Non-medical Strategies Research Articles

A scoping review of the evidence on pharmacological and non-pharmacological interventions for idiopathic hypersomnia.

Idiopathic hypersomnia (IH) is characterized by excessive sleepiness during the day, prolonged sleep at night, and difficulty waking up. The true prevalence of IH is uncertain. ICSD provides criteria for diagnosing IH; however, the definition has evolved. Managing IH involves using pharmacologic and non-pharmacologic approaches, although the most effective strategies are still unclear. The objective of this scoping review was to identify the extent, range, and nature of the available evidence, identify research gaps, and discuss the implications for clinical practice and policy. To conduct this review, a comprehensive search was conducted across scientific databases, without any restrictions on the date or study type. Eligible studies examined the effectiveness of pharmacologic and non-pharmacologic treatments for IH and reported the outcomes of these interventions. Data from the studies were screened, analyzed, and synthesized to provide an overview of the available literature landscape. 51 studies were included in this review, which used various methods and interventions. Pharmacological treatments, particularly modafinil, have been frequently studied and have yielded positive results. There is also emerging evidence for alternative medications such as low-sodium oxybate and pitolisant. Non-pharmacological approaches, such as CBT-H and tDCS have also shown promise in managing IH. This review highlights the complexity of managing IH management and emphasizes the need for personalized multidisciplinary approaches. Pharmacological interventions are important in managing IH and can be complemented by non-medication strategies. Larger-scale studies are necessary to advance our understanding of IH and to improve treatment outcomes.

A pre-visit video/question prompt list intervention to increase youth question-asking about attention deficit hyperactivity disorder during pediatric visits

ObjectiveTo conduct a pragmatic randomized controlled trial to test the effectiveness of an ADHD question prompt list with video intervention to increase youth question-asking and provider education about ADHD during visits. MethodsEnglish-speaking youth ages 11–17 with ADHD and their caregivers were enrolled from two pediatric clinics. Youth were randomized to intervention or usual care groups. Intervention group adolescents watched the video and then completed an ADHD question prompt list before their visits. Multivariable regression was used to analyze the data. ResultsTwenty-one providers and 102 of their patients participated. Intervention group youth were significantly more likely to ask one or more questions about ADHD and its treatment than usual care youth (odds ratio=5.4, 95 % Confidence Interval (CI)= 1.8, 15.9). Providers were significantly more likely to educate youth who asked one or more questions during visits about more ADHD medication areas (unstandardized beta=0.98, 95 % CI=0.31 to 1.64) and more non-medication strategies for ADHD (unstandardized beta=0.50, 95 % CI=0.13 to 0.88). ConclusionThe intervention increased youth question-asking about ADHD and its treatment. Providers provided more education to youth who asked one or more questions about ADHD and its treatment. Practice implicationsProviders and practices should consider having youth complete ADHD question prompt lists and watch the video before visits to increase youth question-asking during visits.

Current issues surrounding Parkinson's disease

The number of people suffering from Parkinson's disease is constantly increasing. Diagnosis is based on the motor and non-motor symptoms present throughout the course of the disease. To preserve patient autonomy, the main therapeutic challenge is to propose a treatment adapted to each profile, in conjunction with the implementation of non-medication strategies, reflection on improved accessibility to existing medication and research into innovative therapies.

Current Evidence-based Approaches to Multimodal Pain Control and Opioid Minimization After Arthroscopic and Knee Preservation Surgery.

Nonarthroplasty knee procedures are common and may cause a wide spectrum of postoperative pain, ranging from minimal to severe, depending on the patient, pathology, and procedure. Procedures include ligament repair and reconstruction, especially anterior cruciate ligament reconstruction, meniscal débridement, repair and transplant, periarticular osteotomy, and cartilage restoration. Multimodal analgesia regimens have been implemented successfully, but notable variation characterizes current protocols. Increased public and physician awareness of the burden of opioid usage in the United States has encouraged the medical community to embrace opioid-minimizing and nonopioid techniques to mitigate the deleterious effects of these medications. Nonopioid medications; anesthesia techniques; surgical techniques; and postoperative nonmedication strategies, including physical therapy, transcutaneous electrical nerve stimulation, cryotherapy, cognitive techniques, and non-Western interventions, can form part of an effective multimodal approach. A multimodal approach can facilitate adequate analgesia without compromising patient satisfaction or outcome.

