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Slocum S, Fiorillo M, Harding E, Owen J, Long R, Dunn T, Martin I. In pursuit of inter-specialty consensus on excited delirium syndrome: a scoping literature review. Forensic Sci Med Pathol 2023; 19:573-594. [PMID: 36350497 DOI: 10.1007/s12024-022-00548-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2022] [Indexed: 11/11/2022]
Abstract
Excited delirium syndrome (ExDS) is a controversial and disputed diagnosis involving altered mentation, agitation, and, frequently, substance abuse. Recently, it has become a common pre-hospital diagnosis, serving as justification for use of force, restraint, and/or medication administration. To conduct a scoping review across three databases to describe the most frequently reported diagnostic criteria for ExDS, as well as to explore its use as a diagnosis for deaths of individuals in the custody of law enforcement. In 2021, three literature databases were searched: Ovid Medline, PsycInfo, and Scopus. Studies were included if they were peer-reviewed, English articles describing (1) ExDS symptoms, (2) substance intoxication with at least 2 ExDS symptoms present, or (3) centering on deaths occurring in the custody of law enforcement and attributed to ExDS. Key study data were extracted and the current literature was described qualitatively. Analysis took place between March and December 2021. A total of 97 studies were identified through initial abstract and secondary full-text review, with noted discrepancies in the definition of ExDS itself. After review, differences in ExDS diagnosis among organizations were explored, along with subsequent clinical impact, particularly in the pre-hospital setting. Resulting impact on patients, particularly those of minoritized ethnic and racial groups, was also noted. Prone aggressive restraint, in particular, is noted as an established risk factor for fatalities in ExDS cases. At this time, ExDS should not be utilized as a diagnosis; major medical organizations have an urgent responsibility to convene to formalize consensus-based diagnostic criteria or to propose alternate management guidelines for agitated and altered persons.
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Affiliation(s)
- Sarah Slocum
- Department of Psychiatry, Geisel School of Medicine, Lebanon, NH, USA.
- New Hampshire Hospital, 36 Clinton St, Concord, NH, 03301, USA.
| | - Matthew Fiorillo
- Department of Psychiatry and Behavioral Health, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Eric Harding
- Medical College of Wisconsin Libraries, Milwaukee, WI, USA
| | - Julie Owen
- Department of Psychiatry and Behavioral Medicine, Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ruby Long
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Thom Dunn
- Psychological Sciences, University of Northern Colorado and Behavioral Health Service, Denver Health Medical Center, Denver, CO, USA
| | - Ian Martin
- Department of Emergency Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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Strömmer EMF, Leith W, Zeegers MP, Freeman MD. The role of restraint in fatal excited delirium: a research synthesis and pooled analysis. Forensic Sci Med Pathol 2020; 16:680-692. [PMID: 32827300 PMCID: PMC7669776 DOI: 10.1007/s12024-020-00291-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2020] [Indexed: 02/02/2023]
Abstract
The purpose of the present study was to perform a comprehensive scientific literature review and pooled data risk factor analysis of excited delirium syndrome (ExDS) and agitated delirium (AgDS). All cases of ExDS or AgDS described individually in the literature published before April 23, 2020 were used to create a database of cases, including demographics, use of force, drug intoxication, mental illness, and survival outcome. Odds ratios were used to quantify the association between death and diagnosis (ExDS vs. AgDS) across the covariates. There were 61 articles describing 168 cases of ExDS or AgDS, of which 104 (62%) were fatal. ExDS was diagnosed in 120 (71%) cases, and AgDS in 48 (29%). Fatalities were more likely to be diagnosed as ExDS (OR: 9.9, p < 0.0001). Aggressive restraint (i.e. manhandling, handcuffs, and hobble ties) was more common in ExDS (ORs: 4.7, 14, 29.2, respectively, p < 0.0001) and fatal cases (ORs: 7.4, 10.7, 50, respectively, p < 0.0001). Sedation was more common in AgDS and survived cases (OR:11, 25, respectively, p < 0.0001). The results of the study indicate that a diagnosis of ExDS is far more likely to be associated with both aggressive restraint and death, in comparison with AgDS. There is no evidence to support ExDS as a cause of death in the absence of restraint. These findings are at odds with previously published theories indicating that ExDS-related death is due to an occult pathophysiologic process. When death has occurred in an aggressively restrained individual who fits the profile of either ExDS or AgDS, restraint-related asphyxia must be considered a likely cause of the death.
