Prolonged Restraint Research Articles

The relationship between patient safety culture and adverse events: A questionnaire survey

BackgroundPatient safety culture is an important factor in the effort to reduce adverse events in the hospital and improve patient safety. A few studies have shown the relationship between patient safety culture and adverse events, yet no such research has been reported in China. ObjectivesThis study aimed to describe nurses’ perception of patient safety culture and frequencies of adverse events, and examine the relationship between them. DesignThis study was a descriptive, correlated study. Setting and participantsWe selected 28 inpatient units and emergency departments in 7 level-3 general hospitals from 5 districts in Guangzhou, China, and we surveyed 463 nurses. MethodsThe Hospital Survey on Patient Safety Culture was used to measure nurses’ perception of patient safety culture, and the frequencies of adverse events which happened frequently in hospital were estimated by nurses. We used multiple logistic regression models to examine the relationship between patient safety culture scores and estimated frequencies of each type of adverse event. ResultsThe Positive Response Rates of 12 dimensions of the Hospital Survey on Patient Safety Culture varied from 23.6% to 89.7%. There were 47.8–75.6% nurses who estimated that these adverse events had happened in the past year. After controlling for all nurse related factors, a higher mean score of “Organizational Learning-Continuous Improvement” was significantly related to lower the occurrence of pressure ulcers (OR=0.249), prolonged physical restraint (OR=0.406), and complaints (OR=0.369); a higher mean score of “Frequency of Event Reporting” was significantly related to lower the occurrence of medicine errors (OR=0.699) and pressure ulcers (OR=0.639). ConclusionsThe results confirmed the hypothesis that an improvement in patient safety culture was related to a decrease in the occurrence of adverse events.

Development and refinement of a technique for short-term intravascular auricular vein catheter placement in mature sows

Intravenous drug administration in adult swine is difficult to perform due to inaccessible superficial veins and thick subcutaneous fat layers. However, successful intravenous drug administration is critical for many biomedical applications including pharmacokinetic studies as extravascular drug administration can influence the drug's absorption and elimination rate. The purpose of this study was to develop and refine an effective technique for indwelling auricular vein catheter placement in the conscious mature sow. We developed a protocol using a topical anesthetic cream and minimal physical restraint to place indwelling catheters in the auricular vein of six multiparous sows. This method was quick (3 min 20 s ± 8 s [mean ± SE per catheter]), effective (11/12 catheters successfully placed) and reliable, allowing a large drug volume (20-22 mL) to be administrated successfully during the trial without relying on prolonged restraint or general anesthesia of the sow.

The effects of ryanodine receptor 1 (RYR1) mutation on plasma cytokines and catecholamines during prolonged restraint in pigs

In the current study, plasma cytokines, including interleukin (IL) 1, IL-2, IL-6, IL-10, IL-12, interferon-γ (IFN-γ) and tumor necrosis factor-α (TNF-α) and catecholamines (adrenaline and noradrenaline) were evaluated during 4h restraint and recovery phase in 60 male pigs. Blood samples were collected from three groups of pigs representing different RYR1 genotypes, namely NN homozygotes (wild-type), Nn heterozygous and nn homozygous (mutant). The 4h restraint evoked an increase in plasma cytokine concentrations in each of the RYR1 genotype groups. During the restraint, the greatest concentrations of plasma IL-6, IL-10, IL-12 and TNF-α in nn homozygous pigs and IFN-γ in NN homozygous were observed. Interleukin 1, IL-2, IL-10, and TNF-α measures were positively intercorrelated in each of the three RYR1 genotype group. A positive correlation was seen between all measured cytokines (with the exception of IL-6) and plasma catecholamine concentrations in Nn heterozygous and nn homozygous pigs. The results suggest that of the cytokine parameters evaluated, IL-6, IL-10, IL-12 and TNF-α of the nn homozygous group seem to show a stronger stress-related response as compared with those of the other two (NN and Nn) groups.

