Guideline Recommendations on Behavioral and Psychological Symptoms of Dementia: A Systematic Review.

OBJECTIVE: To synthesize recommendations on assessing and managing behavioral and psychological symptoms of dementia (BPSDs) in existing clinical practice guidelines on dementia care to learn from and adapt recommendations to a Canadian context and language for describing BPSDs. DESIGN: Systematic review. SETTING AND PARTICIPANTS: Moderate to high-quality clinical practice guidelines on dementia care that made 1 or more recommendations on BPSD assessment or management. METHODS: We searched MEDLINE, Embase, JBI EBM, PsycINFO, AgeLine, and gray literature for clinical practice guidelines on dementia care making recommendations on BPSD, published between January 1, 2011, and October 13, 2022. Two independent reviewers conducted study screening and data abstraction. Four independent reviewers completed quality appraisal using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool; included guidelines had a mean overall AGREE II score ≥4. RESULTS: Our systematic review identified 23 moderate to high-quality clinical practice guidelines (264 recommendations). The mean overall quality score on the AGREE II tool ranged from 4 to 6.5. Recommendations were clearly presented (mean clarity of presentation score 73.5%), but guideline applicability was not consistently addressed (mean applicability score 39.3%). BPSD was the most prevalent term describing neuropsychiatric symptoms (number of guidelines [n] = 14). People with lived experience contributed to 6 guidelines (26.1%). Ten guidelines (43.5%) described 1 or more health equity considerations. Guidelines made recommendations for assessing and managing agitation (n = 12), aggression (n = 10), psychosis (n = 11), depression (n = 9), anxiety (n = 5), apathy (n = 6), inappropriate sexual behavior (n = 3), nighttime behavior (n = 5), and eating disturbances (n = 3). There was substantial variability in recommendation statements, evidence quality assigned to each statement, and strength of recommendations. CONCLUSIONS AND IMPLICATIONS: There are several moderate to high-quality clinical practice guidelines making recommendations on BPSD assessment and management, but variability in recommendation statements across guidelines and insufficient consideration of guideline applicability may hamper guideline dissemination and implementation in clinical practice.

Cosmetic Treatments with Energy-Based Devices in Skin of Color.

The use of energy-based devices in cosmetic treatments for patients with higher Fitzpatrick skin types is a topic of concern due to the increased risk of complications such as hyperpigmentation and scarring. Advancements in technology have enabled the development of safe and effective energy-based modalities for improving skin tone, texture, and signs of aging in patients with higher Fitzpatrick skin types. This article reviews various modalities that have shown positive outcomes in Fitzpatrick skin types 4 to 6.Radiofrequency (RF) skin tightening devices have emerged as a noninvasive method for improving skin laxity by stimulating collagen and elastin production without generating excessive heat, making them suitable for darker skin tones. Microfocused ultrasound (MFUS) is another noninvasive option for skin tightening and lifting. By producing thermal coagulation in the deeper layers of the skin, MFUS stimulates collagen production, resulting in improved skin tightness. Fractional laser resurfacing, both ablative and nonablative, offers effective treatment options for various concerns such as acne scars, skin texture, and dyspigmentation. Nonablative fractional lasers, which target water rather than melanin, are particularly safer for darker skin types. Broadband light devices that emit different wavelengths have shown success in skin rejuvenation, improving wrinkles, pore size, erythema, telangiectasias, and dyspigmentation. Additionally, RF microneedling combines the benefits of both modalities, delivering safe treatment for skin laxity and textural concerns. The short-pulse neodymium-doped yttrium aluminum garnet (Nd:YAG) laser has become a transformative tool for patients with Fitzpatrick skin types 4 to 6. This laser targets melanin, hemoglobin, and water, providing improvements in hyperpigmentation, acne, fine lines, and scar texture. Combining the short-pulse Nd:YAG laser with other treatments like chemical peels or microneedling has shown synergistic effects and enhanced outcomes. Understanding these modalities and tailoring treatments to specific concerns is crucial for safe and effective solutions in patients with higher Fitzpatrick skin types.

Use of the Child Opportunity Index to Examine Racial Variations in Outpatient Antibiotic Prescribing to Children.