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Affiliation(s)
- Ellen M F Strömmer
- CAPHRI School for Public Health and Primary Care, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, Netherlands.
| | - Wendy Leith
- CAPHRI School for Public Health and Primary Care, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, Netherlands
| | - Maurice P Zeegers
- CAPHRI School for Public Health and Primary Care, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, Netherlands
| | - Michael D Freeman
- CAPHRI School for Public Health and Primary Care, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, Netherlands
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Stevenson R, Tracy DK. Acute behavioural disturbance: a physical emergency psychiatrists need to understand. BJPSYCH ADVANCES 2020. [DOI: 10.1192/bja.2020.67] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
SUMMARYThe phenomenon of acute behavioural disturbance (ABD) (also known as acute behavioural disorder or excited delirium) is an underrecognised and potentially life-threatening syndrome, and an emergency in psychiatric settings. Causes are discussed and the pathophysiology explained. The challenges faced by practitioners are highlighted, including how ‘standard’ control and restraint can exacerbate symptoms. Initial treatment strategies are suggested.
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Funayama M, Takata T. Psychiatric inpatients subjected to physical restraint have a higher risk of deep vein thrombosis and aspiration pneumonia. Gen Hosp Psychiatry 2020; 62:1-5. [PMID: 31734627 DOI: 10.1016/j.genhosppsych.2019.11.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 11/04/2019] [Accepted: 11/08/2019] [Indexed: 12/21/2022]
Abstract
Physical restraint in clinical settings can lead to potentially lethal complications. Although this is a life-and-death issue, no comprehensive large-scale study relating medical complications to physical restraint has yet been performed. The 1308 psychiatric inpatients in our retrospective cohort study were categorized into two groups: a physical restraint group (those who had been subjected to physical restraint while hospitalized; n = 110) and a non-physical restraint group (those never subjected to physical restraint; n = 1198). We assessed differences between the two groups with respect to the occurrence of medical complications subsequent to restraint. To control for potentially confounding factors, linear discriminant regression analysis was used to identify whether physical restraint itself affected the occurrence of medical complications. The physical restraint group had a higher risk for deep vein thrombosis (P < .01, OR = 6.0, 95%CI: 2.4-13.9) and aspiration pneumonia (P < .01, OR = 4.1, 95%CI: 2.1-7.6) when compared with the non-physical restraint group. Even after controlling for potentially confounding factors, physical restraint substantially raised the risk of deep vein thrombosis and aspiration pneumonia (P < .01, P = .01, respectively). Although this study population was derived from a single psychiatric unit, physical restraint may lead to serious medical conditions. To avoid this unwanted consequence, the use of physical restraint should be minimized and physical therapy is highly recommended.
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Affiliation(s)
- Michitaka Funayama
- Department of Neuropsychiatry, Ashikaga Red Cross Hospital, Tochigi 3260843, Japan.
| | - Taketo Takata
- Department of Neuropsychiatry, Ashikaga Red Cross Hospital, Tochigi 3260843, Japan
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An Instrument to Measure Mental Health Professionals' Beliefs and Attitudes towards Service Users' Rights. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16020244. [PMID: 30654510 PMCID: PMC6352182 DOI: 10.3390/ijerph16020244] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 01/11/2019] [Accepted: 01/11/2019] [Indexed: 11/16/2022]
Abstract
We aimed at developing and validating a scale on the beliefs and attitudes of mental health professionals towards services users' rights in order to provide a valid evaluation instrument for training activities with heterogeneous mental health professional groups. Items were extracted from a review of previous instruments, as well as from several focus groups which have been conducted with different mental health stakeholders, including mental health service users. The preliminary scale consisted of 44 items and was administered to 480 mental health professionals. After eliminating non-discriminant and low weighting items, a final scale of 25 items was obtained. Exploratory and confirmatory factor analyses produced a four-factor solution consisting of the following four dimensions; system criticism/justifying beliefs, freedom/coercion, empowerment/paternalism, and tolerance/discrimination. The scale shows high concordance with our theoretical model as well as adequate parameters of explained variance, model fit, and internal reliability. Additional work is required to assess the cultural equivalence and psychometrics of this tool in other settings and populations, including health students.
