Current practices in managing acutely disturbed patients at three hospitals in Rio de Janeiro-Brazil: a prevalence study Are Low Doses of Antipsychotics Effective in the Management of Psychomotor Agitation? A Randomized, Rated-Blind Trial of 4 Intramuscular Interventions TREC-Rio trial: a randomised controlled trial for rapid tranquillisation for agitated patients in emergency psychiatric rooms [ISRCTN44153243] The expert consensus guideline series. Treatment of behavioral emergencies 2005. Efficacy of nonpharmacologic interventions for agitation in advanced dementia: a randomized, placebo-controlled trial. Treatment of agitation in AD Psychomotor agitation in major depressive disorder is a predictive factor of mood-switching. Nonpharmacological therapeutic techniques to decrease agitation in geriatric psychiatric patients with dementia. Antidepressants and driving ability: results from a clinical study. [Effectiveness results of olanzapine in acute psychotic patients with agitation in the emergency room setting: results from NATURA study]. World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Pharmacological Treatment of Anxiety, Obsessive-Compulsive and Post-Traumatic Stress Disorders – First Revision Patterns of pharmacological maintenance treatment in a community mental health services bipolar disorder cohort study (SIN-DEPRES). Mortality among patients with non-affective functional psychoses in a metropolitan area of south-eastern Brazil. Pharmaceutical care program for elderly patients with uncontrolled hypertension. The PRIME North America randomized double-blind clinical trial of olanzapine versus placebo in patients at risk of being prodromally symptomatic for psychosis: II. Baseline characteristics of the “prodromal” sample Impact of non-pharmacological interventions on prevention and treatment of delirium in critically ill patients: protocol for a systematic review of quantitative and qualitative research Impact of a Low-Cost and Simple Intervention in Enhancing Treatment Adherence in a Brazilian Asthma Sample
Background The medical management of aggressive and violent behaviour is a critical situation for which there is little evidence . In order to prepare for a r and omised trial , due to start in the psychiatric emergency rooms of Rio de Janeiro in 2001 , a survey of current practice was necessary . Methods A seven day survey of pharmacological management of aggressive people with psychosis in the emergency rooms of all four public psychiatric hospitals in Rio de Janeiro , Brazil . Results In one hospital data were not available . Of the 764 people with psychosis attending these ERs , 74 were given IM medication for rapid tranquillisation ( 9.7 % , 2.1/week/100,000 ) . A haloperidol-promethazine mix ( with or without other drugs ) was used for the majority of patients ( 83 % ) . Conclusion The haloperidol-promethazine mix , given intramuscularly for rapid tranquilization , is prevalent in Rio , where it is considered both safe and efficient . However , scientific evaluation of all pharmacological approaches to rapid tranquilization of psychotic people is inadequate or incomplete and a r and omized trial of IM haloperidol-promethazine is overdue Background Psychomotor agitation can be associated with a wide range of medical conditions . Although clinical practice advocates the use of several drugs for the management of psychomotor agitation , there are still very few controlled studies comparing the profiles of action and the adverse effects of different drugs that induce tranquilization . Objectives The purpose of this study was to compare the efficacy and safety of 4 low-dose pharmacological interventions used to control psychomotor agitation guided by the clinical response . Methods Using a r and omized , rated-blind design , 100 agitated patients were assigned to receive 1 of 4 treatments : haloperidol ( 2.5 mg ) + promethazine ( 25 mg ) ( HLP + PMZ ) , haloperidol ( 2.5 mg ) + midazolam ( 7.5 mg ) ( HLP + MID ) , ziprasidone ( 10 mg ) ( ZIP ) , or olanzapine ( 10 mg ) ( OLP ) . Patients were evaluated just before the intervention and after 30 , 60 , and 90 minutes , using the Agitation-Calmness Evaluating Scale . Adverse effects were assessed within 24 hours after the intervention , using selected items from the UKU Scale ( Ugvalg Klinisk Undersgelser Side Effect Scale ) . According to the clinical indication , medication could be repeated twice after the first injection . Data were analyzed using general linear model with repeated measures and logistic regression . Results All