To examine further racial and ethnic variations in antibiotic prescribing to children, we used the Child Opportunity Index. Black children were less likely to be prescribed an antibiotic. Low- and moderate-opportunity areas were associated with greater rates of antibiotic prescribing, after adjusting for race and other factors.

A Simulation-Based Training Program in Rapid Sequence Induction for Novice Anesthesiology Trainees Using a Novel Checklist.

Background: The novice anesthesiology trainee is required to assimilate the technical and nontechnical skills required to safely perform a rapid sequence induction (RSI). Acquisition of this core competency is traditionally achieved using operating room-based experiential learning, which may be associated with significant gaps in early trainee preparation. We conducted a study to explore the role of a new, customized, high-fidelity simulation-based training program designed to address this gap in RSI training. We then assessed mean performance scores of participants in the simulator and 4 weeks later. Methods: This observational study assessed participants' performance in the simulator on the day of training and in the workplace 4 weeks later. There is no universally agreed checklist or cognitive aid incorporating nontechnical skills and planning for unanticipated difficult airway management in RSI, so we applied a new scoring checklist developed by 6 experts using the modified Delphi technique. Results: Our task scoring checklist included nontechnical skills and consisted of 37 weighted parameters with a maximum performance score of 171. On the day of training, mean performance score was 105 (SD of 16). At the workplace evaluation 4 weeks after simulation training, the mean performance score of participants had increased to 140 (SD of 14.5; P = .001). The 95% confidence intervals for the simulator and workplace participant scores were 92 to 118 and 128 to 152, respectively. Conclusions: The results suggest that this simulation-based training in RSI was associated with an improvement in RSI performance in novice trainees and may complement the current system of workplace-based training.

A desktop systems analysis of critical incidents within a university hospital department of anaesthesia.

INTRODUCTION: Medical error is frequently the result of latent systems factors. Incident reporting systems face many challenges including inability of the system to process reports adequately, inadequate feedback mechanisms and lack of staff engagement especially from doctors. This paper describes a pragmatic physician-led desktop approach to a systems analysis of anaesthesia-related critical incidents which could be used to enhance incident reporting processing within the existing national incident reporting system. METHODS: Anaesthesiologists within a university teaching hospital were encouraged to report incidents anonymously during the 6-month study period from July 2019 to January 2020. Information was collected on incident details, outcome and preventability. A desktop systems analysis was performed to categorise incidents and to determine contributory factors. Latent errors were considered according to the level of the organisational hierarchy at which they occurred and solutions directed accordingly. RESULTS: Seventy cases were included giving a reporting rate of 1.76%. Airway/breathing circuit problems (34%) were most frequently cited incidents, followed by other equipment (27%), medication errors (20%) and airway events (19%). The vast majority of events were considered preventable. Most incidents were near misses or of negligible adverse effect with only 6% requiring more than minor treatment. Organisational and strategic contributory factors were identified in 83% of cases, 93% of which were addressable within the department. CONCLUSION: Implementing local incident reporting systems can be used to complement existing systems at the macro and mesolevel and can be used to improve system processing, create a phased response to latent errors and enhance engagement.

Enhancing the design and utilization of asthma action plans through community-based participatory research in an urban African American community.

BACKGROUND: Across the U.S., large inequities in asthma prevalence and outcomes persist, disproportionately affecting low-income, minoritized children. West Louisville is particularly impacted by these inequities due to a complex interplay of socioeconomic, historical, and industrial processes. Additionally, low health literacy and mistrust in healthcare exacerbate poor asthma self-management. OBJECTIVE: To engage community members and health professionals to address childhood asthma management in a marginalized community experiencing significant health inequities. PATIENT INVOLVEMENT: Although prior asthma knowledge was not required, the majority of our community advisory council (CAC) members either had asthma or cared for children/grandchildren with asthma. Through facilitated decision-making using the Boot Camp Translation approach, the CAC chose to focus on improving asthma self-management in their community through enhancing the design and utilization of asthma action plans (AAPs). METHODS: Upon adding inhaler images to a user-friendly AAP, the CAC developed and implemented a provider incentive program and a health communication campaign to promote the Tool's utilization. Evaluation of the intervention consisted of a short questionnaire measuring relevant patient demographics and campaign knowledge, and phone interviews with providers to gather feedback on the incentive and Tool design. RESULTS: Over the short two-month intervention, a total of 8 practices with 28 providers used 153 Tools to provide asthma self-management counseling. The majority of providers preferred the enhanced Tool to other AAPs they had used. Inhaler images facilitating improved communication regarding asthma medications. DISCUSSION: Using a participatory approach, a community preferred intervention targeting barriers to effective asthma control increased provider utilization and community awareness of AAPs and bridged a communication gap between patients and providers. PRACTICAL VALUE: Leveraging community members' (including patients/caregivers) and health professionals' expertise led to the development of an enhanced patient-education tool and an effective provider incentive program with the potential to improve childhood asthma management in marginalized populations.

