BACKGROUND:Behavioural emergencies involving aggression in acute care hospitals are increasing globally. Acute care staff are often not trained or confident in their prevention or management. Of available training options simulation-based education is superior for clinical medical education and is gaining acceptance for teaching clinical aggression management skills. OBJECTIVE:The aim of this study was to conduct a systematic review of the effectiveness of simulation-based education for teaching aggression management skills for health professionals working in acute healthcare settings. METHODS:The study protocol was prepared in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) statement, registered (27/02/2020) and published. We included randomised controlled trials, non-randomised controlled trials, quasi-experimental studies, and observational studies involving healthcare professionals in acute hospital settings or trainee health professionals who received simulation-based training on managing patient aggression. Comprehensive searches were conducted in PubMed, Ovid MEDLINE, PsycINFO, CINAHL and The Cochrane Library. Two reviewers independently screened all records, extracted data and assessed risk of bias. The primary outcomes included patient outcomes, quality of care, and adverse effects. Secondary outcomes included workplace resource use, healthcare provider related outcomes, knowledge (de-escalation techniques), performance, attitudes, and satisfaction. A narrative synthesis of included studies was performed because substantial variation of interventions and outcome measures precluded meta-analyses. RESULTS:Twenty-five studies were included with 2790 participants, 2585 (93 %) acute care hospital staff and 205 (7 %) undergraduate university students. Twenty-two studies combined simulation-based education with at least one other training modality. Three studies were randomised controlled trials, one was a pilot and feasibility cluster randomised controlled trial, one was a three-group post-test design and twenty were pre-/post-test design. Twenty-four studies were deemed to be high/critical or serious risk of bias. Four studies collected primary outcome data, all using different methods and with inconsistent findings. Twenty-one studies assessed performance in the test situation, seven studies provided objective ratings of performance and eighteen provided self-report data. Twenty-three studies reported objective or subjective improvements in secondary outcomes. CONCLUSIONS:Acute healthcare staff who completed simulation-based education on managing clinical aggression showed statistically significant improvements in knowledge and self-reported confidence. However, there is a lack of evidence about the magnitude of these improvements and impact on patient outcomes. REGISTRATION:PROSPERO Registration Number CRD42020151002. TWEETABLE ABSTRACT:Simulation-based education improved acute healthcare clinician knowledge and confidence in managing aggression.