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Kersting XAK, Hirsch S, Steinert T. Physical Harm and Death in the Context of Coercive Measures in Psychiatric Patients: A Systematic Review. Front Psychiatry 2019; 10:400. [PMID: 31244695 PMCID: PMC6580992 DOI: 10.3389/fpsyt.2019.00400] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 05/21/2019] [Indexed: 11/13/2022] Open
Abstract
Background: For centuries coercive measures in psychiatry have been means of averting acute danger. It has been known for almost as long that these measures can lead to harm or even death to those affected. Over the past two decades the topic has increasingly been the subject of scientific discussion and research. While the legal and ethical preconditions for coercive measures in psychiatry as well as epidemiological studies on their incidence and patients' subjective experiences have increasingly come into focus, research on possible adverse events has lagged behind. To our knowledge there is no systematic review on the harmful or even fatal physical adverse effects of coercive interventions in psychiatry. Methods: We searched the databases PubMed and CINAHL for primary literature with a search string based on the PICO framework including key words describing different psychiatric diagnoses, coercive measures, and harms. Results: In total, 67 eligible studies (mainly case reports and case series) of very heterogeneous quality were included. Two RCTs were found reporting position-dependent cardiac deterioration, but were, however, carried out with healthy people and were characterized by a small number of cases. Death was the most frequently reported harm: cardiac arrest by chest compression in 14 studies, cardiac arrest by strangulation in 9, and pulmonary embolism in 8 studies. Further harms were, among others, venous thromboembolism and injuries. Injuries during physical restraint were reported in 0.8-4% of cases. For other kinds of coercive interventions, there are no sufficient data. Venous thromboembolism occurred in a considerable percentage of cases during mechanical restraint, also under prophylaxis. The most commonly reported coercive measure was restraint, distinguishing in mechanical restraint (43 studies), physical restraint (22 studies), bedrails (eight studies), vest restraint (7 studies), and chair restraint (6 studies). Forced medication was explicitly mentioned only in two, but seems to have occurred in nine studies. Six studies included seclusion. Conclusion: Coercive measures can lead to physical harm or even death. However, there is a significant lack of data on the incidence of such adverse events related to coercive interventions. Though reported anecdotally, physical adverse events during seclusion appear to be highly underresearched.
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Affiliation(s)
- Xenia A K Kersting
- Clinic for Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany.,MVZ Venusberg of the University Hospital Bonn, Bonn, Germany
| | - Sophie Hirsch
- Clinic for Psychiatry and Psychotherapy I, Ulm University (Weissenau), Ulm, Germany
| | - Tilman Steinert
- Clinic for Psychiatry and Psychotherapy I, Ulm University (Weissenau), Ulm, Germany.,Zentrum für Psychiatrie Suedwuerttemberg, Weissenau, Germany
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Baldwin S, Hall C, Blaskovits B, Bennell C, Lawrence C, Semple T. Excited delirium syndrome (ExDS): Situational factors and risks to officer safety in non-fatal use of force encounters. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2018; 60:26-34. [PMID: 30217327 DOI: 10.1016/j.ijlp.2018.06.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 06/14/2018] [Accepted: 06/24/2018] [Indexed: 06/08/2023]
Abstract
STUDY OBJECTIVE Police use of force (UoF) encounters include individuals with Excited Delirium Syndrome (ExDS) with some frequency. Situational factors and risks to officer safety associated with these encounters have not been well studied. We examined the likelihood that subjects displaying various concomitant features of ExDS were under the influence of drugs and/or alcohol. We also examined the extent of subject violence, and the impact of this behaviour on the encounter (e.g., the odds of a struggle). Greater understanding of the prevalence of ExDS and the specific risk it represents to law enforcement officers and the subjects they encounter will guide appropriate policy and response strategies. METHODS A prospective evaluation of a consecutive cohort of subjects involved in UoF encounters with police was conducted. Data were collected from January 2012 to December 2015. Consistent with previous research, the presence of six or more features was used to identify probable cases of ExDS. The odds that subjects in a state of probable ExDS were under the influence of drugs and/or alcohol was calculated and compared against subjects who exhibited less than three features of ExDS. In addition, the violent nature of subjects (e.g., the odds of a subject being in possession of a weapon) displaying various concomitant features of the syndrome was examined. The number of sudden and unexpected arrest-related death (ARDs) was documented. RESULTS UoF occurred in 9006 of 10.9 million police-public interactions (0.08%). Of the UoF encounters, 156 (1.7%) subjects displayed six or more features of ExDS. With four recorded sudden and unexpected ARDs of violent and agitated subjects in our cohort, up to 6.3% of these subjects experiencing probable ExDS could be expected to be at risk of sudden death. Logistic regression analyses indicated that there were significantly higher odds that subjects exhibiting more features of ExDS (e.g., six or more) were under the influence of drugs. On the other hand, there were significantly lower odds that individuals exhibiting ExDS were under the influence of alcohol alone. In addition, those displaying a greater number of features demonstrated higher odds of engaging in assaultive behaviour, presenting a threat of grievous bodily harm or death, and being involved in a struggle that went to the ground with an officer. A slight increase in the presence of weapons was observed in encounters with probable ExDS. CONCLUSION Our study provides important information to guide the development of policy and procedure in law enforcement. Police encounter a subject with ExDS 1 in every 58 UoF incidents (1.7%). Those individuals are at higher odds of being intoxicated with drugs according to officers' assessments and at risk of being further exerted during a struggle on the ground, both of which appear to play a major role in deaths associated to ExDS. There is a demonstrable increase in risk to officers and public safety from the violent behaviour displayed by subjects presenting a greater number of features of ExDS. Our data suggests that up to 6.3% of subjects in a state of ExDS could succumb to ARDs; however, we cannot comment on the prevalence of death for persons with ExDS who do not encounter police. Further research is needed to determine which force options optimize outcome for police and subjects. Additionally, research surrounding pathophysiology leading to death should focus on subjects with six or more features of ExDS. Ultimately, a better understanding in this area will contribute to improving the outcomes of these encounters for those suffering from ExDS and those tasked with assisting them.