Natural killer cell cytotoxicity, cytokine and neuroendocrine responses to opioid receptor blockade during prolonged restraint in pigs

This study evaluated porcine natural killer cell cytotoxicity (NKCC), plasma cytokines including interleukin (IL) 1β, IL-6, IL-10, IL-12 and tumor necrosis factor-α and plasma stress-related hormones including prolactin (PRL), growth hormone (GH), β-endorphin (BEND), ACTH and cortisol (COR) during a 4h restraint and recovery phase after saline or naloxone (1mg/kg BW) administration. The restraint preceded with saline altered NKCC and IL-12 concentration (an early from15 to 60min increase followed by a decrease) and increased other measured cytokines and hormones concentrations. Naloxone pretreatment blocked the suppressive effects of the restraint on NKCC and IL-12 and altered IL-10, IL-6, TNF-α, PRL and ACTH concentrations. Furthermore, in naloxone-injected pigs, a positive correlation was found between NKCC and all measured cytokines (with the exception of IL-6) and BEND, ACTH and COR. Results suggest that naloxone-sensitive opioid pathways could influence the mechanisms underlying the immune system (including NKCC) response during stress.

Probiotic Lactobacillus reuteri Attenuates the Stressor-Enhanced Severity of Citrobacter rodentium Infection

Stressor exposure has been shown to enhance host susceptibility and the severity of a plethora of illnesses, including gastrointestinal disease. In mice, susceptibility to Citrobacter rodentium has been shown to be dependent on host genetics as well as the composition of the intestinal microbiota, but the effects of stressor exposure on this gastrointestinal pathogen have not been elucidated fully. Previously, our lab showed that exposure to the prolonged-restraint stressor prior to a challenge with C. rodentium alters the intestinal microbiota community structure, including a reduction of beneficial genera such as Lactobacillus, which may contribute to stressor-enhanced C. rodentium-induced infectious colitis. To test the effects of stressor exposure on C. rodentium infection, we exposed resistant mice to a prolonged-restraint stressor concurrent with pathogen challenge. Exposure to prolonged restraint significantly enhanced C. rodentium-induced infectious colitis in resistant mice, as measured by increases in colonic histopathology, colonic inflammatory mediator gene production, and pathogen translocation from the colon to the spleen. It was further tested if the beneficial bacterium Lactobacillus reuteri could reduce the stressor-enhanced susceptibility to C. rodentium-enhanced infectious colitis. While L. reuteri treatment did not reduce all aspects of stressor-enhanced infectious colitis, it did significantly reduce pathogen translocation from the colon to the spleen. Taken together, these data demonstrate the deleterious effects that prolonged stressor exposure can have at the onset of a gastrointestinal infection by its ability to render a resistant mouse highly susceptible to C. rodentium. Probiotic treatment ameliorated the systemic manifestations of stress on colonic infection.

Concomitant docosahexaenoic acid administration ameliorates stress-induced cognitive impairment in rats

Long chain n-3 fatty acids, especially eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) may slow cognitive decline. DHA plays an important role in neural function and decreased plasma DHA are associated with cognitive decline in healthy elderly adults and in patients with Alzheimer's disease. In this study we tested a hypothesis that DHA protects cognitive functions of male Wistar rats against negative impact of prolonged restraint stress. Specifically, we attempted to characterize the preventive action of prolonged treatment with DHA enriched preparation (daily dose of DHA: 300mg/kg, p.o. for 21days) in comparison with positive control (fluoxetine: 10mg/kg daily, p.o. for 21days) against an impairment caused by chronic restraint stress (2h daily for 21days) on recognition memory tested in a object recognition task and on the spatial working memory tested in Morris water maze. We found that administration of DHA enriched preparation prevented deleterious effects of chronic restraint stress both on recognition (p<0.01) and on the working spatial memory (p<0.001).

Prolonged Restraint Stress Increases IL-6, Reduces IL-10, and Causes Persistent Depressive-Like Behavior That Is Reversed by Recombinant IL-10