Promoting Interdisciplinary, Participatory Approaches to Address Childhood Asthma Disparities in an Urban Black Community.

Black children are twice as likely as non-Hispanic white children to have asthma due to an interplay of socioeconomic, historical, and industrial factors. The underlying socio-economic and structural inequities result in poor adherence to recommended asthma management treatments. National guidelines suggest asthma action plans (AAPs) as a tool for patient self-management, yet they remain underutilized. Boot Camp Translation (BCT), rooted in community-based participatory research, provides a method for engaging communities to improve health literacy. This article describes the successful use of BCT to develop a culturally relevant AAP promotion campaign in West Louisville, a predominantly Black community that experiences social and health disparities.

Gendered powerlessness in at-risk adolescent and young women: an empirical model.

In the United States, youth aged 13-24 comprised approximately 21% of new HIV infections in 2017; 13% of these infections occurred among women, the majority of whom (86%) acquired HIV through heterosexual contact (Centers for Disease Control and Prevention. 2019a. HIV and youth. Retrieved from https://www.cdc.gov/hiv/group/age/youth/index.html, Centers for Disease Control and Prevention. 2019b. HIV among women. Retrieved from https://www.cdc.gov/hiv/group/gender/women/index.html). We fit and validated a developmentally appropriate empirical model of Connell's Theory of Gender and Power (Connell, R. W. 1987. Gender and power: Society, the person and sexual politics. Stanford, CA: Stanford University Press, Connell, R. W. 2013. Gender and power: Society, the person and sexual politics. Hoboken, NJ: John Wiley & Sons) in a sample of young women and assessed whether gendered powerlessness reflected a multidimensional higher-order latent factor, as the theory implies. Anonymous computer-assisted interviews were administered to at-risk, sexually active young women (N = 1,101). Factor analyses and structural equation modeling were used to determine the dimensionality of gendered powerlessness. Associations with condom use were examined to validate the model. We fit a three-component model of gendered powerlessness, but not a higher-order latent factor. We observed that high scores on two dimensions of gendered powerlessness - cathexis and sexual division of power - were associated with lower likelihood of condom use. Our three-component model helps elucidate the role that components of gendered powerlessness play in young women's health behaviors and underscores the need for measures tailored to young women at high risk of contracting HIV.

The untapped potential of behaviour analysis and interprofessional care.

Interprofessional collaboration has become a sought-after component of quality mental health care. Higher education institutions and mental health organizations seek to equip clinicians with the ability to provide cohesive clinical services while working collaboratively with a diverse group of professionals. Although research suggests that there may be benefits of interprofessional collaboration in mental health settings, collaborative practice initiatives have struggled with conceptual and methodological limitations. A behaviour analytic contribution to interprofessional care provides a philosophical position with an analytical goal distinguished by the prediction and influence of events, theoretical clarity, and methodological rigour that are needed within interprofessional research and practice. At the philosophical level, the extension of functional contextualism to interprofessional care research may provide a framework to achieve the valued ends of improving interprofessional collaboration and ultimately improving health-related outcomes for service users. Interprofessional collaboration can be conceptualized as metacontingency, a behaviour analytic concept that allows for a group level analysis of contributing social components. This paper uses the example of mental health care to guide a conceptual analysis of the potential application of behaviour analytic methodology within interprofessional practice, research, and education.

A phase I study of OSI-461 in combination with mitoxantrone in patients with advanced solid tumors potentially responsive to mitoxantrone.

