found to cause the most severe incidents, followed by female civil psychiatric patients. Male forensic patients caused the least severe incidents. The findings have important clinical implications, such as corroborating the need for an intensive treatment program for aggressive and disruptive civil psychiatric patients, as well as emphasizing the importance of gender-responsive treatment
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Purpose: The aim of this study was to evaluate how Scheimpflug-derived parameters of eyes with Fuchs endothelial corneal dystrophy (FECD) are influenced by Descemet membrane endothelial keratoplasty (DMEK) depending on FECD severity and the presence of subclinical edema. Methods: A retrospective cohort study including 115 eyes (115 patients) that underwent DMEK for FECD and a control group of 27 eyes with nonpathological corneas was conducted. Preoperative and 6 months postoperative Scheimpflug imaging was used to analyze pachymetry, presence of tomographic features (loss of isopachs/displacement of the thinnest point/focal posterior depression), and corneal backscatter. FECD severity was based on the modified Krachmer scale and the absence/presence of subclinical edema. Results: Scheimpflug-derived pachymetry, tomographic, and corneal backscatter parameters were correlated with FECD severity, and all changed from preoperatively to postoperatively (all P < 0.05). Postoperative central corneal thickness, anterior and posterior corneal backscatter, and presence of focal posterior depression remained different from the control group (all P < 0.05). Of eyes without preoperative clinical edema (n = 75), 18.7% showed 0 or 1 tomographic feature (no edema group) and 82.4% had 2 or 3 features (subclinical edema group). Compared with the control group, postoperative best-corrected visual acuity for the “no edema” group did not differ (0.03 ± 0.12 vs. −0.02 ± 0.08 logarithm of the minimum angle of resolution, P = 0.150) but was worse for the subclinical edema group (0.06 ± 0.08 vs. −0.02 ± 0.08 logarithm of the minimum angle of resolution, P = 0.001). Conclusions: For eyes without preoperative edema, more parameters reversed back to ‘normal’ levels than for eyes with (sub)clinical edema. Although most analyzed parameters correlated with FECD severity, corneal tomography might be best suited for objective grading of disease severity to aid in surgical decision-making.
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Background Children with speech sound disorders (SSD) are at higher risk of communication breakdown, but the impact of having an SSD may vary from child to child. Determining the severity of SSD helps speech-language therapists (SLTs) to recognise the extent of the problem and to identify and prioritise children who require intervention. Aims This study aimed to identify severity factors for SSD in order to develop a multifactorial Speech Sound Disorder Severity Construct (SSDSC) using SLTs’ views and the International Classification of Functioning, Disability and Health (ICF). Method In an explorative five-staged qualitative study, the research question was answered: ‘How do SLTs determine the severity of SSD in children?’. A total of 91 SLTs from The Netherlands participated in data collection and analysis. The iterative process included three different qualitative research methodologies (thematic analysis [TA], constructivist grounded theory [CGT] and content analysis [CA]) to ensure validation of the results by means of method triangulation. Results SLTs considered nine themes: intelligibility, speech accuracy, persistence, the child's perception, impact, communicative participation, concomitant factors, professional point of view, and environmental factors. The themes were summarised in three main severity factors: (I) Speech accuracy, (II) The child's perception of the impact of their speech, and (III) Intelligibility in communication. Other severity factors were concomitant factors and impact. Expertise and support were identified as facilitators or barriers that may worsen or relieve the severity of SSD. Conclusions This study highlights the need for SLTs to rethink how they think about severity as a simplistic construct reflecting only speech accuracy. It is recommended that a broader holistic approach to measuring severity is adopted.
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QUESTION: In adults who experience nocturnal leg cramps, does stretching of the calf and hamstring muscles each day just before sleep reduce the frequency and severity of the cramps?DESIGN: A randomised trial with concealed allocation and intention-to-treat analysis.PARTICIPANTS: Eighty adults aged over 55 years with nocturnal leg cramps who were not being treated with quinine.INTERVENTION: The experimental group performed stretches of the calf and hamstring muscles nightly, immediately before going to sleep, for six weeks. The control group performed no specific stretching exercises. Both groups continued other usual activities.OUTCOME MEASURES: Participants recorded the frequency of nocturnal leg cramps in a daily diary. Participants also recorded the severity of the pain associated with nocturnal leg cramps on a 10-cm visual analogue scale. Adverse events were also recorded.RESULTS: All participants completed the study. At six weeks, the frequency of nocturnal leg cramps decreased significantly more in the experimental group, mean difference 1.2 cramps per night (95% CI 0.6 to 1.8). The severity of the nocturnal leg cramps had also decreased significantly more in the experimental group than in the control group, mean difference 1.3 cm (95% CI 0.9 to 1.7) on the 10-cm visual analogue scale.CONCLUSION: Nightly stretching before going to sleep reduces the frequency and severity of nocturnal leg cramps in older adults.