Altered inflammatory cytokine profiles are often observed in individuals suffering from major depression. Recent clinical work reports on elevated IL-6 and decreased IL-10 in depression. Elevated IL-6 has served as a consistent biomarker of depression and IL-10 is proposed to influence depressive behavior through its ability to counterbalance pro-inflammatory cytokine expression. Clinical and animal studies suggest a role for IL-10 in modifying depressive behavior. Murine restraint stress (RST) is regularly employed in the study of behavioral and biological symptoms associated with depressive disorders. While responses to acute RST exposure have been widely characterized, few studies have examined the ongoing and longitudinal effects of extended RST and fewer still have examined the lasting impact during the post-stress period. Consistent with clinical data, we report that a protocol of prolonged murine RST produced altered cytokine profiles similar to those observed in major depressive disorder. Parallel to these changes in circulating cytokines, IL-10 mRNA expression was diminished in the cortex and hippocampus throughout the stress period and following cessation of RST. Moreover, chronic RST promoted depressive-like behavior throughout the 28-day stress period and these depressive-like complications were maintained weeks after cessation of RST. Because of the correlation between IL-10 suppression and depressive behavior and because many successful antidepressant therapies yield increases in IL-10, we examined the effects of IL-10 treatment on RST-induced behavioral changes. Behavioral deficits induced by RST were reversed by exogenous administration of recombinant IL-10. This work provides one of the first reports describing the biological and behavioral impact following prolonged RST and, taken together, this study provides details on the correlation between responses to chronic RST and those seen in depressive disorders.

India's Nuclear Odyssey: Implicit Umbrellas, Diplomatic Disappointments, and the Bomb

Why did India merely flirt with nuclear weapons in the 1960s and 1970s only to emerge as a nuclear power in the 1990s? Although a variety of factors informed India's prolonged restraint and subsequent breakthrough, new evidence indicates that India's “nuclear odyssey” can be understood as a function of Indian leaders' ability to secure their country through nonmilitary means, particularly implicit nuclear umbrellas and international institutions. In the 1960s and 1970s, India was relatively successful in this regard as it sought and received implicit support from the superpowers against China. This success, in turn, made acquiring the bomb a less pressing question. At the end of the Cold War, however, nonmilitary measures ceased to be viable for India. In the late 1980s, waning Soviet support and the failure of Rajiv Gandhi's diplomatic initiatives led to the creation of India's de facto nuclear arsenal. In the 1990s, India developed a more overt capability, not simply because the pro-bomb Bharatiya Janata Party came to power, but also because its external backing had vanished and because its efforts to improve its security through diplomacy proved unsuccessful.

Effect of seated restraint and body size on lung function

Previous studies of death during law enforcement restraint have focused on lying restraint positions; this study extends this work to seated restraint positions. Lung function in a standing control position was compared with lung function in seated positions using 40 volunteers. No significant reduction in lung function was detected in an upright seated position. When participants were leant forward while seated, significant reductions in lung function occurred. The application of restraint holds in the seated, leant forward position resulted in a non-significant further reduction in lung function. Reductions in lung function were greater in those participants with higher body mass index (BMI). Seated restraint positions with the person leant forward may increase the risk of harm or death during prolonged restraint. The risk will be further increased where the person exhibits higher BMI.

Long‐Term Administration of Cod Liver Oil Ameliorates Cognitive Impairment Induced by Chronic Stress in Rats

Cod liver oil (CLO) is a rich source of omega-3 fatty acids (FA), especially eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). The existing data suggest that EPA and DHA are the active agents of fish oil. In this study, we tested a hypothesis that the active constituents of CLO alleviate the negative impact of prolonged restraint stress on cognitive functions of male Wistar rats. Specifically, we attempted to characterize the preventive action of long-lasting treatment with CLO [0.375 ml/100 g body weight (equivalent to a dose of 300 mg/kg DHA and 225 mg/kg EPA), p.o. for 21 days] against an impairment caused by chronic restraint stress (2 h daily for 21 days) on recall as tested in a passive avoidance situation and on the spatial reference and working memory tested in a Barnes maze as well as on locomotor activity and anxiety behavior tested respectively in an open field and elevated plus-maze. We found that CLO administration statistically significantly (p < 0.01, both) prevented the deleterious effects of chronic restraint stress on recall and the spatial memory.