Weblink for SR: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004381.pub4/full. Does music therapy for autistic people increase global improvement, quality of life, social interaction and verbal and non-verbal communication and decrease total autism severity1? Twenty-six randomised controlled trials (1165 participants) have examined the short- and medium-term effect of music therapy with evidence current up until August 2021. Intervention durations ranged from 3 days to 8 months. More than half of the studies were conducted in North America or Asia. All participants had received a diagnosis of autism spectrum disorder (autism); however, there was wide variability in children's characteristics including language, autism symptoms and cognition. In all studies most participants (>50%) were male. Most studies (80%) focused on children aged between two to 12 years. One study included only adults. Most (17) studies administered therapy on a one-to-one basis, eight in a group setting and one used a family-based setting. Frequency of therapy varied from daily to weekly and ranged from 10 to 60 min in length. Twelve studies used a ‘highly structured’ approach with receptive techniques (listening to live or recorded music) or a mix of receptive and active techniques (e.g. music involved signs and words to be learned or participants were invited to play an instrument or sing songs). Fourteen studies mainly focused on the interactive and relational aspects of music therapy (e.g. improvisation, musical games, choice making, synchronisation). One study combined music with dance/movement. These interventions were compared to standard care or a placebo group (e.g. the control group attended ‘therapy’ but sessions were non-specific and did not include the music intervention). Studies provided data for the following primary outcomes: global improvement (N = 8 studies), quality of life (N = 3), verbal communication (N = 11), non-verbal communication (N = 11), social interaction (N = 14, multiple measures used), total autism symptom severity (N = 9, usually measured with the Autism Behaviour Checklist or the Childhood Autism Rating Scale) and adverse events (N = 2). Secondary outcomes were presented by studies for adaptive behaviours, quality of family relationships, identity formation, depression and cognitive ability. Risk of bias was low for over 80% of included studies in the areas of blinding of outcome assessment (i.e. the assessors were blind to whether the participant was in the intervention or placebo groups), incomplete outcome data, selective reporting and other bias. Risk of bias was unclear for all studies for blinding of participants and personnel, primarily because the risk of bias introduced by therapists conducting the intervention was unclear. Risk of bias was unclear or high for 80% of studies for allocation concealment (i.e. concealing whether an individual is allocated to the intervention or placebo/standard care group) and 40% of studies used random sequence generation to randomise participants into their groups. As shown in Figure 1, there was a small but statistically significant increase in global improvement scores immediately following music therapy, with moderate certainty evidence from 8 studies. There was no significant increase in global improvement for studies following children from 1 to 11 months post intervention from 3 studies. For the outcome of autism symptoms (Fig. 2) there was a moderate statistically significant reduction in autism symptoms for the 9 studies immediately post intervention and for 2 studies that followed participants up for 1–5 months. However, there was no statistically significant reduction in symptoms in the one study that followed up more than 5 months post intervention. For the outcome of autism symptoms there was moderate certainty of the evidence. Those in the music therapy group showed a small but significant increase in quality-of-life scores immediately post-intervention with moderate certainty of the evidence in three studies reporting these outcomes. One study reported quality of life 7 months post intervention and did not find a significant difference between the intervention and placebo group. Two studies reported on the presence of adverse outcomes and in both studies the intervention group did not experience a higher number of adverse events than the placebo group, with moderate certainty of the evidence. Based on the evidence provided by this review, there are some small, group positive effects and no harm identified compared with children who did not receive music therapy. What is still not certain is how the positive outcomes translate to everyday functioning, whether there are benefits for some children and not others, whether the effects of music therapy are retained long term and what ‘dose’ of music therapy is optimal. Furthermore, it is unclear if specific types of music therapy are more effective than others. As with other autism interventions, this makes clear recommendations difficult, and clinicians and parents/caregivers will need to balance potential benefits against both direct and indirect costs, including opportunity costs. Also, not yet certain is whether the reported benefits are due to the music therapy provided by a trained music therapist or other elements of the interaction. Fifty percent of studies used a comparison with an interactive activity without music therapy but further work is needed to understand the key therapeutic elements. Considerations prior to commencement include whether music therapy is likely to be effective for each child and family's goals. A lifespan perspective is also needed, including finding the best time for each child to participate in the intervention.2 We would encourage families to explore music therapy options at a time their child shows interest in making or moving to music or they believe their child may enjoy the experience. More studies that use approaches that are similar to those used in a clinical setting are needed to increase the evidence base for the clinical application of accessible music therapy. Further research is required to demonstrate effectiveness of this therapy using consistent, meaningful outcome measures and quantifying dose, type, intensity and duration of therapy. While more than a third of the studies reported a primary outcome of autism symptoms, it is important to consider whether this outcome is preferred by autistic individuals and their families or whether assessing and monitoring other outcomes may be more relevant and meaningful, such as adaptive behaviours, independence, activities and participation. Open access publishing facilitated by Monash University, as part of the Wiley - Monash University agreement via the Council of Australian University Librarians.

Aggression and high-risk behaviours triggered by children in paediatric hospitals are increasing globally. There is a paucity of research describing behavioural emergencies in paediatric acute care settings. We conducted a 1-year retrospective study of behavioural emergencies that triggered an emergency response team attendance in a quaternary paediatric hospital. In 2018, 218 children triggered 1050 behavioural emergencies, which utilised 386 h of the emergency response team time. Thirty-three (15%) children triggered more than five activations each (range 6–272) and nearly half (16) were children with autism spectrum disorder or intellectual disability. More than 80% of children who triggered an emergency team response also had at least one psychiatric co-morbidity. Behavioural emergencies, by definition, put staff, children or their families at risk. They occur frequently in hospital with some children repeating these behaviours despite allocation of resources and expertise. New approaches to prevention and amelioration are needed.

AimTo investigate associations between clinical factors and the development of autism spectrum disorder (ASD) in children with tuberous sclerosis complex (TSC), specifically seizures, electroencephalogram abnormalities, tubers and other neurostructural abnormalities, and genetic factors.MethodMEDLINE, Embase, PubMed, the Cochrane Library, and Web of Science were searched until January 2019. Studies that considered the predefined factors for development of ASD in children with TSC were included, following PRISMA‐P guidelines. Two authors independently reviewed titles, abstracts, and full texts, extracted data, and assessed risk of bias.ResultsForty‐two studies with 3542 children with TSC were included. ASD was associated with a history of seizures (odds ratio [OR] 3.79, 95% confidence interval [CI] 1.77–8.14), infantile spasms compared with other seizure types (OR 3.04, 95% CI 2.17–4.27), onset of any seizure type during infancy (OR 2.65, 95% CI 1.08–6.54), and male sex (OR 1.62, 95% CI 1.23–2.14). There was no association with tuber number, tuber location, or genotype.InterpretationWhile a causal link between seizures and ASD in children with TSC cannot be inferred, a strong association between seizures and ASD in children with TSC, particularly with seizure onset during infancy and specifically infantile spasms, is present. Children with TSC and infant‐onset seizures should be monitored for emerging features of ASD. What this paper adds Seizures and autism spectrum disorder (ASD) strongly associate in children with tuberous sclerosis complex (TSC). Infant‐onset seizures and infantile spasms are particularly strongly associated with ASD in TSC.