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Affiliation(s)
- Simon Baldwin
- Carleton University, Ottawa, Ontario, Canada; Royal Canadian Mounted Police, Ottawa, Ontario, Canada.
| | - Christine Hall
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada; Faculty of Medicine, Department of Emergency Medicine, University of British Columbia, Canada; Faculty of Medicine, Department of Community Health Sciences, University of Calgary, Canada
| | | | | | - Chris Lawrence
- Police Research Lab, Carleton University, Ottawa, Ontario, Canada
| | - Tori Semple
- Carleton University, Ottawa, Ontario, Canada
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Kennedy DB, Savard DM. Delayed In-Custody Death Involving Excited Delirium. JOURNAL OF CORRECTIONAL HEALTH CARE 2018; 24:43-51. [DOI: 10.1177/1078345817726085] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Daniel B. Kennedy
- Department of Sociology, Anthropology, Social Work and Criminal Justice, Oakland University, Rochester, MI, USA
| | - Dennis M. Savard
- Department of Criminal Justice, Saginaw Valley State University, University Center, MI, USA
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Baldwin S, Hall C, Bennell C, Blaskovits B, Lawrence C. Distinguishing features of Excited Delirium Syndrome in non-fatal use of force encounters. J Forensic Leg Med 2016; 41:21-7. [DOI: 10.1016/j.jflm.2016.03.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 03/18/2016] [Accepted: 03/27/2016] [Indexed: 11/24/2022]
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Bak J, Zoffmann V, Sestoft DM, Almvik R, Siersma VD, Brandt-Christensen M. Comparing the effect of non-medical mechanical restraint preventive factors between psychiatric units in Denmark and Norway. Nord J Psychiatry 2015; 69:433-43. [PMID: 25614990 DOI: 10.3109/08039488.2014.996600] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The use of mechanical restraint (MR) is controversial, and large differences regarding the use of MR are often found among countries. In an earlier study, we observed that MR was used twice as frequently in Denmark than Norway. AIMS To examine how presumed MR preventive factors of non-medical origin may explain the differing number of MR episodes between Denmark and Norway. METHODS This study is a cross-sectional survey of psychiatric units. Linear regression was used to assess the confounding effects of the MR preventive factors, i.e. whether a difference in the impact of these factors is evident between Denmark and Norway. RESULTS Six MR preventive factors confounded [∆exp(B)> 10%] the difference in MR use between Denmark and Norway, including staff education (- 51%), substitute staff (- 17%), acceptable work environment (- 15%), separation of acutely disturbed patients (13%), patient-staff ratio (- 11%), and the identification of the patient's crisis triggers (- 10%). CONCLUSIONS These six MR preventive factors might partially explain the difference in the frequency of MR episodes observed in the two countries, i.e. higher numbers in Denmark than Norway. One MR preventive factor was not supported by earlier research, the identification of the patient's crisis triggers; therefore, more research on the mechanisms involved is needed. CLINICAL IMPLICATIONS None of the six MR preventive factors presents any adverse effects; therefore, units in Denmark and Norway may consider investigating the effect of implementing, the identification of the patient's crisis triggers, an increased number of staff per patient, increased staff education, a better work environment and reduced use of substitute staff in practice.