Fibromyalgia or Chronic Fatigue Educational Preferences: In-person vs Virtual

PURPOSEThis investigation consisted of a survey of patients diagnosed with fibromyalgia or chronic fatigue who participated in the Fibromyalgia and Chronic Fatigue Clinic (FCFC) in a tertiary care center. This study assessed if patients preferred in-person or virtual educational sessions for their treatment program during the COVID pandemic. We hypothesized a relatively even split as to the preference of in-person or virtual sessions. The FCFC, operational since 1999, consists of in-depth educational sessions, led by RN staff. Patients receive 8 hours of education, divided into two 4-hour sessions. Educational topics include symptoms, pathophysiology, medication, and non-medication strategies. Since the inception of our clinic, these educational sessions have been provided via an in-person group setting. However, given the ramifications of the COVID-19 pandemic and the resultant changes in travel and infection control policies, we began offering the sessions online via Zoom. Currently we provide the option of traditional in-person or online sessions. Though the options are appreciated by our patients, we did not have any data to support the benefits or barriers that each of these options have. METHODSThe survey-based observational study utilized a Qualtrics survey that was emailed directly to patients following participation in either class format. After determining there were insufficient numbers from the in-person class participants, we printed out paper copies and asked patients who were willing, to complete those forms. This study was determined to be a quality assurance project by our Institutional Review Board. RESULTS90 patients completed the survey: 53 from the virtual sessions and 37 from in-person. Results highlighted patient preferences. CONCLUSIONAll patients reported they found the information valuable and that they were generally satisfied with their educational sessions. Virtual attendees identified some potential limitations, mainly not feeling as connected with peers or as engaged in the sessions.

N11 Adherence, self-care and illness perception in patients with Inflammatory Bowel Disease – a qualitative study

Abstract Background Medical treatment (MT) is key in the management of Inflammatory Bowel Disease (IBD, ulcerative colitis [UC] and Crohn’s disease [CD]) and non-adherence is a barrier to treatment efficacy. Approximately 30 % of patients with IBD is non-adherent to MT. Self-care is defined as; the process of maintaining health through health-promoting practices and managing illness. Adherence is an important part of self-care in IBD. Illness perception relates to understanding disease and potential consequences. The aim of this study is to add deeper understanding of adherence and non-adherence as part of self-care and explore the links to illness perception and self-efficacy in patients with IBD. Methods Semi-structured interviews were conducted face-to-face with 15 IBD patients (5 CD, 9 UC, 1 IBD-U, Table 1) at a university IBD-clinic in Sweden. Patients were invited to ensure richness of data and maximum variation of disease duration, age, and sex. Interviews were recorded, transcribed verbally, and analysed with inductive, latent content analysis. Results Analysis resulted in three main categories and ten subcategories. The first category, Disease Perception, included the observation that a majority of the informants monitors disease through bowel symptoms. However, perception of severe illness was linked to low daily function. Most informants used stress reduction and diet to reduce symptoms. Some informants struggled with acceptance of disease while others seem to have reached higher acceptance. Fear related to disease was expressed, e.g., colonoscopies, cancer and progress of disease. The second category, Health Care Perception, showed that informants highly desired a personal connection with the doctor. Some informants expressed trust issues due to delayed diagnosis, kindreds’ bad experiences from health care or emotional trauma related to disease onset or care. Unmet need of information mainly concerned the health care system, the diagnosis and MT. The third category, Treatment Perception, included the informants’ ambivalence towards MT, where worries of potential harm from MT was central. Preferences on administration of MT was a factor that influenced adherence. Many informants perceived that non-medical strategies are more or equally important as MT to decrease symptom burden. Conclusion The findings add understanding of reasons for adherence and non-adherence to MT and demonstrates the complex mechanisms behind this phenomenon. The informants’ evaluation of risk and benefit with MT covers considerations that are not entirely medically established. This highlights the importance of a trustful dialogue and shared decision making between patient and health care provider in order to increase adherence.

ANESTHESIA OR SEDATION OF NEWBORNS IN INTENSIVE CARE: HOW TO DETERMINE THE OPTIMAL WAY?