Background and objective: Aggression and high-risk behaviors, which can result in behavioral emergencies, are common in children with autism and can be magnified in the hospital environment. Children with autism, with or without intellectual disability, have complex communication needs which require a sophisticated level of knowledge, understanding and skill from health care professionals. Pediatric acute care nursing staff are often not trained and lack confidence in managing children with autism. The purpose of this study was to conduct a pilot and feasibility cluster randomized controlled trial (RCT) of simulation-based education for staff in managing behavioral emergencies with autism spectrum disorder (ASD) in the hospital setting.Methods: This study used a mixed method, to explore the acceptability and feasibility of delivering a large-scale cluster RCT and assess trial processes including recruitment, completion rates, contamination, and outcome measures. The simulation-based training format comprised two scenarios involving an adolescent with autism, intellectual disability and aggressive behaviors. Two pediatric wards of similar size and patient complexity were selected to participate in the study and randomized to receive either simulation-based education plus web-based education materials or web-based education materials only. Results: The RCT design is feasible with recruitment, acceptability and completion rates reaching target. Self-perceived baseline levels of confidence in managing aggression in children were mid-range and lower for children with autism and intellectual disability. Forty to fifty percent of intervention participants rated the training highly in terms of developing skills and knowledge respectively. The mean group score for observer ratings of de-escalation across four simulations was 20 out of a possible 35. Data for ward aggression were not collected.Conclusions: Simulation-based education is an acceptable training format for acute care pediatric nurses. This study is feasible to conduct as a cluster RCT with some modifications to this protocol including assessment of baseline differences in confidence. Observer ratings of de-escalation skills indicated that more than one episode of training may be required for acute care pediatric staff to successfully de-escalate aggressive incidents. As such, we will use repeated simulation scenario exercises for each intervention group in the next trial.

Background An increasing number of incidents involving aggressive behaviour in acute care hospitals are being witnessed worldwide. Acute care hospital staff are often not trained or confident in managing aggression. Competent management of clinical aggression is important to maintain staff and patient safety. Training programmes for acute care staff are infrequently described in the literature and rarely reported for paediatric staff. Simulation training allows practice of skills without patient risk and may be more effective than traditional teaching formats for aggression management. Aim and design The aim of this proof of concept study was to develop a simulation-based education session on aggression management for acute care paediatric staff based on best practice principles, to evaluate the acceptability of this training programme and to gain an understanding of the impact of the training on participants’ perceived confidence in managing clinical aggression. Two separate simulation exercises were delivered as a 2-h component of a hospital management of clinical aggression (MOCA) training day. Participants completed a written survey immediately prior to, at completion of the simulation-based group training, and at 3–6 months following the simulation training. Findings Nine training days were conducted in 2017 for nursing, medical, allied health, education and security staff with a total of 146 participants (83% were acute care nurses). Two thirds (68%) of participants had experienced clinical aggression as part of their routine work, with 51% overall reporting a lack of confidence managing these patients. Immediately following the simulation training, 80% of all participants reported feeling more confident in managing clinical aggression, 47% reported a 1-point increase in confidence, whilst 33% of participants reported a 2- or 3-point increase. At 3–6 months post-training, 66% of respondents ( N = 44) reported continued confidence in managing aggression with 100% of participants stating they would recommend simulation training to colleagues. Conclusions Simulation training is an acceptable method of training and shows promise to improve staff-perceived confidence for managing behavioural emergencies in acute paediatric health care settings. In addition, there were potential enduring positive impacts at 3 months after the study. Whilst resource and time intensive, further research assessing the benefits of utilising simulation training in this setting is warranted in order to minimise staff burn-out and improve outcomes for these very vulnerable patients.

