Incidence of severe infection in patients with rheumatoid arthritis taking biologic agents: a systematic review.

OBJECTIVE: The objective of this review was to estimate the population-based incidence and determine the types of severe infection and deaths experienced by patients with rheumatoid arthritis taking biologic agents. INTRODUCTION: Since the late 1990s, various biologic and synthetic drugs have been developed to treat rheumatoid arthritis. In recent years, the incidence of severe infection in patients with rheumatoid arthritis in Western nations has been determined by observational studies; however, no systematic review has been conducted on this topic. INCLUSION CRITERIA: The following inclusion criteria were considered: i) observational studies on patients with rheumatoid arthritis treated with biologic agents; ii) studies reporting the number of severe infections requiring hospitalization for treatment; iii) studies reporting person-years of observation data; and iv) studies based on rheumatoid arthritis registries, medical records from rheumatology centers, or insurance claim databases. METHODS: PubMed, CINAHL, Embase, and Web of Science were searched to identify published studies. The reference lists of all studies selected for critical appraisal were screened for additional studies. Unpublished studies were searched on MedNar and OpenGrey databases. All the searches were updated on December 6, 2021. After removing the duplicates, 2 independent reviewers screened titles and abstracts against the inclusion criteria and then assessed full texts against the criteria. Two reviewers independently appraised the study and outcome levels for methodological quality using the critical appraisal instrument for cohort studies from JBI. Two reviewers extracted the relevant information related to severe infection and drugs. RESULTS: Fifty-two studies from 21 countries reported severe infection rates associated with using 8 biologic agents, plus nonbiologic disease-modifying antirheumatic drugs. In total, 18,428 infections with 395,065 person-years of biologic drug exposure were included in the analysis. Thirty-five studies included infections in outpatients receiving intravenous antibiotic therapy. Fifteen studies reported the first episode of infection, and the remaining studies did not specify either the first or all of the episodes of infection. Inclusion of viral infection and/or opportunistic infection varied among studies. Fifteen studies reported the site of infection; respiratory, skin/soft tissue, urinary tract, and sepsis/bacteremia were commonly reported. Ten studies reported the case fatality rates, ranging from 2.5% to 22.2%. Meta-analysis was conducted for 8 biologic agents and conventional disease-modifying antirheumatic drugs. The infection rate varied from 0.9 to 18.1/100 person-years. The meta-analysis revealed an infection rate of 5.0/100 person-years (95% CI 3.8-6.7) among patients receiving tumor necrosis factor inhibitors (heterogeneity 98.2%). The meta-analysis for the other 3 biologic agents revealed a point estimate of 5.5 to 8.7/100 person-years with high heterogeneity. Sensitivity analysis indicated that registry-based studies were less likely to have very low or very high infection rates compared with other data sources. The definition of infection, the patient composition of the cohorts, and the type of databases appeared to be the primary sources of clinical and methodological heterogeneity. CONCLUSIONS: Due to high statistical heterogeneity, the meta-analysis was not suited to estimating a summary measure of the infection rate. Developing standardized data collection is necessary to compare infection rates across studies. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42020175137.

Factors associated with EMS on-scene time and its regional difference in road traffic injuries: a population-based observational study.

BACKGROUND: The outcome of road traffic injury (RTI) is determined by duration of prehospital time, patient's demographics, and the type of injury and its mechanism. During the emergency medical service (EMS) prehospital time interval, on-scene time should be minimized for early treatment. This study aimed to examine the factors influencing on-scene EMS time among RTI patients. METHODS: We evaluated 19,141 cases of traffic trauma recorded between April 2014 and March 2020 in the EMS database of the Nara Wide Area Fire Department and the prehospital database of the emergency Medical Alliance for Total Coordination of Healthcare (e-MATCH). To examine the association of the number of EMS phone calls until hospital acceptance, age ≥65 years, high-risk injury, vital signs, holiday, and nighttime (0:00-8:00) with on-scene time, a generalized linear mixed model with random effects for four study regions was conducted. RESULTS: EMS phone calls were the biggest factor, accounting for 5.69 minutes per call, and high-risk injury accounted for an additional 2.78 minutes. Holiday, nighttime, and age ≥65 years were also associated with increased on-scene time, but there were no significant vital sign variables for on-scene time, except for the level of consciousness. Regional differences were also noted based on random effects, with a maximum difference of 2 minutes among regions. CONCLUSIONS: The number of EMS phone calls until hospital acceptance was the most significant influencing factor in reducing on-scene time, and high-risk injury accounted for up to an additional 2.78 minutes. Considering these factors, including regional differences, can help improve the regional EMS policies and outcomes of RTI patients.