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Affiliation(s)
- Jesper Bak
- Jesper Bak, R.N., S.D., M.P.H., Ph.D. student, Head nurse, Mental Health Centre Sct. Hans , Roskilde , Denmark . E-mail:
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Paterson B, Bennet L, Bradley P. Positive and Proactive Care: could new guidance lead to more problems? BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2014; 23:939-941. [PMID: 25251176 DOI: 10.12968/bjon.2014.23.17.939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Prahlow JA. Investigation of Deaths of Chronically Disabled Persons and Institutionalized Persons. Acad Forensic Pathol 2014. [DOI: 10.23907/2014.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The investigation of deaths involving chronically disabled and/or institutionalized persons represents an important challenge to the medicolegal death investigation community. For the purposes of this review, the chronically disabled and/or institutionalized are considered to include three non-mutually exclusive subcategories: the disabled elderly, the severely disabled, and psychiatric patients. Because deaths within certain of these populations tend to be common and expected, a very important goal when such deaths occur is the appropriate referral of cases to the medical examiner/coroner. Although each subcategory has distinct issues of importance regarding death investigation, there is also a reasonable amount of overlap between the three groups. This review provides an overview of the three subcategories, the reasons such persons may be at risk for premature, unexpected, or unnatural death, the many important issues of concern when investigating deaths within these vulnerable populations, and important preventative strategies within each group.
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Affiliation(s)
- Joseph A. Prahlow
- Forensic Pathologist at The Medical Foundation in South Bend, IN, and a Professor of Pathology at Indiana University School of Medicine-South Bend
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O'Brien AJ, Thom K. Police use of TASER devices in mental health emergencies: a review. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2014; 37:420-426. [PMID: 24656744 DOI: 10.1016/j.ijlp.2014.02.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The proliferation of TASER devices among police forces internationally has been accompanied by concerns about injuries and health effects, and about the use of TASER devices on vulnerable populations such as people with mental illness. TASER devices have generated a flood of research studies, although there remain unanswered questions about some of the key issues. This paper outlines the introduction of TASER devices to policing and their subsequent widespread adoption. The paper considers the role of police in mental health emergencies with a particular focus on use of TASER devices. Some factors contribute to the special vulnerability of people with mental illness to the effects of TASER devices. The paper also reviews research into use of TASER devices and raises issues about conflict of interest in research into TASER devices. We conclude that TASER devices look set to play a significant role in policing in the future. We make suggestions for a future research programme, and suggest guidelines for publication of papers in which there may be a conflict of interest.
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Affiliation(s)
- Anthony J O'Brien
- Centre for Mental Health Research, University of Auckland, Private Bag 92019, Auckland, New Zealand.
| | - Katey Thom
- Centre for Mental Health Research, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand
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Bak J, Zoffmann V, Sestoft DM, Almvik R, Brandt-Christensen M. Mechanical restraint in psychiatry: preventive factors in theory and practice. A Danish-Norwegian association study. Perspect Psychiatr Care 2014; 50:155-66. [PMID: 25040212 DOI: 10.1111/ppc.12036] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Revised: 06/10/2013] [Accepted: 06/27/2013] [Indexed: 12/11/2022] Open
Abstract
PURPOSE To examine how potential mechanical restraint preventive factors in hospitals are associated with the frequency of mechanical restraint episodes. DESIGN AND METHODS This study employed a retrospective association design, and linear regression was used to assess the associations. FINDINGS Three mechanical restraint preventive factors were significantly associated with low rates of mechanical restraint use: mandatory review (exp[B] = .36, p < .01), patient involvement (exp[B] = .42, p < .01), and no crowding (exp[B] = .54, p < .01). PRACTICE IMPLICATIONS None of the three mechanical restraint preventive factors presented any adverse effects; therefore, units should seriously consider implementing these measures.
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Affiliation(s)
- Jesper Bak
- Mental Health Centre Sct. Hans, Roskilde, Denmark
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Vilke GM, DeBard ML, Chan TC, Ho JD, Dawes DM, Hall C, Curtis MD, Costello MW, Mash DC, Coffman SR, McMullen MJ, Metzger JC, Roberts JR, Sztajnkrcer MD, Henderson SO, Adler J, Czarnecki F, Heck J, Bozeman WP. Excited Delirium Syndrome (ExDS): Defining Based on a Review of the Literature. J Emerg Med 2012; 43:897-905. [DOI: 10.1016/j.jemermed.2011.02.017] [Citation(s) in RCA: 101] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2010] [Revised: 08/31/2010] [Accepted: 02/20/2011] [Indexed: 11/15/2022]
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Bak J, Brandt-Christensen M, Sestoft DM, Zoffmann V. Mechanical restraint--which interventions prevent episodes of mechanical restraint?- a systematic review. Perspect Psychiatr Care 2012; 48:83-94. [PMID: 21967236 DOI: 10.1111/j.1744-6163.2011.00307.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
PURPOSE To identify interventions preventing mechanical restraints. DESIGN AND METHODS Systematic review of international research papers dealing with mechanical restraint. The review combines qualitative and quantitative research in a new way, describing the quality of evidence and the effect of intervention. FINDINGS Implementation of cognitive milieu therapy, combined interventions, and patient-centered care were the three interventions most likely to reduce the number of mechanical restraints. PRACTICE IMPLICATIONS There is a lack of high-quality and effective intervention studies. This leaves patients and metal health professionals with uncertainty when choosing interventions in an attempt to prevent mechanical restraints.