treatment options promoted a reduction in agitation , without causing excessive sedation , although a lower reduction in agitation was observed with HLP + PMZ and ZIP compared with HLP + MID and OLZ . The need for an additional dose of medication was observed in 22 patients , and only 8 remained agitated during the entire 90-minute period . A higher risk for the development of extrapyramidal symptoms within the following 24 hours was observed with HLP + PMZ . Discussion Low doses of haloperidol combined with midazolam can be as effective as olanzapine in reducing psychomotor agitation without increasing the risk of extrapyramidal effects . Because of the higher risk for the occurrence of extrapyramidal symptoms , the combination of haloperidol with promethazine should be considered a second-line treatment option Background Agitated or violent patients constitute 10 % of all emergency psychiatric treatment . Management guidelines , the preferred treatment of clinicians and clinical practice all differ . Systematic review s show that all relevant studies are small and none are likely to have adequate power to show true differences between treatments . Worldwide , current treatment is not based on evidence from r and omised trials . In Brazil , the combination haloperidol-promethazine is frequently used , but no studies involving this mix exist . Methods TREC-Rio ( Tranquilização Rápida-Ensaio Clínico [ Translation : Rapid Tranquillisation- Clinical Trial ] ) will compare midazolam with haloperidol-promethazine mix for treatment of agitated patients in emergency psychiatric rooms of Rio de Janeiro , Brazil . TREC-Rio is a r and omised , controlled , pragmatic and open study . Primary measure of outcome is tranquillisation at 20 minutes but effects on other measures of morbidity will also be assessed . TREC-Rio will involve the collaboration of as many health care professionals based in four psychiatric emergency rooms of Rio as possible . Because the design of this trial does not substantially complicate clinical management , and in several aspects simplifies it , the study can be large , and treatments used in everyday practice can be evaluated OBJECTIVES Due to inherent dangers and barriers to research in emergency setting s , few data are available to guide clinicians about how best to manage behavioral emergencies . Key constructs such as agitation are poorly defined . This lack of empirical data led us to undertake a survey of expert opinion , results of which were published in the 2001 Expert Consensus Guidelines on the Treatment of Behavioral Emergencies . Several second-generation ( atypical ) antipsychotics ( SGAs ) are now available in new formulations for treating behavioral emergencies ( e.g. , intramuscular [ i.m . ] olanzapine and ziprasidone ; rapidly dissolving tablets of olanzapine and risperidone ) . Critical questions face the field . The SGAs are significantly different from the FGAs and from each other and have not been studied in unselected patients as were the FGAs . Can the SGAs can be thought of as a class , do all antipsychotics have similar anti-agitation effects in different conditions , and , if equally effective , what limits might their safety profiles impose ? Should antipsychotics be used more specifically to treat psychotic conditions , while benzodiazepines ( BNZs ) alone are used nonspecifically ? Few data are available concerning combinations of SGAs and BNZs , and findings concerning the traditional combination of haloperidol plus a BNZ may not be relevant to combinations with SGAs . The culture is also evolving with more emphasis on patient involvement in treatment decisions . An international consensus has been developing that calming rather than sedation is the appropriate endpoint of behavioral emergency interventions . We undertook a new survey of expert opinion to up date recommendations from the earlier survey . METHOD A written survey of 61 questions ( 1,020 options ) was mailed to 50 experts in the field , 48 ( 96 % ) of whom completed it . The survey sought to define level of agitation at which emergency interventions are appropriate , scope of assessment depending on urgency and patients ' ability to cooperate , guiding principles for selecting interventions , and appropriate physical and medication strategies at different levels of diagnostic confidence for a variety of provisional diagnoses and complicating conditions . A modified version of the R AND Corporation 's 9-point scale for rating appropriateness of medical decisions was used to score most options . Consensus was defined as a non-r and om distribution of scores by chi-square " goodness-of-fit " test . We assigned a categorical rank ( first line/preferred , second line/alternate , third line/usually inappropriate ) to each option based on the 95 % confidence interval around the mean . Ratings were used to develop guidelines for preferred strategies in key clinical situations . This study received financial support from multiple sponsors , with the panel kept blind to sponsorship to reduce possible bias . Medication ratings were based on responses of only those respondents with direct experience with each drug . In reporting practice patterns , the panel was asked to respond based on actual data rather than estimates . RESULTS The expert panel reached consensus on 78 % of the options rated on the 9-point scale . The responses suggest that physicians can make provisional diagnoses with some confidence and that pharmacological and nonpharmacological interventions are selected differentially based on diagnosis and other salient demographic and medical features . BNZs are recommended when no data are available , when there is no specific treatment ( e.g. , personality disorder ) , or when they may have specific benefits ( e.g. , intoxication ) . No single SGA emerges as a nonspecific replacement for haloperidol ; instead , different SGAs are preferred in various circumstances consistent with current evidence . To the degree that haloperidol is recommended , it is almost always in combination with a BNZ ; haloperidol alone is preferred only in the medically compromised . In contrast , the SGAs are more often recommended for use alone , and the panel would avoid combining BNZs with some SGAs . Oral risperidone alone or combined with a BNZ receives strong support in a variety of situations . Oral olanzapine was rated very similarly to risperidone , with slightly higher ratings than risperidone in situations where it has been studied ( e.g. , schizophrenia , mania ) and slightly lower ratings where it has not been studied or safety may be a concern ; there was less support for combining oral olanzapine with a BNZ . For oral treatment of agitation related to schizophrenia or mania , olanzapine alone , risperidone alone or combined with a BNZ , and haloperidol plus a BNZ are first line , with strong support also for combining divalproex with the antipsychotic for presumed mania . Oral ziprasidone and quetiapine generally received similar second-line ratings in most situations . If a parenteral agent is needed , i.m . olanzapine alone received somewhat more support than i.m . ziprasidone alone ; however , there was more support for i.m . ziprasidone alone or combined with a BNZ than for i.m . olanzapine plus a BNZ , probably reflecting safety concerns . For example , for a provisional diagnosis of schizophrenia , first-line parenteral options are i.m . olanzapine or ziprasidone alone or i.m . haloperidol or ziprasidone combined with a BNZ . Neither of the new parenteral formulations received as much support as traditional agents ( i.m . BNZs , i.m . haloperidol ) when no data are available or the diagnosis involves medical comorbidity or intoxication . When initial intervention with risperidone , ziprasidone , or haloperidol is unsuccessful , the panel recommended adding a BZD to the antipsychotic . However , when initial treatment with olanzapine or quetiapine is unsuccessful , increasing the dosage is recommended . Perphenazine was consistently rated second line and droperidol and chlorpromazine received third-line ratings throughout . CONCLUSIONS Within the limits of expert opinion and with the expectation that future research data will take precedence , these guidelines suggest that the SGAs are now preferred for agitation in the setting of primary psychiatric illnesses but that BNZs are preferred in other situations BACKGROUND A r and omized , placebo-controlled clinical trial was undertaken to determine the efficacy of nonpharmacologic individualized interventions ( individualized to address unmet needs such as boredom or pain ) in decreasing agitation in persons with dementia . METHOD Agitated nursing home residents with advanced dementia ( from 9 nursing homes in 5 locations in Maryl and , United States ) were r and omized into an  intervention group ( n = 89 ) and a  placebo control group ( n = 36 ) . On the basis of data from baseline assessment , a systematic methodology for individualizing nonpharmacologic interventions , Treatment Routes for Exploring Agitation ( TREA ) , was used with the