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BACKGROUND: Antipsychotic-induced weight gain (AIWG) is a substantial contributor to high obesity rates in psychiatry. Limited management guidance exists to inform clinical practice, and individuals with experience of managing AIWG have had no or minimal input into its development. A lack of empirical research outlining patient values and preferences for management also exists. Recommendations addressing weight management in psychiatry may be distinctly susceptible to ideology and sociocultural values regarding intervention appropriateness and expectations of self-management, reinforcing the need for co-produced management guidance. This study is the first to ask: how do individuals conceptualise preferred AIWG management and how can this be realised in practice? AIMS: 1. Explore the management experiences of individuals with unwanted AIWG. 2. Elicit their values and preferences regarding preferred management. METHOD: Qualitative descriptive methodology informed study design. A total of 17 participants took part in semi-structured interviews. Data analysis was undertaken using reflexive thematic analysis. RESULTS: Participants reported that clinicians largely overestimated AIWG manageability using dietary and lifestyle changes. They also reported difficulties accessing alternative management interventions, including a change in antipsychotic and/or pharmacological adjuncts. Participants reported current management guidance is oversimplified, lacks the specificity and scope required, and endorses a 'one-size-fits-all' management approach to an extensively heterogenous side-effect. Participants expressed a preference for collaborative AIWG management and guidance that prioritises early intervention using the range of evidence-based management interventions, tailored according to AIWG risk, participant ability and participant preference. CONCLUSION: Integration of this research into guideline development will help ensure recommendations are relevant and applicable, and that individual preferences are represented.
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BACKGROUND: Shared decision-making (SDM) has yet to be successfully adopted into routine use in psychiatric settings amongst people living with severe mental illnesses. Suboptimal rates of SDM are particularly prominent amongst patients with psychotic illnesses during antipsychotic treatment choices. Many interventions have been assessed for their efficacy in improving SDM within this context, although results have been variable and inconsistent. AIMS: To generate an in-depth understanding of how, why, for whom, and to what extent interventions facilitating the application of SDM during antipsychotic treatment choices work and the impact of contextual factors on intervention effectiveness. METHODS: This review will use realist review methodology to provide a causal understanding of how and why interventions work when implementing SDM during antipsychotic treatment choices. The cohort of interest will be those experiencing psychosis where ongoing treatment with an antipsychotic is clinically indicated. The review will take place over five stages; (1) Locating existing theories, (2) Searching for evidence, (3) Selecting articles, (4) Extracting and organising data and (5) Synthesizing evidence and drawing conclusions. An understanding of how and why interventions work will be achieved by developing realist programme theories on intervention effectiveness through iterative literature reviews and engaging with various stakeholder groups, including patient, clinician and carer representatives. DISCUSSION: This is the first realist review aiming to identify generative mechanisms explaining how and why successful interventions aimed at improving SDM within the parameters outlined work and in which contexts desired outcomes are most likely to be achieved. Review findings will include suggestions for clinicians, policy and decision-makers about the most promising interventions to pursue and their ideal attributes.
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Antipsicóticos , Tomada de Decisão Compartilhada , Transtornos Psicóticos , Humanos , Antipsicóticos/uso terapêutico , Transtornos Psicóticos/tratamento farmacológico , Transtornos Psicóticos/psicologia , Participação do Paciente , Comportamento de EscolhaRESUMO
BACKGROUND: People with Parkinson's disease (PwP) often report problems with their handwriting before they receive a formal diagnosis. Many PwP suffer from deteriorating handwriting throughout their illness, which has detrimental effects on many aspects of their quality of life. AIMS: To assess a 6-week online training programme aimed at improving handwriting of PwP. METHODS: Handwriting samples from a community-based cohort of PwP (n = 48) were analysed using systematic detection of writing problems (SOS-PD) by two independent raters, before and after a 6-week remotely monitored physiotherapy-led training programme. Inter-rater variability on multiple measures of handwriting quality was analysed. The handwriting data was analysed using pre-/post-design in the same individuals. Multiple aspects of the handwriting samples were assessed, including writing fluency, transitions between letters, regularity in letter size, word spacing, and straightness of lines. RESULTS: Analysis of inter-rater reliability showed high agreement for total handwriting scores and letter size, as well as speed and legibility scores, whereas there were mixed levels of inter-rater reliability for other handwriting measures. Overall handwriting quality (p = 0.001) and legibility (p = 0.009) significantly improved, while letter size (p = 0.012), fluency (p = 0.001), regularity of letter size (p = 0.009), and straightness of lines (p = 0.036) were also enhanced. CONCLUSIONS: The results of this study show that this 6-week intensive remotely-monitored physiotherapy-led handwriting programme improved handwriting in PwP. This is the first study of its kind to use this tool remotely, and it demonstrated that the SOS-PD is reliable for measuring handwriting in PwP.