PURPOSE: To find the maximum tolerated dose (MTD) of OSI-461 in combination with mitoxantrone in patients with advanced solid tumors. METHODS: This was a Phase I study using cohort dose escalation of OSI-461 dosed orally twice daily in combination with mitoxantrone 12 mg/m(2) given on Day 1 of each 21-day cycle. RESULTS: OSI-461 dose was escalated to 1,000 mg po bid. One patient experienced a dose-limiting toxicity (DLT). Three patients discontinued the study due to adverse events (AE). Two patients (10%) had a partial response, and ten patients (50%) had stable disease as best response. CONCLUSION: The combination of OSI-461 and mitoxantrone was well tolerated. Dose escalation was stopped because of toxicities in a concurrent Phase I trial. The response rate seen in patients with prostate cancer was comparable to response rates seen in trials of mitoxantrone and prednisone alone, and further studies of the combination of OSI-461 and mitoxantrone were not pursued.

A pharmacokinetic and safety study of intravenous arsenic trioxide in adult cancer patients with renal impairment.

PURPOSE: This study evaluated the pharmacokinetic and safety profiles of arsenic trioxide given twice per week in adult cancer patients with advanced malignancies and varying degrees of renal function. METHODS: Patients received intravenous arsenic trioxide 0.15 mg/kg twice weekly for 4 weeks, followed by a 2-week rest period. The pharmacokinetic profiles of the pharmacologically active arsenical species, arsenious acid (As(III)), and its metabolites, monomethylarsonic acid (MMA(V)) and dimethylarsinic acid (DMA(V)), were evaluated during the first cycle for 72 h following doses on days 1 and 22. Safety assessments were made at each treatment visit. RESULTS: Twenty patients received an average of 11 doses. Compared with normal renal function, mild to severe renal impairment decreased urinary excretion of As(III) and increased exposure to MMA(V) and DMA(V) 1.4- to 8-fold after multiple dose administration. Only severe renal impairment substantially increased exposure to As(III) (AUC(0-t ) increased by 18% after a single dose and 40% after multiple doses). The safety profile of arsenic trioxide after limited treatment on a twice-per-week schedule was comparable across all renal function groups. CONCLUSION: Renal impairment did increase the systemic exposure to arsenic and its methylated metabolites following standard daily dosing of arsenic trioxide. The data from the limited number of patients with severe renal dysfunction did not suggest that severe renal impairment affected the safety profile of arsenic trioxide in cancer patients who received limited treatment with arsenic trioxide.

Six-month safety results of calcium hydroxylapatite for treatment of nasolabial folds in Fitzpatrick skin types IV to VI.

BACKGROUND: Recently, the cosmetic market has seen an increase in the options for treatment for people with dark skin. OBJECTIVES: This study evaluates the use of calcium hydroxylapatite (CaHA), a dermal filler indicated for the correction of moderate to severe facial wrinkles and folds, including the nasolabial folds (NLFs) in individuals with dark skin. METHODS: This open-label, nonrandomized, prospective, five-center trial enrolled 100 patients aged 18 and older with Fitzpatrick skin types IV to VI. CaHA was injected subdermally with a 25- to 27-gauge needle. Participants received a range of 0.6 to 2.8 mL of CaHA and returned at 3 and 6 months to be assessed for keloid formation, hypertrophic scarring, and hyper- or hypopigmentation. If necessary, each subject was offered a touch-up at the conclusion of the 6-month visit. RESULTS: No reports of keloid formation, hypertrophic scarring, hypo- or hyperpigmentation, or other clinically significant adverse events were recorded. CONCLUSIONS: People with dark skin injected subdermally with CaHA do not show signs of keloid formation, hypertrophic scarring, or hyper- or hypopigmentation. Because of this safety feature, as well as other characteristics of the product already shown in clinical literature, CaHA is an attractive dermal filler in this population.

Oncology outpatient and provider responses to a computerized symptom assessment system.