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PURPOSE: The Nasality Severity Index 2.0 (NSI 2.0) forms a new, multiparametric approach in the identification of hypernasality. The present study aimed to investigate the correlation between the NSI 2.0 scores and the perceptual assessment of hypernasality. METHOD: Speech samples of 35 patients, representing a range of nasality from normal to severely hypernasal, were rated by four expert speech-language pathologists using visual analogue scaling (VAS) judging the degree of hypernasality, audible nasal airflow (ANA) and speech intelligibility. Inter- and intra-listener reliability was verified using intraclass correlation coefficients. Correlations between NSI 2.0 scores and its parameters (i.e. nasalance score of an oral text and vowel /u/, voice low tone to high tone ratio of the vowel /i/) and the degree of hypernasality were determined using Pearson correlation coefficients. Multiple linear regression analysis was used to investigate the possible influence of ANA and speech intelligibility on the NSI 2.0 scores. RESULTS: Overall good to excellent inter- and intra-listener reliability was found for the perceptual ratings. A moderate, but significant negative correlation between NSI 2.0 scores and perceived hypernasality (r=-0.64) was found, in which a more negative NSI 2.0 score indicates the presence of more severe hypernasality. No significant influence of ANA or intelligibility on the NSI 2.0 was observed based on the regression analysis. CONCLUSION: Because the NSI 2.0 correlates significantly with perceived hypernasality, it provides an easy-to-interpret severity score of hypernasality which will facilitate the evaluation of therapy outcomes, communication to the patient and other clinicians, and decisions for treatment planning, based on a multiparametric approach. However, research is still necessary to further explore the instrumental correlates of perceived hypernasality. LEARNING OUTCOMES: The reader will be able to (1) describe and discuss current issues and influencing variables regarding perceptual ratings of hypernasality; (2) describe and discuss the relationship between the Nasality Severity Index 2.0, a new multiparametric approach to hypernasality, and perceptual judgments of hypernasality based on visual analogue scale ratings; (3) compare these results with the correlations based on a single parameter approach and (4) describe and discuss the possible influence of audible nasal airflow and speech intelligibility on the NSI 2.0 scores.
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PURPOSE: We investigated changes in ARDS severity and associations with outcome in COVID-19 ARDS patients.METHODS: We compared outcomes in patients with ARDS classified as 'mild', 'moderate' or 'severe' at calendar day 1, and after reclassification at calendar day 2. The primary endpoint was 28-day mortality. We also identified which ventilatory parameters had an association with presence of severe ARDS at day 2. We repeated the analysis for reclassification at calendar day 4.RESULTS: Of 895 patients, 8.5%, 60.1% and 31.4% had mild, moderate and severe ARDS at day 1. These proportions were 13.5%, 72.6% and 13.9% at day 2. 28-day mortality was 25.3%, 31.3% and 32.0% in patients with mild, moderate and severe ARDS at day 1 (p = 0.537), compared to 28.6%, 29.2% and 44.3% in patients reclassified at day 2 (p = 0.005). No ventilatory parameter had an independent association with presence of severe ARDS at day 2. Findings were not different reclassifying at day 4.CONCLUSIONS: In this cohort of COVID-19 patients, ARDS severity and mortality between severity classes changed substantially over the first 4 days of ventilation. These findings are important, as reclassification could help identify target patients that may benefit from alternative approaches.
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Scar contractures are a common complication after burn injuries. These contractures are characterized by impairment of joint mobility, leading to a risk for limitations during daily activities, and restrictions in participation in society. Qualifying its severity is not well established in burn care. This study, therefore, examined different approaches to determine the severity of limited mobility in the knee joint due to scar contracture.To determine the severity of burn scar contractures development of the knee over time, the following approaches were analyzed: prevalence, the degree of limitation, the ability to perform basic daily activities, and the need for reconstructive surgery. Range of motion data of the knee joint was extracted from a 12-month prospective multicenter cohort study in the Netherlands.Based on prevalence, mean degree of limitation, and the classification based on mathematical division, limitations in knee flexion would be seen as giving the most problems. On the other hand, when classified in terms of impact on function, limitations in extension were found to be giving most problems, although flexion limitations interfered slightly longer with the basic activities of standing, walking, and climbing stairs.Depending on the chosen approach, the severity of burn scar contractures is projected differently. Interpreting the severity of a burn scar contracture of the knee, preferably should be based on a function-based classification system of the degree of range of motion impairment, activity limitations and participation restrictions in society. Because that does justice to the real impact of burn scar contracture on the individual burn survivor.