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Doença de Parkinson , Humanos , Reprodutibilidade dos Testes , Qualidade de Vida , Escrita ManualRESUMO
BACKGROUND: Whether non-genetic prognostic factors significantly influence the variable prognosis of antipsychotic-induced weight gain (AIWG) has not yet been systematically explored. METHODS: Searches for both randomized and non-randomized studies were undertaken using four electronic databases, two trial registers, and via supplemental searching methods. Unadjusted and adjusted estimates were extracted. Meta-analyses were undertaken using a random-effects generic inverse model. Risk of bias and quality assessments were undertaken using Quality in Prognosis Studies (QUIPS) and Grading of Recommendations Assessment, Development and Evaluation (GRADE), respectively. RESULTS: Seventy-two prognostic factors were assessed across 27 studies involving 4426 participants. Only age, baseline body mass index (BMI), and sex were suitable for meta-analysis. Age (b=-0.044, 95%CI -0.157-0.069), sex (b=0.236, 95%CI -0.086-0.558), and baseline BMI (b=-0.013 95%CI -0.225-0.200) were associated with nonsignificant effects on AIWG prognosis. The highest quality GRADE rating was moderate in support of age, trend of early BMI increase, antipsychotic treatment response, unemployment, and antipsychotic plasma concentration. Trend of early BMI increase was identified as the most clinically significant prognostic factor influencing long-term AIWG prognosis. CONCLUSIONS: The strong prognostic information provided by BMI trend change within 12 weeks of antipsychotic initiation should be included within AIWG management guidance to highlight those at highest risk of worse long-term prognosis. Antipsychotic switching and resource-intensive lifestyle interventions should be targeted toward this cohort. Our results challenge previous research that several clinical variables significantly influence AIWG prognosis. We provide the first mapping and statistical synthesis of studies examining non-genetic prognostic factors of AIWG and highlight practice, policy, and research implications.
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Antipsicóticos , Transtornos Psicóticos , Humanos , Antipsicóticos/efeitos adversos , Prognóstico , Transtornos Psicóticos/tratamento farmacológico , Aumento de Peso , Índice de Massa CorporalRESUMO
Background: There is a scarcity of research in applying the Screening Tool of Older Person's Prescriptions/Screening Tool to Alert to Right Treatment (STOPP/START) criteria to older adults admitted to a psychiatric hospital. Objectives: The primary aim of this study was to determine the extent of polypharmacy in older adults admitted to a psychiatric hospital and to assess the number of STOPP/START triggers detected and recommended by pharmacists. Secondary objectives include evaluating if the STOPP/START criteria is a useful tool to improve prescribing in this setting by assessing the implementation rates of STOPP/START triggers. Methods: This was a prospective, longitudinal study in a psychiatry inpatient setting. Data were collected over a 7-week period. Explicit informed consent was obtained from participants. Medication reconciliation was completed and participants' medications were reviewed using STOPP/START criteria. The number of STOPP/START triggers detected, recommended and implemented was recorded. Results: Sixty-two patients were included in the study. Ninety-four percent were prescribed ≥5 medications and 55% were prescribed ≥10 medications on admission. The mean number of medications prescribed per patient increased from 10 on admission to 12 at follow-up. Of 174 Potential Inappropriate Medications (PIMs) detected, 41% were recommended for review and, of these only 31% were implemented. 27% of the 77 Potential Prescribing Omissions (PPOs) detected were recommended for review and only 23% of those were implemented. Conclusion: STOPP/START did not reduce the prevalence of polypharmacy in this setting. The implementation rates observed in this study were much lower than those observed in non-psychiatric settings.