Culturally Congruent Health Activities for the Prevention of Functional Disabilities Among Older Adults in Japan's Forest Communities.

INTRODUCTION: In Japan's forest areas, cultural capital and older adults play key roles in helping to sustain the community. The purpose was to explore cultural values/beliefs related to culturally congruent health activities among older adults in forest communities. METHOD: The qualitative ethnonursing research method was used. Data were collected through fieldwork and key informants' interviews (n = 14) over 1 year. The setting was a traditional village with 80% forest cover. RESULTS: Findings included two universal cultural values/beliefs, which were "community identity as a community member" and "our cohesion and connection as community members." Additionally, two diverse cultural values/beliefs were found: "gender-based differences" and "differences between those having experience working outside the forest community and those without this experience." These were related to community-based health activities. DISCUSSION: These values/beliefs were suggested to develop a multilayered network around health activities in order to prevent functional disabilities among older adults.

Association between postpartum depression and social support satisfaction levels at four months after childbirth.

This study clarifies the association between postpartum depression (PPD) and satisfaction with social support after childbirth through an anonymous survey of 427 postpartum mothers. Mothers' PPD was found to be significantly associated with satisfaction levels regarding formal-instrumental support (OR: 0.32, 95% CI: 0.162-0.632), informal-instrumental support (OR: 0.547, 95% CI: 0.313-0.955), and informal-psychological support (OR: 0.591, 95% CI: 0.384-0.912) in a multivariate logistic regression analysis. To prevent PPD, specialists as formal support providers must provide qualified care based on comprehensive judgments, and families as informal support providers should help with childcare, housework, and mental support.

Differences in the risk of severe falls between patients aged <65 years and patients aged ≥65 years at a psychiatric hospital based on 12-year incident reports.

PURPOSE: This study compared age differences in risk factors for falls requiring treatment in psychiatric patients. DESIGN AND METHODS: An incident database was used to compare fall incidents in patients aged less than 65 years and those aged greater than or equal to 65 years. FINDINGS: Approximately 30% of fallers were less than 65 years. Mental status and medication were the main risk factors. Decreased activities of daily living were associated with the most falls in patients greater than or equal to 65 years. PRACTICE IMPLICATIONS: Fall risk differed between the two age groups. Medication may play a major role in falls among patients less than 65 years.

Analysis of inedible substance ingestion at a Japanese psychiatric hospital.

BACKGROUND: Inedible substance ingestion increases the risk of ileus, poisoning, and suffocation. Prevention is especially important in a psychiatric setting. This study aimed to analyze the incidence of inedible substance ingestion in a Japanese psychiatric hospital. METHODS: Inedible substance ingestion incidents were extracted from an incident report database spanning 2000-2012 at a 400-bed psychiatric hospital in Japan. We tabulated the frequencies of incidents in accordance with major diagnosis, ingested materials, incident levels, and time of occurrence. RESULTS: The incidence rate was 0.09/1000 patient days, and 149 cases in 105 patients were classified as having experienced inedible substance ingestion. The most common diagnosis was dementia (n = 58), followed by schizophrenia (n = 22). Materials ingested by dementia patients were nappies or gauze attached to the patient's body after medical procedures. Materials ingested by schizophrenic patients were liquid soap, detergent or shampoo, and cigarettes. Inedible substance ingestion among dementia patients occurred mostly before or during meals. Among schizophrenic patients, the peak period of incidents was in the evening. CONCLUSIONS: Dementia patients were overrepresented in the inedible substance ingestion incidents. Items they wore or applied to their bodies were often subject to ingestion, and such behaviours mostly occurred around meal time. Therefore, the nursing staff were able to discover them quickly and treat most of the cases free of serious consequences. In contrast, schizophrenic patients were underrepresented in the incidents, and most cases involved ingestion of detergent powder or cigarettes, resulting in more serious consequences and requiring treatment.

Quantitative evaluation of changes in the clock-watching behavior of a patient with semantic dementia.