intervention group : an unmet need was hypothesized , a corresponding treatment category was identified , and specifics of the treatment were chosen to fit the person 's need , past identity , preferences , and abilities . ( Unmet needs were hypothesized based on physician evaluations , structured staff interviews , relative question naires , direct observations of agitation with the Agitation Behavior Mapping Instrument [ the primary outcome measure ] and affect with Lawton 's Modified Behavior Stream [ the secondary outcome measure ] , and resident assessment s. ) TREA interventions were implemented for 2 weeks , and observations of agitation and affect were recorded . The study was conducted from June 2006 until December 2011 . RESULTS Relative to a control group , TREA interventions for unmet needs produced statistically significant declines in total ( P < .001 ) , physical nonaggressive ( P < .001 ) , and verbal agitation ( P = .004 ) and significant increases in pleasure ( P < .001 ) and interest ( P < .05 ) . CONCLUSIONS This is the first large r and omized controlled trial to demonstrate the efficacy of TREA and one of only a few such trials of nonpharmacologic interventions for agitation in persons with dementia . The translation of these findings into practice is sorely needed and would require structural changes dedicating staff time to observing each agitated resident , determining unmet needs , obtaining appropriate intervention material s , conducting the individualized nonpharmacologic interventions , and evaluating results . TRIAL REGISTRATION Clinical Trials.gov identifier : NCT00820859 Background : Treatment of agitation is a crucial problem in the care of patients with AD . Although antipsychotic and antidepressant medications and behavior management techniques ( BMT ) have each been used to treat agitation , clinical trials of these treatments have been characterized by small sample sizes and uncontrolled treatment design s. Objective : To compare haloperidol , trazodone , and BMT with placebo in the treatment of agitation in AD out patients . Methods : A total of 149 patients with AD and their caregivers participated in a r and omized , placebo-controlled , multicenter trial . Blind assessment was conducted at baseline and after 16 weeks of treatment . The three active treatments were haloperidol , trazodone , and BMT . The Alzheimer ’s Disease Cooperative Study Clinical Global Impression of Change was the primary outcome measure . Secondary outcomes included patient agitation , cognition , and function , and caregiver burden . Results : Thirty-four percent of subjects improved relative to baseline . No significant differences on outcome were obtained between haloperidol ( mean dose , 1.8 mg/d ) , trazodone ( mean dose , 200 mg/d ) , BMT , or placebo . Significantly fewer adverse events of bradykinesia and parkinsonian gait were evident in the BMT arm . No other significant difference in adverse events was seen . Symptoms did not respond differentially to the different treatments . Conclusions : Comparable modest reductions in agitation occurred in patients receiving haloperidol , trazodone , BMT , and placebo .  More effective pharmacologic , nonpharmacologic , and combination treatments are needed BACKGROUND The relationship between psychomotor agitation in unipolar depression and mood-switching from depression to manic , hypomanic and mixed states has been controversial . We investigated the future risk of initial mood-switching as a function of psychomotor agitation in unipolar depression . METHODS We identified 189 participants diagnosed with major depressive disorder ( MDD ) . We divided all patients with MDD into two categories ( 1 ) agitated patients ( n=74 ) , and ( 2 ) non-agitated patients ( n=115 ) . These groups were prospect ively followed and compared by time to mood-switching . Kaplan-Meier survival curves , log-rank test for trend for survivor functions , and Cox proportional hazard ratio estimates for a multivariate model were conducted to examine the risk of mood-switching by psychomotor agitation . RESULTS During follow-up , mood-switching occurred in 20.3 % of the agitated patients and 7.0 % of the non-agitated patients . In the Kaplan-Meier survival estimates for time to incidence of mood-switching with agitated or non-agitated patients , the cumulative probability of developing mood-switching for agitated patients was higher than those for non-agitated patients ( log-rank test : χ(2)=7.148 , df=1 , p=0.008 ) . Survival analysis was also performed using Cox proportional