The effects of therapeutic activity kits in emergency department patients with dementia: Study protocol for a pragmatic randomized control trial.

AIM: To determine the effectiveness of therapeutic activity kits on health service use and treatment delivered in the emergency department (ED) in patients with pre-morbid dementia. DESIGN: Pragmatic randomized control trial with equal parallel groups. METHODS: Participants with dementia will be randomly assigned to the control group (N = 56) or the intervention group (N = 56). The intervention group will be given access to a therapeutic activity kit containing several different activities and sensory stimuli to engage the person with dementia during their ED stay in addition to usual care, and the control group will be given usual care only. A research nurse will observe participants at 30-60-min intervals throughout their ED stay for responsive behaviours, one-on-one nursing, and the use of chemical and physical restraint. This study has received Research Ethics Committee approval from the institutional review board and funding from the Rosemary Bryant Foundation (May 2019). DISCUSSION: Emergency departments are busy and noisy environments and can be intimidating and disorientating for patients with dementia, which can result in responsive behaviours. Responsive behaviours are often managed with restrictive interventions, such as chemical or physical restraint, or with constant bedside nursing (one-on-one nursing) to ensure patient safety. Alternatively, non-restrictive and non-pharmacological interventions that divert or occupy the attention of patients such as those contained in the therapeutic activity kit can be considered as a more person-centred strategy. Therapeutic activity kits have been reported as feasible for the use in ED; however, there is limited quality evidence at present to support the implementation of such interventions in the ED. IMPACT: If this study is successful, it will demonstrate that a therapeutic activity kit containing activities (puzzles, colouring, music, and tactile activities) is inexpensive, easily implemented intervention that can prevent this patient group from demonstrating unsafe behaviours and requiring one-on-one nursing and restraints.

Is neonatal abstinence syndrome related to the amount of opiate used?

OBJECTIVE: To determine if a relationship exists between the dose of heroin and/or substitute medication used in pregnancy and neonatal abstinence syndrome (NAS). DATA SOURCES: Ovid online was used to search the following: EMBASE, Ovid MEDLINE, CINHAL, PscyINFO, Cochrane Database of Systematic Reviews. STUDY SELECTION: English language journal articles reporting original research undertaken and published between 1995 and 2009 that examined relationships between NAS and opiate use in pregnancy and with patterns of substance abuse that reflect those of the United Kingdom and other high-resource settings. DATA EXTRACTION: The studies were reviewed independently by two authors using predefined quality criteria. DATA SYNTHESIS: This was a narrative review; key messages from included studies were discussed in the context of the diversity and commonality of findings in relation to NAS. CONCLUSIONS: No correlation between the amount of fetal opioid exposure and expression of NAS was reported in eight of the 10 studies. This observation was consistent across international boundaries, and studies that included both methadone and buprenorphine.

Antiepileptic medication during pregnancy: does fetal genotype affect outcome?

Congenital abnormalities and impaired development in childhood are attributable to fetal exposure to antiepileptic drugs (AEDs). Pregnancy registries set up to obtain information about the potential risks of fetal exposure to AEDs, in particular major congenital malformations (MCMs), suggest that valproate exposure increases the frequency of congenital malformations more than other AEDs. Furthermore, follow-up studies have drawn attention to cognitive impairments in later childhood after prenatal exposure to valproate. Fetal exposure to AEDs may be influenced by drug transporting proteins in the placenta, including P-glycoprotein (P-gp), multidrug resistance protein (MRP) 1, and breast cancer resistance protein (BCRP). Their location in the syncytiotrophoblast plasma membrane, at the interface of the maternal and fetal circulations, allows these transport proteins to efflux xenobiotics back to the mother and offers the fetus protection from medications taken during pregnancy. Genetic variations in the expression and activity of these transport proteins may influence fetal exposure to AEDs and thus the risk of teratogenicity. Identification of a hierarchy of haplotypes ranging from susceptible to protective of congenital abnormalities could assist genetic counseling, in assessing fetal risks from exposure to AEDs.

Role of MDR1 and MRP1 in trophoblast cells, elucidated using retroviral gene transfer.

Natural differences in expression and retroviral transduction techniques were used to test the hypothesis that MDR1 P-glycoprotein (P-gp) and MRP1 (multidrug resistance-related protein) contribute to xenobiotic handling by placental trophoblast. RT-PCR and Western blotting in placenta, primary cytotrophoblast cell cultures, and BeWo, JAr, and JEG choriocarcinoma cell lines showed that MRP1 was ubiquitously expressed, whereas MDR1 was absent or minimally expressed in BeWo and JEG cell lines. In syncytiotrophoblast, P-gp was localized predominantly to the microvillous, maternal facing plasma membrane, and MRP1 to the basal, fetal facing plasma membrane. Functional studies showed that cyclosporin A-sensitive accumulation of [3H]vinblastine by cells containing both transport proteins was significantly different from those expressing predominantly MRP1. Retroviral gene transfer of MDR1 to BeWo cells confirmed that this difference was due to the relative expression of MDR1. Therefore, both P-gp and MRP1 contribute to xenobiotic handling by the trophoblast. Localization of P-gp to the microvillous membrane suggests an essential role in preventing xenobiotic accumulation by the syncytiotrophoblast and, therefore, in protecting the fetus.