Best practice recommendations on the application of seclusion and restraint in mental health services: An evidence, human rights and consensus-based approach.

WHAT IS KNOWN ON THE SUBJECT?: Seclusion and restraint still regularly occur within inpatient mental health services. The Council of Europe requires the development of a policy on for instance age limits, techniques and time limits. However, they only define the outer limits of such a policy by indicating when rights are violated. Within these limits, many choices remain open. Staff and service managers lack clarity on safe and humane procedures. Research literature provides limited and contradictory insights on these matters. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: The study resulted in 77 best practice recommendations on the practical application of restraint and seclusion as last resort intervention in inpatient youth and adult mental health services, including forensic facilities. To our knowledge, this is the first study in which the development of recommendations on this topic is not only based on scientific evidence, but also on an analysis of European human rights standards and consensus within and between expert-professionals and experts-by-experience. This approach allowed to develop for the first time recommendations on time limits, asking for second opinion, and registration of seclusion and restraint. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The 77 recommendations encourage staff to focus on teamwork, safety measures, humane treatment, age and time limits, asking for second opinion, observation, evaluation and registration when applying seclusion and restraint as last resort intervention. The implementation of the best practice recommendations is feasible provided that they are combined with a broad preventive approach and with collaboration between service managers, staff (educators) and experts-by-experience. Under these conditions, the recommendations will improve safety and humane treatment, and reduce harm to both service users and staff. ABSTRACT: INTRODUCTION: Seclusion and restraint still regularly occur within inpatient mental health services. Professionals lack clarity on safe and humane procedures. Nevertheless, a detailed policy on for instance age limits, techniques and time limits is required. AIM: We developed recommendations on the humane and safe application of seclusion, physical intervention and mechanical restraint in inpatient youth and adult mental health services, including forensic facilities. METHOD: After developing a questionnaire based on a rapid scientific literature review and an analysis of human rights sources stemming from the Council of Europe, 60 expert-professionals and 18 experts-by-experience were consulted in Flanders (Belgium) through a Delphi-study. RESULTS: After two rounds, all but one statement reached the consensus-level of 65% in both panels. The study resulted in 77 recommendations on teamwork, communication, materials and techniques, maximum duration, observation, evaluation, registration, second opinion and age limits. DISCUSSION: Combining an evidence, human rights and consensus-based approach allowed for the first time to develop recommendations on time limits, asking for second opinion and registration. IMPLICATIONS FOR PRACTICE: When combined with a preventive approach and collaboration between service managers, staff (educators) and experts-by-experience, the recommendations will improve safety and humane treatment, and reduce harm to service users and staff.

ANP32A regulates ATM expression and prevents oxidative stress in cartilage, brain, and bone.

Osteoarthritis is the most common joint disorder with increasing global prevalence due to aging of the population. Current therapy is limited to symptom relief, yet there is no cure. Its multifactorial etiology includes oxidative stress and overproduction of reactive oxygen species, but the regulation of these processes in the joint is insufficiently understood. We report that ANP32A protects the cartilage against oxidative stress, preventing osteoarthritis development and disease progression. ANP32A is down-regulated in human and mouse osteoarthritic cartilage. Microarray profiling revealed that ANP32A protects the joint by promoting the expression of ATM, a key regulator of the cellular oxidative defense. Antioxidant treatment reduced the severity of osteoarthritis, osteopenia, and cerebellar ataxia features in Anp32a-deficient mice, revealing that the ANP32A/ATM axis discovered in cartilage is also present in brain and bone. Our findings indicate that modulating ANP32A signaling could help manage oxidative stress in cartilage, brain, and bone with therapeutic implications for osteoarthritis, neurological disease, and osteoporosis.

Normative Functional Outcomes as a New Outcome Assessment Tool Following Hip Procedures.

Patient-reported outcome measures play an important role in evaluating the functional outcome of surgical and nonsurgical treatments of the hip joint. One thousand healthy volunteers completed the modified Harris hip score, the University of California, Los Angeles score, the Hip Osteoarthritis Outcome Score, and the Western Ontario and McMaster Universities Osteoarthritis Index score. Between September 2010 and December 2015, a total of 127 periacetabular osteotomies were performed in 111 patients with symptomatic developmental dysplasia of the hip. Forty-two of these patients (10 male and 32 female) met inclusion criteria. Mean follow-up was 32 months (range, 13-59 months). Pre- and postoperative radiographic analysis of the lateral center-edge angle and the acetabular index was conducted in all cases with a proper pelvic anteroposterior radiograph. The patients completed the modified Harris hip score, the University of California, Los Angeles score, the Hip Osteoarthritis Outcome Score, and the Western Ontario and McMaster Universities Osteoarthritis Index score. The authors investigated the influence of various confounding variables to (1) obtain recommendations when outcome scores are being compared between 2 cohorts and (2) define a normative reference level of "hip-healthy" functionality. This normative level of functionality was used as a target level of functionality following a hip procedure such as periacetabular osteotomy. All functional outcome scores had significantly improved 1 year after periacetabular osteotomy; thus, patients were much better than preoperatively. However, only 55% achieved the 95% functionality of the normative population based on modified Harris hip score and University of California, Los Angeles score. The results were worse for the Hip Osteoarthritis Outcome Score subscales. This approach places the results of surgical procedures in a different but potentially more realistic perspective in terms of expectations and goals. [Orthopedics. 2018; 41(5):e663-e670.].

SMOC2 inhibits calcification of osteoprogenitor and endothelial cells.

Tissue calcification is an important physiological process required for the normal structure and function of bone. However, ectopic or excessive calcification contributes to diseases such as chondrocalcinosis, to calcium deposits in the skin or to vascular calcification. SMOC2 is a member of the BM-40/osteonectin family of calcium-binding secreted matricellular proteins. Using osteoprogenitor MC3T3-E1 cells stably overexpressing SMOC2, we show that SMOC2 inhibits osteogenic differentiation and extracellular matrix mineralization. Stable Smoc2 knockdown in these cells had no effect on mineralization suggesting that endogenous SMOC2 is not essential for the mineralization process. Mineralization in MC3T3-E1 cells overexpressing mutant SMOC2 lacking the extracellular calcium-binding domain was significantly increased compared to cells overexpressing full length SMOC2. When SMOC2 overexpressing cells were cultured in the presence of extracellular calcium supplementation, SMOC2's inhibitory effect on calcification was rescued. Our observations were translationally validated in primary human periosteal-derived cells. Furthermore, SMOC2 was able to impair mineralization in transdifferentiated human umbilical vein endothelial cells. Taken together, our data indicate that SMOC2 can act as an inhibitor of mineralization. We propose a possible role for SMOC2 to prevent calcification disorders.