PURPOSE/OBJECTIVES: To assess patient and provider responses to a computerized symptom assessment system. DESIGN: Descriptive, longitudinal study with retrospective, longitudinal medical records review. SETTING: University-based National Cancer Institute-designated outpatient cancer center. SAMPLE: 80 oncology outpatients receiving chemotherapy, 8 providers, and 30 medical records. METHODS: Patients completed the computerized assessment during three chemotherapy follow-up clinic appointments (times 1, 2, and 3). Patient usability was recorded via an observer checklist (ease of use) and the computer (completion time). Patient satisfaction and impact were assessed during telephone interviews two to three days after times 1 and 3 only. Provider usability and impact were assessed at the end of the study using a questionnaire and focus groups, whereas effect on provider documentation was assessed through chart audits. MAIN RESEARCH VARIABLES: Patient usability (ease of use, completion time), satisfaction, and impact; provider usability and impact. FINDINGS: Patients reported good usability, high satisfaction, and modest impact on discussions with their providers. Providers reported modest usability, modest impact on discussions with patients, and had varied reactions as to how the system affected practice. Documentation of symptoms was largely absent before and after implementation. CONCLUSIONS: This system demonstrated good usability and satisfaction but had only a modest impact on symptom-related discussions and no impact on documentation. IMPLICATIONS FOR NURSING: A computerized system can help address barriers to symptom assessment but may not improve documentation unless it can be integrated into existing medical records systems.

Dietitians' attitudes, perceptions, and usage patterns for fresh-cut fruit and vegetables.

PURPOSE: New fresh-cut fruit and vegetable products are being developed worldwide. Nutrition educators' perceptions of these products were studied. METHODS: Professional dietitians in Nova Scotia were asked to complete a questionnaire on their use of fresh-cut produce. The questionnaire also elicited their attitudes and perceptions about the convenience, taste/quality, nutrition/health benefits, cost, and safety of fresh-cut fruit and vegetables. RESULTS: Sixty-three percent of respondents reported eating five to six servings of fruit and vegetables a day. This group most frequently consumed fresh-cut fruit as snacks or dessert, and vegetables in stir-fry dishes or salads or cooked with meals. In general, fresh-cut fruit and vegetables were perceived as convenient, safe, and nutritious. While approximately 50% of participants felt fresh-cut produce did not differ in taste from whole fresh produce, almost the same number considered whole fresh produce superior in taste. CONCLUSIONS: Dietitians have a generally positive perception of fresh-cut products; however, there is uncertainty about the nutritional value, cost/benefit, and use of the products. Dietitians require more information on the nutrient value of these products and on suggested alternative uses. Attention should be paid to developing fresh-cut products that have good sensory quality.

A phase I and pharmacokinetic trial of erlotinib in combination with weekly docetaxel in patients with taxane-naive malignancies.

PURPOSE: This study aimed to define the maximum tolerated dose of weekly docetaxel combined with daily erlotinib, an oral epidermal growth factor receptor tyrosine kinase inhibitor. EXPERIMENTAL DESIGN: Patients with any solid tumor received 150 mg erlotinib with escalating doses of docetaxel (20, 25, 30, and 35 mg/m(2)) on days 1, 8, and 15 every 28 days. The pharmacokinetics of docetaxel and erlotinib was determined on cycle 2, day 1. Erlotinib was given for a maximum of 12 cycles and docetaxel was given for up to 6 cycles. RESULTS: Twenty-five patients (17 males and 8 females) were enrolled with a median age of 56 years (range, 34-76); Eastern Cooperative Oncology Group performance status of 0/1 was 20/5. One patient had a dose-limiting toxicity in cycle 1 at the 25 mg/m(2) level (grade 3 enterocolitis). At 35 mg/m(2) docetaxel dose level, 6 of 10 patients required dose reductions to 30 mg/m(2) beyond cycle 1 due to neutropenia (3 patients) and mucositis, increased bilirubin, and diarrhea (1 patient each). The clearance of docetaxel and erlotinib of 61.7 and 8.16 L/h, respectively, did not seem to differ from historical controls. Responses were seen in non-small cell lung cancer, prostate cancer, and hepatobiliary cancers, including a complete response lasting 36+ months in a patient with hepatocellular carcinoma. CONCLUSION: Although no maximum tolerated dose was reached in cycle 1 with 35 mg/m(2) docetaxel, repetitive dosing proved intolerable in a substantial number of patients; thus, the recommended phase II dose of weekly docetaxel is 30 mg/m(2) when combined with 150 mg of daily erlotinib.