BACKGROUND: Clock-watching activity in patients with dementia has not been documented in detail. METHODS: A male patient having semantic dementia was monitored at a dementia care unit in a general hospital in Japan. We used an integrated circuit monitoring system to record the distance and location of ambulation and the total number of movements that occurred outside the patient's room. RESULTS: The patient was reported to clock watch a couple of years prior to monitoring. In 2011, when monitoring started, he regularly came out of his room saying, "8 o'clock" about 40 minutes into every hour. It seemed as if he could only recognize the minute hand. The median number of sensor detections increased by 4-fold at this clock-watching phase. Behavior consistent with his clock-watching patterns was also detected during the night. In 2012, clock-watching activity disappeared. CONCLUSIONS: This study documented the progression of clock-watching and subsequent disappearance with worsening cognitive function.

Degree of ambulation and factors associated with the median distance moved per day in Alzheimer's disease patients.

The Integrated Circuit tag monitoring system became available to measure wandering in terms of the distance moved by dementia patients. The purposes of the study were to describe degree of ambulation in patients with Alzheimer's disease (AD) and to examine factors associated with the distance moved. AD patients were recruited at a dementia care unit in Asakayama Hospital, Osaka, Japan. The monitoring system generated the distance moved per day. Demographic and clinical data were abstracted from medical records. Mini-Mental State Examination was used to measure cognitive function. A multiple linear regression was used to predict the distance moved per day. The research was approved by the ethics committee of the university and the hospital, and written informed consent was obtained from the patients' proxies. Majority of the AD subjects monitored had moderate to advance stage of dementia. Patients' age and cognitive function were predictors of the median distance moved/day, and these two variables explained almost half of the variance. Older age and lower cognitive function were associated with reduced median distance moved per day in AD patients.

Discrepancy between subjective and objective assessments of wandering behaviours in dementia as measured by the Algase Wandering Scale and the Integrated Circuit tag monitoring system.

AIM: Although wandering is one of the major research focuses of the behavioural psychological symptoms of dementia, assessment of wandering has mostly relied on caregiver-administered questionnaires. The purpose of this study was to compare staff-administered Algase Wandering Scale outcomes with objective temporal and spatial movement indicators obtained from the Integrated Circuit (IC) tag monitoring system. METHODS: Patients with dementia were recruited from a dementia care unit in Osaka, Japan in 2007. Primary nurses administered the Algase Wandering Scale, and the temporal and spatial movements of the subjects were monitored by the IC tag. Written informed consent was obtained from each subject's proxies. RESULTS: Nurses' assessments of wandering were in agreement with the IC tag outcomes only during the day shift. Spatial movements assessed by the staff did not reflect those measured by the IC tag. CONCLUSION: This objective measurement of wandering showed the limitations in the assessment of spatial and temporal movement by the staff.

Changes in activity patterns after the oral administration of brotizolam in institutionalized elderly patients with dementia.

BACKGROUND: Little is known about the side effects of sedative-hypnotic agents in elderly dementia patients with sleep disorders. The present study describes activity pattern changes after a single dose of brotizolam in elderly patients with dementia. METHODS: We conducted retrospective analysis of prospectively collected data from a case series at Asakayama Hospital (Osaka, Japan) between September 2008 and September 2009. Around-the-clock movements of dementia patients who were administered a single dose of brotizolam were recorded by the integrated circuit tag monitoring system during a 4-week baseline and 7-day peri-administration period. Diurnal and nocturnal activity levels and the onset times of the least-active and most-active phases were then measured. RESULTS: Seven patients (four men, three women; age range 59-85 years) were analyzed. All seven patients had disturbed activity patterns during the peri-administration period. Compared with the pre-administration period, the incidence of reversed rest-activity pattern increased significantly in the post-administration period, as measured by the distance moved per hour (P < 0.000). Patients with advanced stages of dementia had prolonged and delayed activity responses. CONCLUSIONS: Findings showed changes in activity levels and reversed active/resting phases after a single dose of brotizolam in elderly patients with dementia. Use of brotizolam in elderly patients with dementia, especially in advanced stages, calls for closer attention and longer observation periods.

[Difference in sundowning of wandering behavior in patients with Alzheimer disease and frontotemporal dementia].