Stressor Exposure Disrupts Commensal Microbial Populations in the Intestines and Leads to Increased Colonization by Citrobacter rodentium

The gastrointestinal tract is colonized by an enormous array of microbes that are known to have many beneficial effects on the host. Previous studies have indicated that stressor exposure can disrupt the stability of the intestinal microbiota, but the extent of these changes, as well as the effects on enteric infection, has not been well characterized. In order to examine the ability of stressors to induce changes in the gut microbiota, we exposed mice to a prolonged restraint stressor and then characterized microbial populations in the intestines using both traditional culture techniques and bacterial tag-encoded FLX amplicon pyrosequencing (bTEFAP). Exposure to the stressor led to an overgrowth of facultatively anaerobic microbiota while at the same time significantly reducing microbial richness and diversity in the ceca of stressed mice. Some of these effects could be explained by a stressor-induced reduction in the relative abundance of bacteria in the family Porphyromonadaceae. To determine whether these alterations would lead to increased pathogen colonization, stressed mice, as well as nonstressed controls, were challenged orally with the enteric murine pathogen Citrobacter rodentium. Exposure to the restraint stressor led to a significant increase in C. rodentium colonization over that in nonstressed control mice. The increased colonization was associated with increased tumor necrosis factor alpha (TNF-alpha) gene expression in colonic tissue. Together, these data demonstrate that a prolonged stressor can significantly change the composition of the intestinal microbiota and suggest that this disruption of the microbiota increases susceptibility to an enteric pathogen.

7. Prolonged restraint affects microbial richness in the intestines and enhances colonization by the murine pathogen Citrobacter rodentium

7. Prolonged restraint affects microbial richness in the intestines and enhances colonization by the murine pathogen Citrobacter rodentium

Fatal thromboembolic disease: A risk in physically restrained psychiatric patients

Objective Physical restraint is used in circumstances where patients exhibit behavior deemed threatening to their health and/or those around them. This practice has been associated with morbidity and mortality in the context of police custody, hospitals and long-term care facilities. While most of these events relate to short-term immobilization, the risks associated with prolonged physical restraint of psychiatric patients are largely unknown. Method A retrospective review was performed at the Provincial Forensic Pathology Unit for cases of death occurring in physically restrained psychiatric patients. Result We identified three patients who were immobilized by 4 point, 3-to-5 point and waist physical restraints. The immobilization periods ranged from 3 to 5 days. On autopsy, occlusive pulmonary thromboemboli were identified in each patient. None of the patients had previously recognized coagulopathies or significant risk factors for deep vein thrombosis. Postmortem genetic studies for Factor V and prothrombin mutations were negative. Discussion Deep vein thrombosis is likely an under recognized occurrence in physically restrained patients under psychiatric care. We propose that deep vein thrombosis and pulmonary embolism be recognized as a risk factor for prolonged physical restraint. As a result, prospective studies examining the incidence and prevention of this adverse outcome is indicated.

The Effects of Psychological Stressors on the Intestinal Microbiota

The stress response affects virtually every organ in the body and constitutes a coordinated behavioral and physiological response to potentially threatening stimuli that may be physiological or psychological in nature. There is a substantial amount of research focusing on how the stress response affects health, but relatively few studies have focused on the ability of the stress response to affect indigenous populations of bacteria in the intestines, referred to as the intestinal microbiota. Research from our lab, and from others, have demonstrated that psychological stressors early in the life span significantly changes the levels of different types of microbiota that are shed from the intestines in the stool. In our studies, stress in young rhesus monkeys, and even in the prenatal period, led to a significant reduction in the levels of lactobacilli and bifidobacteria shed in the stool. In rodents, prolonged restraint stress resulted in a significant overgrowth of aerobic microbiota, particularly Gram-negative aerobes, in the intestines. Interestingly, there is increasing evidence that alterations in the microbiota are associated with a variety of diseases that are known to be exacerbated during periods of psychological stress, including irritable bowel syndrome and the inflammatory bowel diseases. Thus, our data provide a compelling rationale to test the hypothesis that stress-induced exacerbations of intestinal diseases are in part due to stress-induced alterations of the microbiota.