hazards regression within a multivariate model . The agitation remained significantly associated with incidence of mood-switching ( HR=2.98 , 95 % CI : 1.18 - 7.51 ) . LIMITATIONS We did not make a clear distinction between antidepressant-induced mood-switching and spontaneous switching . CONCLUSIONS The main finding demonstrated that MDD patients with agitation were nearly threefold as likely to experience mood-switching , suggesting that psychomotor agitation in MDD may be related to an indicator of bipolarity Agitation is not only a frequent and disturbing behavior for many patients with dementia , but it also troubles their caregivers and families . Many serious problems and side effects are associated with the use of medications to treat agitation ; therefore , alternative approaches to treating agitation must be assessed . The current article presents results from a quality improvement pilot project that examined the usefulness of a specially design ed , multisensory room intervention for geriatric psychiatric in patients with mild to moderate agitation . Thirty-two visits to the sensory room were made by 13 in patients with dementia . A significant decrease occurred in the Pittsburgh Agitation Scale ( PAS ) total scores over time from pre-room to post-room intervention , as well as 1-hour post-room intervention ( F = 95.3 , p < 0.001 ) . Significant effects were found for all PAS subscales ( i.e. , aberrant vocalizations , motor agitation , and resistance to care ) , with the exception of the aggression subscale . The multisensory room intervention was effective in decreasing some symptoms of agitation in the geriatric psychiatric patient , thus contributing to positive patient , family , and nursing outcomes OBJECTIVE Psychomotor disturbances can frequently be found in depressed patients and may have an important influence on the ability to drive . Additionally , effects of sedation , as seen with some antidepressants , probably impair driving performance . The present study was design ed to evaluate the effects of antidepressant monotherapy on psychomotor functions related to car-driving skills in depressive patients in a routine clinical setting . METHOD In patients ( N = 100 ) who met the ICD-10 and DSM-IV criteria for major depressive disorder were tested under steady-state plasma level conditions prior to being discharged to out-patient treatment . The study ran from January 2004 through March 2005 . All patients participated voluntarily and gave informed consent . According to the German guidelines for road and traffic safety , data were collected with the computerized Act & React Testsystem ART-90 and the Wiener Testsystem , measuring visual perception , reaction time , selective attention , vigilance , and stress tolerance . Psychopathologic symptoms were rated with the Hamilton Rating Scale for Depression . RESULTS Before discharge to outpatient treatment , 24 % of the patients tested were without clinical ly relevant psychomotor disturbances . In 60 % of the cases , mild to moderate impairments could be seen , and about 16 % of the patients were considered as severely impaired in psychomotor functions related to car-driving abilities . Data show that patients treated with selective serotonin reuptake inhibitors ( SSRIs ) or the noradrenergic and specific serotonergic antidepressant ( NaSSA ) mirtazapine had an altogether better test performance in comparison with patients receiving tricyclic antidepressants ( TCAs ) . Differences were most pronounced in measures of reactivity , stress tolerance , and selective attention . Statistically significant differences between patients treated with TCAs or the serotonin-norepinephrine reuptake inhibitor ( SNRI ) venlafaxine could not be found . Among the newer antidepressants there is an advantage for patients treated with mirtazapine , especially in tasks with high multi-channel perception and output dem and s. CONCLUSION About 16 % of depressive patients discharged from hospital to outpatient treatment must be considered unfit to drive . In 60 % of the cases , patients performed at a question able level of fitness for driving , and it seems justified to counsel patients individually , taking into account compensational factors . Data point to an advantage for patients treated with SSRIs or mirtazapine when compared with TCAs or venlafaxine . However , causal relationships can not be drawn from our data INTRODUCTION Patterns of use of antipsychotics are not well described in emergency units . The objective of this study was to describe the