During their stay in the intensive care unit, newborns are subjected to an enormous number of painful procedures and operations. Poorly treated pain during the newborn period can lead to negative remote effects such as cognitive dysfunction, the formation of chronic pain. Therefore, every day reanimatologists accept the challenge to evaluate the pain adequately and to choose right analgesia tactics. The literature review represents the analysis of 87 literary sources over the past 10 years. This article covers the results of multicenter studies and clinical recommendations. It has been determined that optimal treatment of pain and anxiety in newborns requires a multimodal approach, always including non-medication strategies and directed primarily to analgesia. Placing on the chest and breastfeeding, sucking reflex, «skin to skin» contact, «kangaroo» care, swaddling – all these aspects of childcare are effective to reduce physiological and behavioural response to pain in invasive procedures, and also have sedative effect. Every manipulation requires a mandatory analgesic. The choice of the method of anesthesia depends on the invasiveness of the procedure, gestational age and the severity of the condition of the child. It is advisable to combine various non-medication analgesic methods for mild pain, to add medication methods for moderate and severe pain to achieve better therapeutic effect. Neonates who are on prolonged ventilation cannot avoid sedation. However, sedation can be achieved by a combination of non-medication methods and sedatives. In order to prevent tachyphylaxis, analgesics should be rotated, and combinations of opiates with non-narcotic analgesics and adjuvant analgesics should be used. The multimodal approach to pain treatment has the benefits of reducing the dosage of any single drug and mitigating the overall risk of side effects. Acetaminophen, fentanyl or morphine in combination with midazolam are the safest medicines for use in newborns, despite the side effects.

Mediterranean and a posteriori prudent diets are associated with low circulating 3-hydroxylated fatty acids, a proxy of lipopolysaccharide (LPS) burden

Rationale: Lipopolysaccharide (LPS)-type endotoxins, released by Gram-negative bacteria naturally found in the gut microbiota, are recognized as triggers of inflammation and emerge as detrimental factors of healthy ageing. Nutrition represents a promising non-medical strategy to reduce the LPS burden.

116. WHERE DO PEDIATRIC TRAINEES LEARN ABOUT BEHAVIORAL AND MENTAL HEALTH CONDITIONS?

Background/Objectives Although the development and behavior rotation (DBR) aimed to provide pediatric trainees with more experience in caring for children with behavioral and mental health (B/MH) conditions, gaps in B/MH training remain. This national study described the settings in which residents receive training in the assessment and treatment of B/MH problems Methods Cross-sectional survey of applicants for the initial American Board of Pediatrics certifying exam in pediatrics. Respondents rated where they received training in 7 B.M. assessment skills (eliciting parental MH concerns; using screening tools to identify MH concerns; using disorder specific rating scales to help with diagnosis; diagnosing ADHD, anxiety, or depression using DSM-V criteria; and assessing suicidality) and 9 treatment skills (using evidence-based communication strategies to engage patients in treatment; behavioral management counseling; non-medication strategies for ADHD or depression/anxiety; dosing ADHD or depression medications; titrating medications; safety counseling; and co-management with MH specialists). Response options included continuity clinic, DBR, adolescent rotation, subspecialty rotations, child psychiatry rotation, other elective/longitudinal rotation, and/or no training in the skill. Descriptive statistics analyzed these data. Results 62.3% responded to the survey (n=2,086) with an average age of 31.3 years, 73.5% were female, and 60.1% were white. There were no differences in demographics between respondents and non-responders. Respondents reported receiving B/MH training in several settings, with continuity clinic being the predominant training location for all assessment (79%) and treatment (74%) skills. Respondents reported that their DBR was the next most common training setting, followed by adolescent medicine. However, for most skills, less than 50% of respondents reported receiving training in these settings. Across all assessment skills, less than 15% of respondents reported receiving training in other settings, including child psychiatry. Conclusions The majority of learning to care for children with B/MH conditions is in continuity clinic. Efforts must be made to ensure that this learning environment provides teaching with knowledgeable role models.

The Importance of Belonging to a Context: A Nurse-Led Lifestyle Intervention for Adult Persons with ADHD

Living with attention deficit hyperactivity disorder (ADHD) and mental illness involves an increased risk of lifestyle-related diseases. Although there are several ways to provide support to adult persons with ADHD, there is a lack of non-medical strategies for this purpose. This study explore how adult persons with ADHD with mental illness experienced taking part in a nurse-led lifestyle intervention. Fifteen participants participated in a 52-week lifestyle intervention. The analysis revealed two main categories; Building trusting relationships and Health together. This nurse-led lifestyle intervention could be an alternative or complement to current approaches to promoting health in adults with ADHD.