OBJECTIVES: To delineate the difference in sundowning of wandering behavior between patient with Alzheimer Disease (AD) and frontotemporal dementia (FTD). METHODS: The study was conducted in a dementia care unit at A hospital in Osaka, Japan from September 2008 to September 2009. Twenty-four-hour movements of 27 ambulatory inpatients with AD and 7 with FTD were coded consecutively by the IC tag monitoring system. RESULTS: Repeated measures ANOVA after the adjustment of Huynh-Feldt Epsilon (H-F) showed no significant difference in 24 h standardized activity level between two groups (F = 3.74, P = 0.06), and there was no interaction between diagnosis and time (F = 1.42, P > 0.05). The standardized activity levels gradually increased from late afternoon to evening and then reached the highest point at 18:00 in AD group and 19:00 in FTD group. Test of within-subjects contrasts for order 17 was significant (F = 5.24, P < 0.05) and for order 9 was a tendency of significant (F = 4.26; P = 0.05) between two groups. AD group was significant greater active at 5:00, 6:00 and 7:00 (0.75 ± 0.08 vs 0.35 ± 0.16, F = 4.91; 1.13 ± 0.13 vs 0.49 ± 0.26, F = 5.06; 1.24 ± 0.15 vs 0.56 ± 0.28, F = 4.47 respectively, P < 0.05), and less active at 16:00 (1.65 ± 0.11 vs 2.22 ± 0.22, P < 0.05) comparing to FTD group by Bonferroni's multiple comparison test. Meanwhile, the time of peak value of hourly distance moved per day (PV-time) was delayed in FTD group comparing to AD by circular χ² test (14:12 ± 5:12 vs 15:47 ± 4:19, χ² = 87.31, P < 0.01). CONCLUSIONS: The study suggests great possibility of sundowning of wandering behavior in both two subtypes with different temporal pattern of wandering behavior. Comparing to FTD patients, AD patients showed an advanced PV-time and prolonged active phase.

Comparing dementia patients' nighttime objective movement indicators with staff observations.

BACKGROUND: Pharmacological and non-pharmacological approaches are commonly used to treat patients' institutionalised for nighttime wandering. Actigraphy and other scales have been used to evaluate the efficacy of these treatments. However, in clinical settings, nursing records are often the sole source of daily observation of nighttime wandering. Thus, physicians rely on nursing records to evaluate pharmacological and non-pharmacological treatments. This study examined nighttime movements of patients with dementia, comparing the results of integrated circuit tag monitoring with hourly nighttime nursing records. We tested which factors were associated with agreement rates between the two data sources. METHODS: The study hospital was a general hospital in Osaka, Japan. Monitoring was conducted in a closed 60-bed dementia care unit. An integrated circuit tag monitoring system was used to monitor the movement of institutionalised dementia patients for over half a year. The distance moved per hour by subjects was measured using the monitoring system, and the data were compared with hourly nighttime nursing records. Agreement rates were calculated between the two data sources. RESULTS: Thirty-five patients were monitored. Between 10-30% of subjects moved at any given hour during the night. The overall agreement rate between sources of movement data was 39%. Agreement rates were significantly correlated with the interquartile of the distance moved, changes in medication, physical conditions, and behavioural and psychological symptoms of dementia measured during the day. CONCLUSIONS: Although the agreement rate was low, staff appeared to pay more attention to patients associated with notable events during the day and patients exhibiting variability in distance moved.

Pacing and lapping movements among institutionalized patients with dementia.

Wandering is a complex behavior, and defining wandering has been challenging. The current study used the integrated circuit (IC) tag monitoring system to describe the distance moved per day and the spatial movements of patients with dementia. The study was conducted in a 60-bed semiacute dementia care unit in a general hospital in Japan over a 3-month period in 2006. The distance moved per day, the numbers of pacing and lapping movements, and the proportions of the distance moved that was paced or lapped were tabulated in 23 patients diagnosed with dementia. The distance moved per day and the numbers of pacing and lapping movements varied greatly within and among study participants. The median distance moved per day was inversely correlated with participants' age and Mini-Mental State Examination (MMSE) scores (adjusted r(2) = .34, P = .01). Consecutive lapping and pacing movements were rare patients with in Alzheimer's disease (AD), while 2 patients with frontotemporal dementia paced or lapped repeatedly.

Communication network analysis in maternity hospital bulletin board system.

Recent changes in Japanese social environments consequently dropped total fertility rate, and poor interpersonal relationships in local communities have aggravated the environments for childbirth and child-rearing. Under such circumstances, we introduced a bulletin board system (BBS) to an official web-site of a maternity hospital to set up a community for its patients for communication regarding childbirth and the like. Based on the logs from BBS, we graphed types of communication among its users with to describe topologies. Additionally, we calculated degrees of centralization of entire networks and found the hospital role as the administrator becomes smaller as inter-user communication becomes more brisk. The analysis of contents of respective threads also revealed that main topics shifted from gestational matters to postnatal and child-rearing as communication became more brisk, which indicates those postnatal users are also strongly conscious with gestational and progestational contents and contribute to supporting the entire BBS.