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Affiliation(s)
- Jesper Bak
- Mental Health Centre Sct. Hans, Roskilde, Denmark.
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Bowers L, Van Der Merwe M, Paterson B, Stewart D. Manual restraint and shows of force: the City-128 study. Int J Ment Health Nurs 2012; 21:30-40. [PMID: 21733054 DOI: 10.1111/j.1447-0349.2011.00756.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Manual restraint is used to manage disturbed behaviour by patients. This study aimed to assess the relationship of manual restraint and show of force to conflict behaviours, the use of containment methods, service environment, physical environment, patient routines, staff characteristics, and staff group variables. Data from a multivariate, cross-sectional study of 136 acute psychiatric wards in England were used to conduct this analysis. Manual restraint was used less frequently on English acute psychiatric wards (0.20 incidents per day) than show of force (0.28 incidents per day). Both were strongly associated with the proportion of patients subject to legal detention, aggressive behaviours, and the enforcement of treatment and detention. Medical, nursing, and security guard staff provision were associated in different ways with variations in the use of these coercive interventions. An effective ward structure of rules and routines was associated with less dependence on these control methods. Training for manual restraint should incorporate the scenarios of attempted absconding and enforcement of treatment, as well as violent behaviour. Attempts to lessen usage of these interventions could usefully focus on increasing the availability of medical staff to patients, reducing reliance on security guards and establishing a good ward structure.
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Affiliation(s)
- Len Bowers
- Section of Mental Health Nursing, Institute of Psychiatry Department of Mental Health Nursing, City University, London, UK.
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Hall CA, McHale AM, Kader AS, Stewart LC, MacCarthy CS, Fick GH. Incidence and outcome of prone positioning following police use of force in a prospective, consecutive cohort of subjects. J Forensic Leg Med 2012; 19:83-9. [DOI: 10.1016/j.jflm.2011.12.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2011] [Revised: 10/20/2011] [Accepted: 12/12/2011] [Indexed: 10/14/2022]
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Excited delirium syndrome (ExDS): Redefining an old diagnosis. J Forensic Leg Med 2012; 19:7-11. [DOI: 10.1016/j.jflm.2011.10.006] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Revised: 09/03/2011] [Accepted: 10/03/2011] [Indexed: 11/18/2022]
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22
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Electronic Control Device Exposure: A Review of Morbidity and Mortality. Ann Emerg Med 2011; 58:178-88. [DOI: 10.1016/j.annemergmed.2011.01.023] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2010] [Revised: 12/20/2010] [Accepted: 01/28/2011] [Indexed: 11/21/2022]
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23
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Stewart D, Bowers L, Simpson A, Ryan C, Tziggili M. Manual restraint of adult psychiatric inpatients: a literature review. J Psychiatr Ment Health Nurs 2009; 16:749-57. [PMID: 19744064 DOI: 10.1111/j.1365-2850.2009.01475.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Relatively little is known about the prevalence of manual restraint to manage violent or challenging behaviour in hospital psychiatric services or the circumstances of its use. This review identified 45 empirical studies of manual restraint of adult psychiatric inpatients, mostly from the UK. On average, up to five episodes per month of manual restraint might be expected on an average 20-bed ward. Episodes last around 10 min, with about half involving the restraint of patients on the floor, usually in the prone position. Manually restrained patients tend to be younger, male and detained under mental health legislation. Staff value restraint-related training, but its impact on nursing practice has not been evaluated. Research has tended to focus on official reports of violent incidents rather than manual restraint per se. Larger and more complex studies are needed to examine how manual restraint is used in response to different types of incident and in different service settings.
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Affiliation(s)
- D Stewart
- Department of Mental Health and Learning Disability, City University, London E1 2EA, UK.