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Abstract Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19), has challenged healthcare globally. An acute increase in the number of hospitalized patients has neces‑ sitated a rigorous reorganization of hospital care, thereby creating circumstances that previously have been identifed as facilitating prescribing errors (PEs), e.g. a demanding work environment, a high turnover of doctors, and prescrib‑ ing beyond expertise. Hospitalized COVID-19 patients may be at risk of PEs, potentially resulting in patient harm. We determined the prevalence, severity, and risk factors for PEs in post–COVID-19 patients, hospitalized during the frst wave of COVID-19 in the Netherlands, 3months after discharge. Methods: This prospective observational cohort study recruited patients who visited a post-COVID-19 outpatient clinic of an academic hospital in the Netherlands, 3months after COVID-19 hospitalization, between June 1 and October 1 2020. All patients with appointments were eligible for inclusion. The prevalence and severity of PEs were assessed in a multidisciplinary consensus meeting. Odds ratios (ORs) were calculated by univariate and multivariate analysis to identify independent risk factors for PEs. Results: Ninety-eight patients were included, of whom 92% had ≥1 PE and 8% experienced medication-related harm requiring an immediate change in medication therapy to prevent detoriation. Overall, 68% of all identifed PEs were made during or after the COVID-19 related hospitalization. Multivariate analyses identifed ICU admission (OR 6.08, 95% CI 2.16–17.09) and a medical history of COPD / asthma (OR 5.36, 95% CI 1.34–21.5) as independent risk fac‑ tors for PEs. Conclusions: PEs occurred frequently during the SARS-CoV-2 pandemic. Patients admitted to an ICU during COVID19 hospitalization or who had a medical history of COPD / asthma were at risk of PEs. These risk factors can be used to identify high-risk patients and to implement targeted interventions. Awareness of prescribing safely is crucial to prevent harm in this new patient population.
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Paratonia, a distinctive form of hypertonia in patients with dementia, causes loss of functional mobility in early stage dementia to severe contractures and pain in the late stages. The pathogenesis of paratonia is not well understood. Patients in early stage dementia with diabetes mellitus showed a significantly higher risk for the development of paratonia. Both Alzheimer disease and diabetes mellitus are related to higher concentrations of advanced glycation end-products (AGEs). The purpose of this study is to explore the association of AGEs with the prevalence and severity of paratonia in patients with Alzheimer disease.DESIGN: Observational longitudinal, 1-year follow-up cohort study with 3 assessments.SETTING: Day care centers for patients with dementia.PARTICIPANTS: A total of 144 community-dwelling patients with early stage Alzheimer or Alzheimer/vascular disease were recruited from 24 dementia day care centers in The Netherlands.MEASUREMENTS: The presence of paratonia (Paratonia Assessment Instrument), the severity of paratonia (Modified Ashworth Scale for paratonia), and AGE levels (AGE-reader).RESULTS: From the 144 participants (56.3% female and 43.7% male, with a mean [standard deviation] age of 80.7 [7.7] years), 118 participants were available for final follow-up. A significant association between AGE levels and the presence of paratonia (odds ratio 3.47, 95% confidence interval [CI] 1.87-6.44, P < .001) and paratonia severity (β = 0.17, 95% CI 0.11-0.23, P < .001) was determined. In participants who developed paratonia and those with persistent paratonia throughout the study the AGE levels (95% CI -0.38 to -0.13, P < .001 and 95% CI -0.46 to -0.06, P = .012, respectively) and the severity of paratonia (95% CI -0.60 to -0.35, P < .001 and 95% CI -0.38 to -0.12, P < .001, respectively) significantly increased, whereas the AGE levels remained stable in those participants without paratonia. Notwithstanding, change in AGE levels was not significantly (P = .062) related to change in paratonia severity, mixed model analyses provided evidence for both a significant time and between participant effect of AGEs on paratonia severity.CONCLUSIONS: This study suggests that elevated AGE levels are a contributing factor to paratonia and its severity and could be the result of peripheral biomechanical changes reducing elasticity and increasing stiffness. These results provide a new perspective on paratonia and gives rise to further research whether paratonia could be postponed or movement stiffness can be improved by reducing AGE levels.
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PURPOSE: The Nasality Severity Index 2.0 (NSI 2.0) forms a new, multiparametric approach in the assessment of hypernasality. To enable clinical implementation of this index, the short- and long-term test-retest reliability of this index was explored. METHODS: In 40 normal-speaking adults (mean age 32y, SD 11, 18-56y) and 29 normal-speaking children (mean age 8y, SD 2, 4-12y), the acoustic parameters included in the NSI 2.0 (i.e. nasalance of the vowel /u/ and an oral text, and the voice low tone to high tone ratio (VLHR) of the vowel /i/) were obtained twice at the same test moment and during a second assessment two weeks later. After determination of the NSI 2.0, a comprehensive set of statistical measures was applied to determine its reliability. RESULTS: Long-term variability of the NSI 2.0 and its parameters was slightly higher compared to the short-term variability, both in adults and in children. Overall, a difference of 2.82 for adults and 2.68 for children between the results of two consecutive measurements can be interpreted as a genuine change. With an ICC of 0.84 in adults and 0.77 in children, the NSI 2.0 additionally shows an excellent relative consistency. No statistically significant difference was withheld in the reliability of test-retest measurements between adults and children. CONCLUSION: Reliable test-retest measurements of the NSI 2.0 can be performed. Consequently, the NSI 2.0 can be applied in clinical practice, in which successive NSI 2.0 scores can be reliably compared and interpreted. LEARNING OUTCOMES: The reader will be able to describe and discuss both the short-term and long-term test-retest reliability of the Nasality Severity Index 2.0, a new multiparametric approach to hypernasality, and its parameters. Based on this information, the NSI 2.0 can be applied in clinical practice, in which successive NSI 2.0 scores, e.g. before and after surgery or speech therapy, can be compared and interpreted.
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