Cloning of opioid receptors in common carp (Cyprinus carpio L.) and their involvement in regulation of stress and immune response

In mammals opiate alkaloids and endogenous opioid peptides exert their physiological and pharmacological actions through opioid receptors (MOR, DOR and KOR) expressed not only on neuroendocrine cells but also on leukocytes. Therefore, opioids can modulate the immune response. We cloned and sequenced all three classical opioid receptors (MOR, DOR and KOR) in common carp, and studied changes in their expression during stress and immune responses. Messenger RNA of opioid receptors was constitutively expressed in brain areas, specially in the preoptic nucleus NPO (homologous to mammalian hypothalamus). After exposure to prolonged restraint stress, mRNA levels of MOR and DOR decreased in the NPO and in the head kidney. Increased expression of all studied opioid receptors was observed in the pituitary pars distalis (containing ACTH-producing cells). In immune organs, constitutive but lower expression of opioid receptor genes was observed. During in vivo zymosan-induced peritonitis or after in vitro LPS-induced stimulation, when pro-inflammatory functions are activated, expression of the OR genes in leukocytes was concomitantly up-regulated. Additionally, specific agonists of opioid receptors especially reduced leukocyte migratory properties, manifested by reduced chemotaxis and down-regulated expression of chemokine receptors. Our data indicate an evolutionary conserved role for the opioid system in maintaining a dynamic equilibrium while coping with stress and/or infection.

Genetic differences in coping strategies in response to prolonged and repeated restraint in Japanese quail divergently selected for long or short tonic immobility

Exposure to fearful situations elicits behavioral and Hypothalamic–Pituitary–Adrenal (HPA) axis responses characteristic of the coping response of individual animals to counteract environmental challenges. The aim of this study was to investigate behavioral and corticotropic responses concomitantly following prolonged or repeated restraint stress by placing two genotypes of Japanese quail divergently selected for long (LTI) or short (STI) duration of tonic immobility (TI) in a crush cage. In our study, STI quail exhibited higher corticosterone (CORT) levels than LTI quail in response to prolonged restraint. STI quail struggled sooner and much more than LTI quail, and struggling behavior in STI quail progressively decreased during the course of restraint whereas LTI quail displayed very little struggling behavior in the crush cage. LTI quail are thus more likely to adopt a passive behavior coping strategy upon exposure to threat whereas STI quail behave more as active copers. The corticosterone responses shown by LTI and STI quail under restraint stress suggest that adrenocortical correlates of coping behavior in these genotypes of quail may be different from the coping styles previously described in other species. Repeated restraint slightly decreased CORT responses to stress in all experimental groups, but more markedly in male STI quail, whereas adrenal sensitivity and maximum adrenal corticosterone response capacity did not change in any group. On the other hand, neither behavioral habituation nor sensitization processes occurred in the context of repeated restraint in female and male LTI quail and female STI quail, whereas the decreases observed in some behavioral responses were interpreted to be the result of a habituation process in male STI quail.

Medical Ethics and the Interrogation of Guantanamo 063

The controversy over abusive interrogations of prisoners during the war against terrorism spotlights the need for clear ethics norms requiring physicians and other clinicians to prevent the mistreatment of prisoners. Although policies and general descriptions pertaining to clinical oversight of interrogations in United States' war on terror prisons have come to light, there are few public records detailing the clinical oversight of an interrogation. A complaint by the Federal Bureau of Investigation (FBI) led to an Army investigation of an interrogation at the United States prison at Guantanamo Bay. The declassified Army investigation and the corresponding interrogation log show clinical supervision, monitoring and treatment during an interrogation that employed dogs, prolonged sleep deprivation, humiliation, restraint, hypothermia and compulsory intravenous infusions. The interrogation and the involvement of a psychologist, physician and medics violate international and medical norms for the treatment of prisoners.