effectiveness and safety of use of olanzapine in patients with acute psychosis and agitation in the emergency rooms . METHODS In this prospect i ve observational study 278 patients with acute psychosis and agitation were consecutively admitted in 16 psychiatric emergency wards and treated with any oral psychopharmacology treatment , including olanzapine  , according to investigators clinical criteria . Data were collected prospect ively including demographics , diagnosis , concomitant medications , utilization of mechanical restraints , and severity of agitation . Clinical evolution during emergency room stay was assessed with PANSS-Excitement Component , CGI-S and Agitation and Calmness Evaluation Scale ( ACES ) at baseline , before any re-intervention ( if needed ) and at discharge from the emergency room . Safety was also evaluated . RESULTS Olanzapine alone was used in 148 ( 53.2 % ) patients . Most of them ( 77.7 % ) were diagnosed of Schizophrenia and related psychoses . Up to 38 patients ( 25.7 % ) required mechanical restraints . Mean change ( confidence interval [ CI ] 95 % ) from baseline to discharge was significant in all rating scales ; PANSS-EC : -7.46 ( -8.2 , -6.7 ) ; CGI-S : -1.82 ( -2 , -1.6 ) ACES : 1.28 ( 1.1 , 1.5 ) . At discharge 70.3 % of patients went to inpatient units . Five patients ( 3.4 % ) reported adverse events including : bradycardia , dry mouth , sedation , hypertension , hypotension , and orthostatic hypotension . None of them was serious . CONCLUSIONS The utilization of olanzapine alone decreased agitation in psychotic patients in emergency room setting s. Incidence of adverse events was low and it was well tolerated In this report , which is an up date of a guideline published in 2002 ( B and elow et al. 2002 , World J Biol Psychiatry 3:171 ) , recommendations for the pharmacological treatment of anxiety disorder , obsessive-compulsive disorder ( OCD ) and post-traumatic stress disorder ( PTSD ) are presented . Since the publication of the first version of this guideline , a substantial number of new r and omized controlled studies of anxiolytics have been published . In particular , more relapse prevention studies are now available that show sustained efficacy of anxiolytic drugs . The recommendations , developed by the World Federation of Societies of Biological Psychiatry ( WFSBP ) Task Force for the Pharmacological Treatment of Anxiety , Obsessive-Compulsive and Post-traumatic Stress Disorders , a consensus panel of 30 international experts , are now based on 510 published r and omized , placebo- or comparator-controlled clinical studies ( RCTs ) and 130 open studies and case reports . First-line treatments for these disorders are selective serotonin reuptake inhibitors ( SSRIs ) , serotonin-noradrenaline reuptake inhibitors ( SNRIs ) and the calcium channel modulator pregabalin . Tricyclic antidepressants ( TCAs ) are equally effective for some disorders , but many are less well tolerated than the SSRIs/SNRIs . In treatment-resistant cases , benzodiazepines may be used when the patient does not have a history of substance abuse disorders . Potential treatment options for patients unresponsive to st and ard treatments are described in this overview . Although these guidelines focus on medications , non-pharmacological were also considered . Cognitive behavioural therapy ( CBT ) and other variants of behaviour therapy have been sufficiently investigated in controlled studies in patients with anxiety disorders , OCD , and PTSD to support them being recommended either alone or in combination with the above medicines Maintenance therapy in bipolar disorder ( BD ) is usually required to prevent relapses and improve residual symptoms . Therefore , in this study , we describe patterns of pharmacological maintenance treatment and identify associated clinical features . This prospect i ve multicentre epidemiological study recruited a cohort of 739 consecutive out- patients with clinical ly stable BD . Clinical stability was assessed at baseline with the Clinical Global Impression scale for BD and depressive symptoms with the Hamilton Depression Rating Scale .  