Effect of 12 Weeks of Aerobic Training on Liver Enzymes, Thyroid Hormones, and Anthropometric Indices of Obese Children

Background: Fatty liver is one of the chronic liver disorders associated with lipid accumulation in hepatocytes. Hypothyroidism deficiency has been identified as a factor for non-alcoholic fatty liver development due to its important role in fat metabolism. Objectives: This study was conducted to determine the effects of aerobic exercise on non-alcoholic fatty liver disease, hypothyroidism, and anthropometric indices. Methods: Twenty-four obese children were randomly divided into two groups of control (n = 12) and experiment (n = 12). Aerobic exercise was done for 12 weeks. Before and after the training period, we measured the levels of liver enzymes (ALP, AST, and ALT), thyroid hormones (T3, T4, and TSH), and several key anthropometric indices. Liver ultrasonography was done, as well. Results: Aerobic training for 12 weeks significantly reduced the levels of thyroid hormones TSH (P = 0.023) and T4 (P = 0.002), liver enzymes ALT (P = 0.002), AST (P = 0.003), and ALP (P = 0.047), and anthropometric indices BMI (P = 0.001) and WC (P = 0.043) and increased the level of T3 (P = 0.011) in the experimental group. Conclusions: Aerobic training is recommended as a weight control intervention for obese children. It can provide a non-medical strategy in the treatment of NAFLD and hypothyroidism.

Root Cause Analysis to Identify Medication and Non-Medication Strategies to Prevent Infection-Related Hospitalizations from Australian Residential Aged Care Services.

Infections are leading causes of hospitalizations from residential aged care services (RACS), which provide supported accommodation for people with care needs that can no longer be met at home. Preventing infections and early and effective management are important to avoid unnecessary hospital transfers, particularly in the Australian setting where new quality standards require RACS to minimize infection-related risks. The objective of this study was to examine root causes of infection-related hospitalizations from RACS and identify strategies to limit infections and avoid unnecessary hospitalizations. An aggregate root cause analysis (RCA) was undertaken using a structured local framework. A clinical nurse auditor and clinical pharmacist undertook a comprehensive review of 49 consecutive infection-related hospitalizations from 6 RACS. Data were collected from nursing progress notes, medical records, medication charts, hospital summaries, and incident reports using a purpose-built collection tool. The research team then utilized a structured classification system to guide the identification of root causes of hospital transfers. A multidisciplinary clinical panel assessed the root causes and formulated strategies to limit infections and hospitalizations. Overall, 59.2% of hospitalizations were for respiratory, 28.6% for urinary, and 10.2% for skin infections. Potential root causes of infections included medications that may increase infection risk and resident vaccination status. Potential contributors to hospital transfers included possible suboptimal selection of empirical antimicrobial therapy, inability of RACS staff to establish on-site intravenous access for antimicrobial administration, and the need to access subsidized medical services not provided in the RACS (e.g., radiology and pathology). Strategies identified by the panel included medication review, targeted bundles of care, additional antimicrobial stewardship initiatives, earlier identification of infection, and models of care that facilitate timely access to medical services. The RCA and clinical panel findings provide a roadmap to assist targeting services to prevent infection and limit unnecessary hospital transfers from RACS.

Blood Pressure Control Behaviors and Control Rate and Socioeconomic Status in Chinese Adult Hypertensives in 2013