Pediatric CI therapy for stroke-induced hemiparesis in young children

In this laboratory we have developed a set of techniques that randomized controlled studies and a multisite randomized controlled trial have shown can substantially reduce the motor deficit of adult patients with mild to severe chronic strokes. Equivalent results have been obtained with adult patients after traumatic brain injury and brain resection. The basic technique, termed Constraint-Induced Movement therapy or CI therapy was derived directly from basic research with monkeys with mature motor systems and with monkeys given surgical intervention either on their day of birth or prenatally by intrauterine surgical procedures. We report here the results of two randomized controlled trials of CI therapy with young children with asymmetric upper extremity motor deficits of varied etiologies from 8 months to 8 years of age in one study and with children with hemiparesis consequent to prenatal, perinatal, or early antenatal stroke from 2 to 6 years old in a second study. The procedures used with children are very similar to those used with adults and diverge simply to make the basic techniques age-appropriate. All forms of CI therapy for the upper extremity to date involve 3 main elements: (1) intensive training of the more affected extremity, (2) prolonged restraint of the less affected extremity, (3) a ‘transfer package’ of techniques to induce transfer of therapeutic gains achieved in the laboratory to the life situation. The results in children with cerebral palsy are considerably better than those obtained in adults. Marked changes were observed in the quality of movement in the laboratory scored by masked observers from videotape; actual amount of use of the more affected arm in the life situation; active range of motion; and emergence of new classes of behaviour never performed before, such as in individual cases, fine thumb-forefinger grasp, supination, and use of the more affected extremity in crawling with palmar placement and rhythmic alteration. In the second experiment, the control group, after receiving usual and customary care for 6 months, was crossed over to receive CI therapy and exhibited results that were as good as those for the children receiving CI therapy first. Retention of treatment gains was approximately 70% at 6 months after the end of treatment. For some children there was no decrement in retention while for others there was a marked drop-off. One of the important factors contributing to good retention was the compliance of parents with the recommended post-treatment regimen. When retention is poor, brush-up periods may be of value. In the first experiment children were treated for 6 hr/day for 21 consecutive days, while in the second experiment treatment occurred only on the weekdays of the 3-wk treatment period (15 days). The results were at least as good with 15 days of treatment as with 21 consecutive days, thereby allowing the protocol to be fit into the usual therapist work week and making it more practical and less expensive for clinical use. CI therapy does not make movement normal in children with cerebral palsy with asymmetric upper extremity motor disorders. However, as carried out in this laboratory, it can produce a substantial improvement in a majority of cases.

Deep venous thrombosis and pulmonary embolism following physical restraint

We describe a case of deep venous thrombosis (DVT) and pulmonary embolism (PE) following the use of physical restraint in a patient with a diagnosis of acute delusional psychotic disorder. A new case report of DVT and PE associated with prolonged physical restraint is presented. The literature on physical restraint, DVT, and PE was reviewed using a search of Medline and Psychinfo from 1966 to the present. Four other reported cases of DVT and PE were found in association with physically restrained patients. Risk of DVT and PE in association with immobilization during physical restraint may occur in spite of no pre-existing risk factors. Medical guidelines for the prevention of thrombosis following physical restraint are presented. Despite the absence of controlled trials of treatment effectiveness, the catastrophic outcome of DVT and PE warrants early and vigorous intervention in patients undergoing physical restraint.

Health policy and race equality: an illusion of progress?

February 2004 saw the report of an inquiry into the case of David 'Rocky' Bennett, an African–Caribbean with schizophrenia, who had died after prolonged physical restraint by mental health nurses. Among its recommendations the inquiry team, led by the retired judge Sir John Blofeld, called on the Government to admit to the presence throughout the National Health Service of 'institutionalized racism'.1 In his response the Secretary of State for Health, John Reid, made no such admission but he did concede that 'there is discrimination in the NHS, both direct and indirect'. Much, indeed, has been published on inequalities within the Service—affecting not only patients but also staff.2 How is it that, after two decades of race relations initiatives, the culture of the NHS remains resistant to change on these issues? Part of the answer may lie in policy process within the NHS. Two key papers in the 1980s examined the balance of power within the Service. Both Ham3 and Hunter4 concluded, from study of hospital boards, that managers seeking to do the Government's will often fought a losing battle with the conservatism of the health professions; at that time, government could only guide, not instruct. In addition, Hunter noted that the decision-making process was essentially isolated from lay input. Since those times the power structure has changed radically. Governments, frustrated by the inertia or recalcitrance of local health authorities and boards, progressively replaced the system of guidance with central mechanisms of 'command and control'. These changes were coupled with efforts to increase public participation, lay membership of health trusts and authorities being reshaped on the lines of non-executive directorships in the private sector. Such attempts at increasing lay involvement cannot, however, be rated a success. Appointments are essentially made on a personal basis, and community health councils have been replaced by a confusing network divorced from community politics or local government; the stress is on individual consumerist 'choice'. The position today is that management has been strengthened but community power remains virtually non-existent. In this paper I argue that the question of 'institutionalized racism' in the NHS has to be viewed in relation to the elites who make policy.