Psychotropic medications were classified and analysed according to their mechanism as well as use . Logistic regression models were used to examine the associations between pharmacological strategies and clinical features . Longer time since last episode [ odds ratio ( OR ) 1.002 , p < 0.0001 ] and family history of psychiatric disorders ( OR 1.911 , p = 0.028 ) were associated with lithium in monotherapy ;  manic polarity of the most recent episode ( OR 3.300 , p = 0.006 ) and longer duration of clinical stability ( OR 1.009 , p = 0.034 ) with antipsychotic in monotherapy ;  depressive polarity of the most recent episode ( OR 2.567 , p = 0.003 ) and bipolar II disorder diagnosis ( OR 2.278 , p = 0.008 ) with antidepressant combination ;  no ongoing psychiatric co-morbidity ( OR 0.230 , p = 0.004 ) with lithium and anticonvulsant ;  manic polarity of the most recent episode ( OR 3.774 , p < 0.0001 ) with lithium and antipsychotic ;  manic polarity of the most recent episode ( OR 2.907 , p = 0.028 ) with lithium , anticonvulsant and antipsychotic . The pharmacological patterns followed published recommendations , except for the excessive use of antidepressants . This study reveals clinical factors closely related to prescription patterns High mortality rates among those suffering from schizophrenia and related psychoses have been consistently described in developed societies . However , to date there is a lack of data on this matter in Brazil . In order to examine this issue , a prospect i ve 2-year follow-up study was carried out in S. Paulo . The sample consisted of 120 consecutive admissions to psychiatric hospitals in a defined catchment area , aged 18 to 44 years old , with clinical diagnoses of non-affective functional psychoses according to the ICD-9 . After 2 years , 116 ( 96.7 % ) subjects were traced . During the study period there were 7 deaths ( 6.0 % of those traced ) , 5 ( 4.3 % ) due to suicide . All but one of the suicides occurred in the first year after discharge from hospital . Age and sex St and ardised Mortality Ratios ( relative to rates for the population of the city of Sao Paulo ) were 8.4 for overall mortality ( 95 % confidence interval : 4.0 - 15.9 ) and 317.9 for deaths due to suicide ( 95 % confidence interval : 125.2 - 668.3 ) . These results are in agreement with previous studies , and show that in Brazil non-affective functional psychoses are life-threatening illnesses , which need adequate care , particularly when patients go back to live in the community after hospital discharge OBJECTIVE To evaluate the effect of a pilot pharmaceutical care program developed for elderly patients with uncontrolled hypertension . METHODS Nonr and omized single intervention pre/posttest blood pressure study in a community pharmacy in Aracaju , Brazil . This study enrolled elderly patients diagnosed with essential hypertension and uncontrolled blood pressure . Monthly visits were scheduled during a 10-month period . Pharmaceutical interventions were focused on health education and monitoring of drug-related problems . Primary outcomes included target blood pressure control , reduction in blood pressure , pulse pressure , medication adherence , and reduction of anthropometric indices . RESULTS 35 of 51 patients completed the study . After 10 months of intervention , 57.2 % of elderly patients achieved blood pressure control ( P = 0.000 ) and the mean reduction was 26.6 mm Hg ( P < 0.0001 ) for systolic blood pressure , 10.4 mm Hg ( P < 0.0001 ) for diastolic blood pressure , and 15.7 mm Hg ( P < 0.0001 ) for pulse pressure . Medication adherence also improved ( P = 0.0000 ) ; however , anthropometric indices remained unchanged . CONCLUSION The pharmaceutical care program improved outcomes by reducing and controlling blood pressure and improving medication adherence among elderly patients with uncontrolled hypertension The first double-blind placebo-controlled clinical trial of an atypical neuroleptic medication is being conducted in symptomatic treatment-seeking patients meeting new diagnostic criteria for a putative prodromal syndrome . This identifies them as being at high risk for developing psychosis in the near future . The study aims include prevention of psychosis onset and disability , as well as palliation of ongoing symptomatology . The purpose of this report is to describe the study 's " prodromally symptomatic " sample at baseline , i.e. , at intake immediately prior to r and omization and prior to receiving study medication . Sixty treatment-seeking patients meeting prodromal inclusion criteria were recruited across four sites : New Haven , CT ( n=39 ) , Toronto , Ontario ( n=9 ) , Calgary , Alberta ( n=6 ) , and Chapel Hill , NC ( n=6 ) . The sample was young ( median age 16 ) , largely male ( 65 % ) , and came from families with high titers of serious mental illness ( 44 % ) . Most patients ( 93 % ) met criteria for the Attenuated Positive Symptom ( APS ) prodromal syndrome and presented