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BACKGROUND: Adjunctive metformin is the most well-studied intervention in the pharmacological management of antipsychotic-induced weight gain (AIWG). Although a relatively unaddressed area, among guidelines recommending consideration of metformin, prescribing information that would facilitate its applied use by clinicians, for example, provision of a dose titration schedule is absent. Moreover, recommendations differ regarding metformin's place in the hierarchy of management options. Both represent significant barriers to the applied, evidence-based use of metformin for this indication. OBJECTIVE: To produce a guideline solely dedicated to the optimised use of metformin in AIWG management, using internationally endorsed guideline methodology. METHODS: A list of guideline key health questions (KHQs) was produced. It was agreed that individual recommendations would be 'adopted or adapted' from current guidelines and/or developed de novo, in the case of unanswered questions. A systematic literature review (2008-2020) was undertaken to identify published guidelines and supporting (or more recent) research evidence. Quality appraisal was undertaken using the Appraisal of Guidelines Research and Evaluation II tool, A Measurement Tool to Assess Systematic Reviews (AMSTAR) assessment,and the Cochrane Risk of Bias 2 tool, where appropriate. Assessment of evidence certainty and recommendation development was undertaken using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. FINDINGS: We confirmed that no published guideline-of appropriate quality, solely dedicated to the use of metformin to manage AIWG was available. Recommendations located within other guidelines inadequately addressed our KHQs. CONCLUSION: All 11 recommendations and 7 supporting good practice developed here were formulated de novo. CLINICAL IMPLICATIONS: These recommendations build on the number and quality of recommendations in this area, and facilitate the optimised use of metformin when managing AIWG.
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Antipsicóticos , Metformina , Transtornos Psicóticos , Adulto , Antipsicóticos/efeitos adversos , Humanos , Metformina/efeitos adversos , Transtornos Psicóticos/tratamento farmacológico , Aumento de PesoRESUMO
Middle age is increasingly accepted as a key period during which individuals are susceptible to the effect of environmental and lifestyle factors. Emerging research indicates that dietary factors play a crucial role in brain health and cognitive function, and studies in both animals and humans have demonstrated that dietary interventions can mitigate cognitive impairment. Specifically, magnesium has been shown to enhance learning and memory, and magnesium deficiency is associated with impaired hippocampal-dependent memory formation in animal studies. The aim of this study was to examine if supplementation with a magnesium-rich marine mineral blend (MMB) could alter middle-age-related cognitive impairment. Young and middle-aged rats were given access to a control diet or an experimental diet formulated with an MMB for 4 weeks before undergoing a series of behavioral assessments. Supplementation of MMB to middle-aged rats rescued a deficit in cognitive impairment, specifically a pattern separation paradigm that is sensitive to alterations in a type of brain plasticity called neurogenesis. It had no effect on general activity in the open field or performance on other hippocampal-associated tasks. Changes in cognitive function occur as a predictable consequence of aging. Research into whether modification of dietary factors, such as this MMB, may play a role in the prevention of age-related cognitive impairment warrants further investigation.
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Hipocampo , Magnésio , Envelhecimento , Animais , Suplementos Nutricionais , Humanos , Transtornos da Memória , Pessoa de Meia-Idade , Minerais , Neurogênese , RatosRESUMO
BACKGROUND: The measurement of safety culture, the way in which members of an organisation think about and prioritise safety, in a hospital can provide valuable insight and inform quality improvement strategies. AIMS: The aim of this study is to describe the safety culture of a university teaching hospital in the Republic of Ireland. METHODS: This is a mixed methods survey study using the Safety Attitudes Questionnaire (SAQ). The SAQ was distributed to all staff in the study hospital. Staff attitudes towards six domains of patient safety culture were assessed over 32 Likert-scaled items. Thematic analysis was performed on qualitative data. RESULTS: A total of 768 staff members completed and returned a copy of the SAQ. The hospital scored above the international benchmark in five out of six domains, indicating a positive safety culture, but scored below the international benchmark in the domain 'Working Conditions'. This positive safety culture was not mirrored in the qualitative data, from which five themes emerged; three major-Staffing Issues, Patient-Focused Care and Hospital Environment-and two minor-Safe Reporting Culture and Training and Education. CONCLUSIONS: In this study, a mixed methods approach was successfully used to investigate the safety culture in a large Irish hospital. Although the SAQ results indicated a positive safety culture, the qualitative data revealed a number of issues that the hospital staff felt impacted negatively on patient safety. The results of this study will inform future work on the design of an intervention to improve patient safety in the hospital.