Needle placement and injection posterior to the axillary artery may predict successful infraclavicular brachial plexus block: a report of three cases.

PURPOSE: The combined use of ultrasound and nerve stimulation for localization of the brachial plexus during infraclavicular block has not been evaluated. We describe three cases of infraclavicular block where we used ultrasound to place the needle and catheter, observe type of muscle twitch obtained and local anesthetic spread after injection. CLINICAL FEATURES: Injection of local anesthetic after obtaining proximal muscle stimulation was associated with local anesthetic spread between the axillary artery and pectoral muscle. This resulted in block failure (case 1). In case 2, proximal stimulation was associated with anterior spread after a test injection. The needle and subsequently the catheter were repositioned posterior to the axillary artery and distal muscle stimulation obtained. Injection through the catheter resulted in local anesthetic spread posterior to the artery and successful block. In case 3, no distal twitch could be obtained but in light of previous experience the needle and then the catheter were placed posterior to the axillary artery. Posterior local anesthetic spread was observed and successful block ensued despite absence of any muscle stimulation. CONCLUSION: Ultrasound guidance during infraclavicular brachial plexus block enables direct visualization of needle/catheter tip location and confirmation of appropriate local anesthetic spread. Our early experience suggests that spread of injectate posterior to the second part of the axillary artery is associated with successful block.

The average African American male face: an anthropometric analysis.

OBJECTIVES: To determine the average facial proportions of the African American man and compare results with the neoclassical canons of facial proportions and the standard for the North American white man. DESIGN: Cross-sectional survey. METHODS: Photographs and anthropometric measurements of the face were taken of 109 men of African American descent aged between 18 and 30 years, and results were compared with the neoclassical canons of the facial proportion and the averages of the anthropometric measurements for the North American white man. Proportional relationships were calculated based on the averages. Statistical analysis was performed. RESULTS: The neoclassical canons of facial proportion were not found to be applicable to most of the African American men who participated in the study. Of the 24 anthropometric measurements obtained, 21 were significantly different from the measurements of the North American white man (P<.05). We present proportional relationships in our subjects. CONCLUSIONS: The face of the average African American man differs from the neoclassical canons of facial proportion and the averages of anthropometric measurements for the North American white man. The proportional relationships found in our subjects might serve as a template for facial analysis in this patient population.

Analysis of the African American female nose.

The African American nose has been broadly classified as ethnic yet it differs significantly in morphology from that of other ethnic groups with which it is categorized. The objectives of this study were to (1) establish an objective protocol for analysis of the African American female nose using anthropometric measurements, and (2) determine whether subjective subcategorization schemes are a reliable replacement for anthropometry. African American women (n = 107) between the ages of 18 and 30 years consented to participate in this study. Photographs and 14 standard anthropometric measurements were taken of the face and nasal region, including nose length, nose width, special upper face height, intercanthal distance, mouth width, nasal bridge inclination, nasal tip protrusion, ala thickness, nasal root width, nasal bridge length, tangential length of ala, length of columella, nasofrontal angle, and nasolabial angle. Nasal indices including nose width-nose height index, nasal tip protrusion-nose height index, and nasal tip protrusion-nasal width index were calculated. In addition, photographic analysis was performed to evaluate nostril shape, nasal base shape, and nasal dorsal height. Proportional relationships and subcategorization schemes were evaluated. A new method of nasal analysis for the African American woman uses the proportional relationships of the anthropometric measurements. Proportional relationships included a columellar to lobule ratio of 1.5:1, a nasolabial angle of 86 degrees, and an alar width to intercanthal distance ratio of 5:4. The nasal dorsal height classification scheme was the most reliable for subjective analysis. The degree of variability found within this group of young African American women is illustrated by the following indices and their respective ranges: nose width-nose height index mean, 79.7 (range, 57 to 102); nasal tip protrusion-nose height index mean, 33.8 (range, 23 to 46); and nasal tip protrusion-nose width index mean, 42.8 (range, 32 to 61). The guidelines provided are a baseline from which to begin analysis and evaluation.