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24
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Bergk J, Einsiedler B, Steinert T. Feasibility of randomized controlled trials on seclusion and mechanical restraint. Clin Trials 2008; 5:356-63. [DOI: 10.1177/1740774508094405] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Background In psychiatry seclusion and mechanical restraint are most commonly used in the management of violence and self-directed aggression. Both interventions are considered as efficacious and indispensable. Yet, these measures can have deleterious effects on patients. The least restrictive alternative is recommended. Evidence about what kind of intervention is least restrictive is only scarcely available. Up to now, no randomized controlled trial (RCT) on this subject has been conducted. Purpose To describe ethical, methodological and legal problems of RCTs on coercive interventions and to suggest possible solutions. Methods Literature research on possible study designs, ethical considerations and legal regulations was conducted in PubMed. Results Corresponding to the procedures in emergency medicine informed consent can be obtained after the intervention when the patients are capable again. Informed consent refers only to participation in an interview and utilization of data. Randomization can be ethically approved, if exclusion criteria for randomization are defined. A comprehensive cohort study seems to be the most practicable study design. As primary outcome variable an assessment of subjective experiences of the patients' restrictions to human rights. Clinical Trials 2008; 5: 356—363. http://ctjsagepub.com
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Affiliation(s)
- Jan Bergk
- ZfP Weissenau, Department of Psychiatry I, University of Ulm, Weingartshofe str. 2, 88214 Ravensburg, Germany,
| | - Beate Einsiedler
- Institute of Biometrics, University of Ulm, Schwastr, 13, 89075 Ulm, Germany
| | - Tilman Steinert
- ZfP Weissenau, Department of Psychiatry I, University of Ulm, Weingartshofe str. 2, 88214 Ravensburg, Germany
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25
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Grant JR, Southall PE, Fowler DR, Mealey J, Thomas EJ, Kinlock TW. Death in Custody: A Historical Analysis. J Forensic Sci 2007; 52:1177-81. [PMID: 17645746 DOI: 10.1111/j.1556-4029.2007.00500.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This research delineates the historical evolution of death in custody. A retrospective, exploratory analysis of 145,425 cases from Maryland's Office of the Chief Medical Examiner, occurring from 1939 to 2004, was conducted. Two hundred and two custodial deaths were identified and subsequently examined relative to time, agency, decedent characteristics, and cause and manner of death. Results indicate that there have been substantive changes in custodial deaths over time. Cardiovascular disease was the most frequent cause of death from the 1930s to the 1970s, except for the 1940s, when syphilis and tuberculosis took precedence. Asphyxia, the predominant cause of death in the 1980s, reflected an increase in suicidal hangings. Emerging in the 1980s, drug intoxication deaths were prevalent in the 1990s and 2000s. Sudden unexplained deaths involving violent behavior, the use of multiple restraints, and drug intoxication were not identified until the 1980s, coinciding with periods of increased cocaine abuse nationally.
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Affiliation(s)
- Jami R Grant
- Forensic Studies, University of Baltimore, Baltimore, MD 21201, USA.
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26
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Knutzen M, Sandvik L, Hauff E, Opjordsmoen S, Friis S. Association between patients' gender, age and immigrant background and use of restraint--a 2-year retrospective study at a department of emergency psychiatry. Nord J Psychiatry 2007; 61:201-6. [PMID: 17523032 DOI: 10.1080/08039480701352520] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The study aimed to determine rates and types of patient restraint, and their relationship to age, gender and immigrant background. The study retrospectively examined routinely collected data and data from restraint protocols in a department of acute psychiatry over a 2-year period. Each patient is only counted once in this period, controlling for readmission. Of 960 admitted patients, 14% were exposed to the use of restraints. The rate was significantly higher among patients with immigrant background, especially in the younger age groups. Most commonly used were mechanical restraint alone for native-born patients and a combination of mechanical and pharmacological restraints for patients with immigrant background. The use of restraints decreased when patients reached 60 years. Both patients' age and immigrant background seem to have an impact on the use of restraint.
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Affiliation(s)
- M Knutzen
- Department of Psychiatry, Ullevaal University Hospital, Oslo, Norway.
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27
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Raja M, Azzoni A. Hostility and violence of acute psychiatric inpatients. Clin Pract Epidemiol Ment Health 2005; 1:11. [PMID: 16053528 PMCID: PMC1188062 DOI: 10.1186/1745-0179-1-11] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2005] [Accepted: 07/29/2005] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The aim of the present study was to find out the extent of hostility and violence and the factors that are associated with such hostility and violence in a psychiatric intensive care unit. METHODS Retrospective analysis of data prospectively collected in a 6-year period. RESULTS No hostility was observed in 56.1%, hostility in 40.9%, and violence in 3.0% of the admitted cases. Seclusion was never used. Six cases (2.5 per thousand) required physical restraint. Risk factors associated with violence were younger age, suicidal risk, and diagnosis of schizophrenia. Risk factors associated with hostile and violent behavior were younger age at the onset of the disorder, being single, having no children, lower GAF scores, higher BPRS hostility, SAPS, and CGI scores, lower BPRS anxiety-depression score, higher doses of psychoactive drugs, more frequent use of neuroleptics, diagnosis of mania, personality disorder, substance and alcohol related disorders, no diagnosis of depression. CONCLUSION The study confirms the low rate of violence among Italian psychiatric in-patients, the major relevance of clinical rather than socio-demographic factors in respect of aggressive behavior, the possibility of a no seclusion-no physical restraint policy, not associated either with higher rates of hostility or violence or with more severe drug side effects.