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Hospitais de Ensino/normas , Hospitais Universitários/normas , Segurança do Paciente/normas , Gestão da Segurança/métodos , Feminino , Humanos , Irlanda , Masculino , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Several approaches to medication optimisation by identifying drug-related problems in older people have been described. Although some interventions have shown reductions in drug-related problems (DRPs), evidence supporting the effectiveness of medication reviews on clinical and economic outcomes is lacking. Application of the STOPP/START (version 2) explicit screening tool for inappropriate prescribing has decreased inappropriate prescribing and significantly reduced adverse drug reactions (ADRs) and associated healthcare costs in older patients with multi-morbidity and polypharmacy. Therefore, application of STOPP/START criteria during a medication review is likely to be beneficial. Incorporation of explicit screening tools into clinical decision support systems (CDSS) has gained traction as a means to improve both quality and efficiency in the rather time-consuming medication review process. Although CDSS can generate more potential inappropriate medication recommendations, some of these have been shown to be less clinically relevant, resulting in alert fatigue. Moreover, explicit tools such as STOPP/START do not cover all relevant DRPs on an individual patient level. The OPERAM study aims to assess the impact of a structured drug review on the quality of pharmacotherapy in older people with multi-morbidity and polypharmacy. The aim of this paper is to describe the structured, multi-component intervention of the OPERAM trial and compare it with the approach in the comparator arm. METHOD: This paper describes a multi-component intervention, integrating interventions that have demonstrated effectiveness in defining DRPs. The intervention involves a structured history-taking of medication (SHiM), a medication review according to the systemic tool to reduce inappropriate prescribing (STRIP) method, assisted by a clinical decision support system (STRIP Assistant, STRIPA) with integrated STOPP/START criteria (version 2), followed by shared decision-making with both patient and attending physician. The developed method integrates patient input, patient data, involvement from other healthcare professionals and CDSS-assistance into one structured intervention. DISCUSSION: The clinical and economical effectiveness of this experimental intervention will be evaluated in a cohort of hospitalised, older patients with multi-morbidity and polypharmacy in the multicentre, randomized controlled OPERAM trial (OPtimising thERapy to prevent Avoidable hospital admissions in the Multi-morbid elderly), which will be completed in the last quarter of 2019. TRIAL REGISTRATION: Universal Trial Number: U1111-1181-9400 Clinicaltrials.gov: NCT02986425, Registered 08 December 2016. FOPH (Swiss national portal): SNCTP000002183. Netherlands Trial Register: NTR6012 (07-10-2016).
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Sistemas de Apoio a Decisões Clínicas , Hospitalização , Prescrição Inadequada/prevenção & controle , Reconciliação de Medicamentos/métodos , Lista de Medicamentos Potencialmente Inapropriados , Idoso , Doença Crônica/tratamento farmacológico , Estudos de Coortes , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/prevenção & controle , Humanos , Multimorbidade , Polimedicação , Projetos de PesquisaRESUMO
BACKGROUND: A hallmark feature of Parkinson's disease (PD) is the build-up of α-synuclein protein aggregates throughout the brain; however α-synuclein is also expressed in enteric neurons. Gastrointestinal (GI) symptoms and pathology are frequently reported in PD, including constipation, increased intestinal permeability, glial pathology, and alterations to gut microbiota composition. α-synuclein can propagate through neuronal systems but the site of origin of α-synuclein pathology, whether it be the gut or the brain, is still unknown. Physical exercise is associated with alleviating symptoms of PD and with altering the composition of the gut microbiota. METHODS: This study investigated the effects of bilateral nigral injection of adeno-associated virus (AAV)-α-synuclein on enteric neurons, glia and neurochemistry, the gut microbiome, and bile acid metabolism in rats, some of whom were exposed to voluntary exercise. KEY RESULTS: Nigral overexpression of α-synuclein resulted in significant neuronal loss in the ileal submucosal plexus with no change in enteric glia. In contrast, the myenteric plexus showed a significant increase in glial expression, while neuronal numbers were maintained. Concomitant alterations were observed in the gut microbiome and related bile acid metabolism. Voluntary running protected against neuronal loss, increased enteric glial expression, and modified gut microbiome composition in the brain-injected AAV-α-synuclein PD model. CONCLUSIONS AND INFERENCES: These results show that developing nigral α-synuclein pathology in this PD model exerts significant alterations on the enteric nervous system (ENS) and gut microbiome that are receptive to modification by exercise. This highlights brain to gut communication as an important mechanism in PD pathology.