with significant but nonpsychotic suspiciousness , perceptual aberrations , unusual thought content , and conceptual disorganization . They presented with minimal to mild affective symptoms and substance use/abuse , but they were quite functionally compromised ( mean Global Assessment of Functioning ( GAF ) score=42 ) . The prodromal sample was compared with other clinical -trial sample s of adolescent depression , adolescent mania , and first episode schizophrenia . Prodromal patients proved not to be depressed or manic . They were less severely ill than untreated first episode schizophrenia but more severely ill than treated first episode schizophrenia . While not psychotically disabled , these patients nevertheless present with a clinical syndrome . Subsequent reports will detail the effects of drug versus placebo on prodromal symptoms , neuropsychological profile , and the rate of conversion to psychosis Background Critically ill patients have an increased risk of developing delirium during their intensive care stay . To date , pharmacological interventions have not been shown to be effective for delirium management but non-pharmacological interventions have shown some promise . The aim of this systematic review is to identify effective non-pharmacological interventions for reducing the incidence or the duration of delirium in critically ill patients . Methods We will search MEDLINE , EMBASE , CINAHL , Web of Science , AMED , psycINFO and the Cochrane Library . We will include studies of critically ill adults and children . We will include r and omised trials and controlled trials which measure the effectiveness of one or more non-pharmacological interventions in reducing incidence or duration of delirium in critically ill patients . We will also include qualitative studies that provide an insight into patients and their families ’ experiences of delirium and non-pharmacological interventions . Two independent review ers will assess studies for eligibility , extract data and appraise quality . We will conduct meta-analyses if possible or present results narratively . Qualitative studies will also be review ed by two independent review ers , and a specially design ed quality assessment tool incorporating the CASP framework and the POPAY framework will be used to assess quality . Discussion Although non-pharmacological interventions have been studied in population s outside of intensive care units and multicomponent interventions have successfully reduced incidence and duration of delirium , no systematic review of non-pharmacological interventions specifically targeting delirium in critically ill patients have been undertaken to date . This systematic review will provide evidence for the development of a multicomponent intervention for delirium management of critically ill patients that can be tested in a subsequent multicentre r and omised trial . Systematic review registration PROSPERO The aim of this study was to evaluate adherence to treatment in persistent asthma in Brazil to determine the factors associated with non-adherence and to measure the efficacy of telephone calls in enhancing adherence . In a prospect i ve , multicenter , interventional clinical trial with parallel groups , asthmatics were r and omized into an intervention group or a control group . Asthmatics included in the intervention group received an initial telephone call to record demographic information and asthma characterization . After that , biweekly telephone calls were made to promote treatment adherence . Asthmatics included in the control group received only the initial and final telephone calls . Both groups received three packages of salmeterol/fluticasone for 3 months . The main outcome measure was the percentage of participants who took the prescribed doses of the drug .  A total of 271 patients were included . The overall adherence rate was 51.9 % for the control group and 74.3 % for the intervention group . This meant a reduction of relative risk ( RRR ) of 47 % ( p < 0.001 ) . The number needed to treat ( NNT ) was 4.5 . The only variable associated with better adherence was severe persistent asthma . A low-cost easily implemented intervention , tailored to each individual , enhanced the adherence rate among Brazilian asthmatic patients
Verbal de-escalation techniques have been shown to decrease agitation and reduce the potential for associated violence in the emergency setting .
OBJECTIVE To present the essential guidelines for non-pharmacological management of patients with psychomotor agitation in Brazil .