Background: Hypertension has reached an epidemic proportion in China but is often sub-optimally controlled. Sufficient engagement in BP-lowering strategies can result in effective BP control. However, studies about the pattern of self-management practices and the contribution of antihypertensive strategies to BP control quality by further considering the role of socioeconomic factors in Chinese hypertensive population using nationwide representative data were incompletely investigated. Methods: We used data from a national representative survey which sampled 177,099 adults aged ≥18 in mainland China in 2013-2014. A total of 31,714 diagnosed hypertensives were included in the analyses. Information regarding general characteristic, history of chronic diseases, and profiles of self-care behaviors was collected by questionnaire-based interview. Laboratory tests and physical measurements were undertaken on each participant. The prevalence of BP control behaviors and BP control rate were examined overall and by several SES factors. Rao-Scott chi-square tests were used for comparisons between subgroups. A Venn diagram was used to present the distribution and overlap of behaviors. Findings: 72·9% reported consistent adherence to medication, 12·9% exhibited non-adherence to medication, 21·6% reported adopting lifestyle modifications, 16·0% reported BP monitoring, 8·1% did not use any strategies, and 2·1% reported seeking other agents. People who took medications consistently were more likely to adopt non-pharmaceutical strategies than those who did not adhere to prescription. Those who were older, being higher income and education levels, had urban residency and being widowed/separated status were more likely to use combined medication and non-medication strategies. Consistent medication generated a control rate of 29·3%, higher than occasional medication (24·4%) and lifestyle modification (26·4%). Lifestyle changes worked a little better than taking no measures (26·4% vs· 26·1%). Poor medication adherence worked even worse than taking no measures (24·4% vs. 26·1%), and consistent medication paired with non-pharmacological agents worked better than any single treatment. Socioeconomic status such as age, gender, marital status and geographical region remained confounding factors in terms of causality between strategies and BP control quality. Interpretation: Population-based health education programs and SES-considered interventions were needed to encourage better engagement in prescribed treatment and combined strategies to help address unfavorable BP control profiles. Funding Statement: National Key Research and Development Project (2018YFC1313904). Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: The study protocol was approved by the ethical committee of the Chinese Center for Disease Control and Prevention. All study participants were informed and signed a written consent.

Incontinentia pigmenti burden scale: designing a family burden questionnaire

BackgroundIncontentia pigmenti (IP) is a rare multisystem disorder of ectodermal origin comprising skin, dental, ocular and central nervous system features. Symptomatic treatments are adapted to each family according to the patient’s disability. Due to its rarity, the family IP burden in its broadest sense (psychological, social, economic and physical) has not yet been evaluated.AimTo design a questionnaire allowing assessing the family burden of IP (F’BoIP).MethodA questionnaire was developed using a standardized methodology for designing quality of life questionnaires according to the following steps: conception, development, and validation. A multidisciplinary working group was designed, including experts in questionnaire development, dermatologists specialised in IP patient care and representatives of the French IP association. A cultural and linguistic validation into US English was conducted, based on the original French version.ResultsA 20-item conceptual questionnaire was generated. Subsequent confirmatory analyses produced a 20-item questionnaire grouped into four domains, demonstrating internal consistency (Cronbach’s alpha: 0.93), reproducibility and high reliability. The F’BoIP questionnaire significantly correlated with other validated questionnaires: Family Dermatology Life Quality Index (F-DLQI), Perceived Stress Scale (PSS) and SF-12 mental and SF12 physical scores, indicating good external validity.ConclusionThe F’BoIP questionnaire is the first specific tool to assess the family burden of IP and can be used by both family members of IP patients and by health care professionals. It is a valuable tool which evaluates medical and nonmedical strategies to improve the daily life of families affected by this orphan disease.

Non-Medical Strategies to Improve Pregnancy Outcomes of Women with Gestational Diabetes Mellitus: A literature review

This review aimed to examine the literature related to non-medical strategies used to improve pregnancy outcomes of women with gestational diabetes mellitus (GDM) and to determine the risk of bias of the selected studies. Treatment for GDM is changing due to the increased prevalence of GDM-related maternal and neonatal complications. A growing body of evidence suggests that early detection, aggressive monitoring and management of GDM using non-medical strategies can greatly improve outcomes for pregnant women and their babies. PubMed® (National Library of Medicine, Bethesda, Maryland, USA), Cumulative Index to Nursing and Allied Health Literature® (EBSCO Information Services, Ipswich, Massachusetts, USA), SCOPUS® (Elsevier, Amsterdam, Netherlands) and other electronic databases were searched for relevant literature published between 2005–2015. A total of 15 studies on women with GDM that met the inclusion criteria were included in this review and assessment of risk of bias was performed for each study. The results of the studies were consistent with findings of significant improvement in maternal and neonatal outcomes when diet was combined with moderate exercise, self-monitoring of blood glucose and individualised health education. Future intervention studies in this area should be focussed on identifying and implementing factors that enhance and encourage adherence to the healthy behaviours mentioned above.

Aerobic exercise can modulate the underlying mechanisms involved in the development of diabetic complications.