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Affiliation(s)
- Michele Raja
- Università degli Studi di Roma "La Sapienza". Scuola di Specializzazione in Psichiatria. Servizio Psichiatrico di Diagnosi e Cura, Ospedale Santo Spirito, Rome, Italy
| | - Antonella Azzoni
- Università degli Studi di Roma "La Sapienza". Scuola di Specializzazione in Psichiatria. Servizio Psichiatrico di Diagnosi e Cura, Ospedale Santo Spirito, Rome, Italy
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28
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Capezuti E. Minimizing the use of restrictive devices in dementia patients at risk for falling. Nurs Clin North Am 2004; 39:625-47. [PMID: 15331306 DOI: 10.1016/j.cnur.2004.02.015] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The accumulating empirical evidence demonstrates that restrictive devices can be removed without negative consequences. Most importantly, use of nonrestrictive measures has been correlated with positive patient outcomes and represents care that is dignified and safe for confused elders. Most of these nonrestrictive approaches promote mobility and functional recovery; however, testing of individual interventions is needed to further the science. As the research regarding restrictive devices has been translated into professional guidelines and regulatory standards, the prevalence of usage has declined dramatically. New institutional models of care discouraging routine use of restrictive devices also will foster innovative solutions to clinical problems associated with dementia.
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Affiliation(s)
- Elizabeth Capezuti
- John A. Hartford Foundation Institute for Geriatric Nursing, Division of Nursing, Steinhardt School of Education, New York University, 246 Greene Street, 6th Floor, New York, NY 10003-6677, USA.
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29
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Mohr WK, Petti TA, Mohr BD. Adverse effects associated with physical restraint. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2003; 48:330-7. [PMID: 12866339 DOI: 10.1177/070674370304800509] [Citation(s) in RCA: 192] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Restraint use is not monitored in the US, and only institutions that choose to do so collect statistics. In 1999, investigative journalists reported lethal consequences proximal to restraint use, making it a life-and-death matter that demands attention from professionals. This paper reviews the literature concerning actual and potential causes of deaths proximal to the use of physical restraint. METHOD Searching the electronic databases Medline, Cinahl, and PsycINFO, we reviewed the areas of forensics and pathology, nursing, cardiology, immunology, psychology, neurosciences, psychiatry, emergency medicine, and sports medicine. CONCLUSIONS Research is needed to provide clinicians with data on the risk factors and adverse effects associated with restraint use, as well as data on procedures that will lead to reduced use. Research is needed to determine what individual risk factors and combinations thereof contribute to injury and death.
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Affiliation(s)
- Wanda K Mohr
- Rutgers University, College of Nursing, Newark, New Jersey, USA.
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30
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Paterson B, Bradley P, Stark C, Saddler D, Leadbetter D, Allen D. Deaths associated with restraint use in health and social care in the UK. The results of a preliminary survey. J Psychiatr Ment Health Nurs 2003; 10:3-15. [PMID: 12558917 DOI: 10.1046/j.1365-2850.2003.00523.x] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Many aspects of the management of acutely disturbed behaviour have only relatively recently come under systematic scrutiny. Perhaps regrettably one of the last amongst the range of strategies that may be employed to be subjected to rigorous examination has been physical restraint. Considerable debate has recently taken place around what represents good practice in this sensitive and controversial area but the continuing dearth of research in some aspects of this area of practice has meant that this discussion has arguably been over reliant on 'expert' opinion. Questions continue regarding some fundamental issues of restraint, including the relative risks involved in alternative approaches, and anxieties have been expressed about the potential for injuries and death to result from restraint. This article outlines the results of a survey that sought to explore the incidence of deaths associated with restraint in health and social care settings in the UK. The outcome of an initial analysis of the cases identified is then discussed, with reference to the literature on restraint-related deaths, in order to identify the implications for practice.
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Affiliation(s)
- B Paterson
- Department of Nursing and Midwifery, University of Stirling, UK.
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31
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Parkes J. A review of the literature on positional asphyxia as a possible cause of sudden death during restraint. ACTA ACUST UNITED AC 2002. [DOI: 10.1108/14636646200200005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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