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Sistema Nervoso Entérico/patologia , Microbioma Gastrointestinal , Transtornos Parkinsonianos , Substância Negra/metabolismo , alfa-Sinucleína/toxicidade , Animais , Vetores Genéticos , Humanos , Injeções Intraventriculares , Masculino , Ratos , Ratos Sprague-Dawley , Ratos Transgênicos , Transfecção , alfa-Sinucleína/administração & dosagemAssuntos
Doença de Parkinson/terapia , Condicionamento Físico Animal , alfa-Sinucleína/administração & dosagem , Animais , Regulação da Expressão Gênica , Humanos , Masculino , Doença de Parkinson/etiologia , Desempenho Psicomotor , Ratos , Ratos Sprague-Dawley , Transfecção , alfa-Sinucleína/genética , alfa-Sinucleína/metabolismoRESUMO
Accumulating evidence demonstrates that dietary supplementation with functional food ingredients play a role in systemic and brain health as well as in healthy ageing. Conversely, deficiencies in calcium and magnesium as a result of the increasing prevalence of a high fat/high sugar "Western diet" have been associated with health problems such as obesity, inflammatory bowel diseases, and cardiovascular diseases, as well as metabolic, immune, and psychiatric disorders. It is now recognized that modulating the diversity of gut microbiota, the population of intestinal bacteria, through dietary intervention can significantly impact upon gut health as well as systemic and brain health. In the current study, we show that supplementation with a seaweed and seawater-derived functional food ingredient rich in bioactive calcium and magnesium (0.1% supplementation) as well as 70 other trace elements, significantly enhanced the gut microbial diversity in adult male rats. Given the significant impact of gut microbiota on health, these results position this marine multi-mineral blend (MMB) as a promising digestive-health promoting functional food ingredient.
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Suplementos Nutricionais , Alimento Funcional , Microbioma Gastrointestinal/efeitos dos fármacos , Minerais/farmacologia , Alga Marinha/química , Animais , Comportamento Animal/efeitos dos fármacos , DNA Bacteriano/isolamento & purificação , Microbioma Gastrointestinal/genética , Masculino , Minerais/química , Modelos Animais , RNA Ribossômico 16S/genética , Ratos , Ratos Sprague-DawleyRESUMO
Parkinson's disease (PD) is no longer primarily classified as a motor disorder due to increasing recognition of the impact on patients of several nonmotor PD symptoms, including cognitive dysfunction. These nonmotor symptoms are highly prevalent and greatly affect the quality of life of patients with PD, and so, therapeutic interventions to alleviate these symptoms are urgently needed. The aim of this study was to investigate the potential neuroprotective effects of voluntary running on cognitive dysfunction in an adeno-associated virus-α-synuclein rat model of PD. Bilateral intranigral administration of adeno-associated virus-α-synuclein was found to induce motor dysfunction and a significant loss of nigral dopaminergic neurons, neither of which were rescued by voluntary running. Overexpression of α-synuclein also resulted in significant impairment on hippocampal neurogenesis-dependent pattern separation, a cognitive task; this was rescued by voluntary running. This was substantiated by an effect of running on neurogenesis levels in the dorsal dentate gyrus, suggesting that the functional effects of running on pattern separation were mediated via increased neurogenesis.