Diabetes mellitus is a highly prevalent metabolic disorder that affects many molecular pathways, causing a shift from a physiologic to a pathophysiologic state. Alterations in the molecular pathways promote diabetic complications and, thus, many medical and nonmedical therapies have been directed at preventing these complications. Despite the beneficial effects on moderating glycemic control, medical therapies may also have unfavorable side effects. This makes nonmedical therapeutic approaches more attractive due to lower pharmacological side effects of these strategies compared to medical agents. Aerobic exercise is now considered as a major nonmedical strategy that can promote beneficial and protective effects to counteract the development of diabetic complications via attenuation of the major molecular mechanisms involved in diabetes.

An observational study of pain self-management strategies and outcomes: does type of pain, age, or gender, matter?

Background and aims Acute pain is differentiated from chronic pain by its sudden onset and short duration; in contrast, chronic pain is characterized by a duration of at least several months, typically considered longer than normal healing time. Despite differences in definition, there is little information on how types of self-management strategies or outcomes differ when pain is chronic rather than acute. Additionally, age and gender are thought to be related to types of strategies used and outcomes. However, strategies used and outcomes can be influenced by level of education, socioeconomic status, occupation, and access to the health care system, which can confound associations to type of pain, age or gender. The purpose of this study was to examine the association of strategies used for pain self-management and outcomes with type of pain, acute or chronic, age, or gender in a socioeconomically homogenous population, pharmacists. Methods Pharmacists with acute or chronic pain and a valid email completed an on-line questionnaire on demographic characteristics, pain characteristics, pharmacological and non-pharmacological strategies for managing pain, and outcomes (e.g. pain intensity). Univariate analysis was conducted by stratifying on type of pain (acute or chronic), then stratifying on gender (men vs. women) and age (younger vs. older). The a priori alpha level was 0.05. Results A total of 366 pharmacists completed the questionnaire, 212 with acute pain (average age=44±12.1; 36% men) and 154 with chronic pain (average age=53±14.0; 48% men). The chronic pain group reported substantially higher levels of pain before treatment, level of post-treatment pain, level of pain at which sleep was possible, and goal pain levels (effect sizes [ES's]=0.37-0.61). The chronic pain group were substantially more likely to use prescription non-steroidal anti-inflammatory medications (NSAIDS), opioids, and non-prescription pain relievers (ES's=0.29-0.80), and non-medical strategies (ES's=0.56-0.77). Participants with chronic pain also were less confident (ES=0.54) and less satisfied (ES=0.52). In contrast, there were no differences within either the acute or chronic pain groups related to gender and outcomes. In the acute pain group, there also were no gender differences related to management strategies. However, younger age in the acute pain group was associated with use of herbal remedies and use of rest. Within the chronic pain group, men were more likely to use NSAIDS and women more likely to use hot/cold packs or massage while older participants were more likely to use massage. Variability in post-treatment level of pain and percent relief was high in all groups (coefficient of variation=25%-100%). Conclusions The differences between acute and chronic pain were substantial and included differences in demographic characteristics, pain characteristics, management strategies used, and outcomes. In contrast, few associations between age and gender with either management strategies or outcomes were identified, although the variability was high. Implications When managing or researching pain management, acute pain should be differentiated from chronic pain. Because of the substantial variability within the gender and age groups, an individual approach to pain management irrespective of age and gender may be most useful.

Prevalence and course of lower limb disease activity and walking disability over the first 5 years of juvenile idiopathic arthritis: results from the childhood arthritis prospective study.

ObjectiveThe aim was to investigate the time course of lower limb disease activity and walking disability in children with JIA over a 5-year course.MethodsThe Childhood Arthritis Prospective Study is a longitudinal study of children with a new JIA diagnosis. Childhood Arthritis Prospective Study data include demographics and core outcome variables at baseline, 6 months and yearly thereafter. Prevalence and transition rates from baseline to 5 years were obtained for active and limited joint counts at the hip, knee, ankle and foot joints; and walking disability, measured using the Childhood Health Assessment Questionnaire walking subscale. Missing data were accounted for using multiple imputation.ResultsA total of 1041 children (64% female), with a median age of 7.7 years at first visit, were included. Baseline knee and ankle synovitis prevalence was 71 and 34%, respectively, decreasing to 8–20 and 6–12%, respectively, after 1 year. Baseline hip and foot synovitis prevalence was <11%, decreasing to <5% after 6 months. At least mild walking disability was present in 52% at baseline, stabilizing at 25–30% after 1 year.ConclusionLower limb synovitis and walking disability are relatively common around the time of initial presentation in children and young people with JIA. Mild to moderate walking disability persisted in ∼25% of patients for the duration of the study, despite a significant reduction in the frequency of lower limb synovitis. This suggests that there is an unmet need for non-medical strategies designed to prevent and/or resolve persistent walking disability in JIA.

Staff and patient accounts of PRN medication administration and non-pharmacological interventions for anxiety.

Most psychiatric inpatients will receive psychotropic PRN medication during their hospital stay for agitation, anxiety, and/or insomnia. While helpful in some cases, caution is warranted with regard to PRN use due to inherent risks of additional medication; therefore, experts advise that non-pharmacological interventions should be attempted first where indicated. However, research to date highlights that, in practice, non-pharmaceutical approaches are attempted in a minority of cases. While some information is known about the practice of PRN administration and the use of and barriers to implementing non-pharmacological interventions for treating acute psychiatric symptoms, full understanding of this practice is hampered by poor or altogether missing documentation of the process. This study used interviews with patients and staff from two psychiatric hospitals to collect first-person accounts of administering PRN medication for anxiety, thereby addressing the limitations of relying on documented notation found in previous research. Our results indicate that nurses are engaging in non-pharmacological interventions more often than had previously been captured in research. However, the types of strategies suggested are not typically evidence based and further, only happening approximately half the time. The barriers to providing such care are centred on two main beliefs about client choice and efficacy of these non-medical strategies. Implications for research and practice are discussed.

Current Treatment Options: Headache Related to Menopause-Diagnosis and Management.

Menopause is a life-changing event in numerous ways. Many women with migraine hold hope that the transition to the climacteric state will coincide with a cessation or improvement of migraine. This assumption is based mainly on common lay perceptions as well as assertions from many in the healthcare community. Unfortunately, evidence suggests this is far from the rule. Many women turn to a general practitioner or a headache specialist for prognosis and management. A natural instinct is to manipulate the offending agent, but in some cases, this approach backfires, or the concern for adverse events outweighs the desire for a therapeutic trial, and other strategies must be pursued. Our aim was to review the frequency and type of headache syndromes associated with menopause, to review the evidence for specific treatments for headache associated with menopause, and to provide management recommendations and prognostic guidance. We reviewed both clinic- and population-based studies assessing headache associated with menopause. Headache in menopause is less common than headache at earlier ages but can present a unique challenge. Migraine phenotype predominates, but presentations can vary or be due to secondary causes. Other headache types, such as tension-type headache (TTH) and cluster headache (CH) may also be linked to or altered by hormonal changes. There is a lack of well-defined diagnostic criteria for headache syndromes associated with menopause. Women with surgical menopause often experience a worse course of disease status than those with natural menopause. Hormonal replacement therapy (HRT) often results in worsening of migraine and carries potential for increased cardiovascular and ischemic stroke risk. Estrogen replacement therapy (ERT) in patients with migraine with aura (MA) may increase the risk of ischemic stroke; however, the effect is likely dose-dependent. Some medications used in the prophylaxis of migraine may be useful in ameliorating the vasomotor and mood effects of menopause, including venlafaxine, escitalopram, paroxetine, and gabapentin. Other non-medication strategies such as acupuncture, vitamin E, black cohosh, aerobic exercise, and yoga may also be helpful in reducing headache and/or vasomotor symptoms associated with menopause. The frequency and type of headache associated with menopause is variable, though migraine and TTH are most common. Women may experience a worsening, an improvement, or no change in headache during the menopausal transition. Treatment may be limited by vascular risks or other medical and psychiatric factors. We recommend using medications with dual benefit for migraine and vasomotor symptoms including venlafaxine, escitalopram, paroxetine, and gabapentin, as well as non-medication strategies such as acupuncture, vitamin E, black cohosh, aerobic exercise, and yoga. If HRT is pursued, continuous (rather than cyclical) physiological doses should be used, transdermal route of administration is recommended, and the patient should be counseled on the potential for increased risk of adverse events (AEs). Concomitant use of a progestogen decreases the risk of endometrial hyperplasia with ERT. Biological mechanisms are incompletely understood, and there is a lack of consensus on how to define and classify headache in menopause. Further research to focus on pathophysiology and nuanced management is desired.