BACKGROUNDChildren with autism spectrum disorder (ASD) frequently demonstrate aggression and externalizing behaviors in the acute care hospital environment. Pediatric acute care nursing staff are often not trained in managing aggression and, in particular, lack confidence in preventing and managing externalizing behaviors in children with ASD. High-fidelity simulation exercises will be used in this study to provide deliberate practice for acute care pediatric nursing staff in the management of aggressive and externalizing behaviors.OBJECTIVEThe purpose of this study is to conduct a pilot and feasibility cluster randomized controlled trial (RCT) to evaluate the effectiveness of simulation-based education for staff in managing aggression and externalizing behaviors of children with ASD in the hospital setting.METHODSThis study has a mixed design, with between-group and within-participant comparisons to explore the acceptability and feasibility of delivering a large-scale cluster RCT. The trial process, including recruitment, completion rates, contamination, and completion of outcome measures, will be assessed and reported as percentages. This study will assess the acceptability of the simulation-based training format for two scenarios involving an adolescent with autism, with or without intellectual disability, who displays aggressive and externalizing behaviors and the resulting change in confidence in managing clinical aggression. Two pediatric wards of similar size and patient complexity will be selected to participate in the study; they will be randomized to receive either simulation-based education plus web-based educational materials or the web-based educational materials only. Change in confidence will be assessed using pre- and posttraining surveys for bedside nursing staff exposed to the training and the control group who will receive the web-based training materials. Knowledge retention 3 months posttraining, as well as continued confidence and exposure to clinical aggression, will be assessed via surveys. Changes in confidence and competence will be compared statistically with the chi-square test using before-and-after data to compare the proportion of those who have high confidence between the two arms at baseline and at follow-up. The simulation-based education will be recorded with trained assessors reviewing participants' abilities to de-escalate aggressive behaviors using a validated tool. This data will be analyzed using mean values and SDs to understand the variation in performance of individuals who undertake the training. Data from each participating ward will be collected during each shift for the duration of the study to assess the number of aggressive incidents and successful de-escalation for patients with ASD. Total change in Code Grey activations will also be assessed, with both datasets analyzed using descriptive statistics.RESULTSThis study gained ethical approval from The Royal Children's Hospital Melbourne Human Research Ethics Committee (HREC) on November 1, 2019 (HREC reference number: 56684). Data collection was completed in February 2020. Data analysis is due to commence with results anticipated by August 2020.CONCLUSIONSWe hypothesize that this study is feasible to be conducted as a cluster RCT and that simulation-based training will be acceptable for acute care pediatric nurses. We anticipate that the intervention ward will have increased confidence in managing clinical aggression in children with ASD immediately and up to 3 months posttraining.TRIAL REGISTRATIONAustralian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12620000139976; http://www.ANZCTR.org.au/ACTRN12620000139976.aspx.INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)DERR1-10.2196/18105.

Behavioural emergencies due to high-risk behaviours are increasing globally in paediatric health care settings and place the child, their family, other inpatients and staff at high-risk of harm. High-risk behaviours have been reported in up to two thirds of children with autism spectrum disorder (ASD) and intellectual disability (ID). Admission to hospital can trigger high-risk behaviours in children, especially those with ASD or ID, and increase their intensity or frequency. Patient and staff safety can be compromised if staff are not confident or competent in managing aggressive outbursts. As well as the safety risks, these behaviours result in delayed treatment, prolonged procedure times, increased health care costs and poorer health outcomes. Having a critical mass of well-trained staff who are confident in preventing and managing behavioural emergencies is important. However, these skills may be beyond the usual scope of practice of the acute paediatric health care provider. Paediatric acute health care is a complex specialty encompassing children with a wide range of developmental levels who operate within an array of unique family-centred care systems. Staff need many and varied skills and strategies that can be adapted to effectively interact with the spectrum of ages, developmental stages, neurodiversity and parental/carer involvement experienced in the acute paediatric setting. Simulation-based education (SBE) has been found to be superior to traditional clinical medical education for clinical skill acquisition and is gaining acceptance as a training method for teaching skills in managing clinical aggression. Simulation training allows practice of skills without patient risk and may be more effective than traditional teaching formats for aggression management. The aim of this thesis is to better understand the cause of behavioural emergencies caused by children in hospital and to use this knowledge to develop, implement and evaluate a simulation-based training program for acute care paediatric staff on managing aggression in children with ASD or ID. The program of research was established with four objectives linked to four independent studies, each informing the next. First, we conducted a systematic review to assess the effectiveness of simulation-based training for increasing de-escalation knowledge, skills and behaviour of staff working in the acute care setting. Second, we conducted a one-year retrospective study of behavioural emergencies that triggered an emergency response team attendance in a quaternary paediatric hospital to understand their frequency, type, context and management. Third, we designed a simulation-based education session about prevention and management of aggression in a neurotypical adolescent. We used a proof-of-concept study design to evaluate the acceptability of this training and to gain an understanding of the impact on participants’ self-perceived confidence levels in managing clinical aggression. Fourth, we designed a more specific simulation training program about management of aggression and high-risk behaviours in adolescents with ASD and ID in the hospital setting. Our final study was a pilot and feasibility cluster randomised controlled trial (RCT) of this simulation-based education, with mixed method design. Understanding aggression and high-risk behaviours in paediatric health care settings is an emerging area of research. The findings of these four studies have increased our understanding of the prevention and management of aggression and high-risk behaviours in acute care paediatric settings. Simulation-based education could become an important part of a multi-faceted strategy that is now needed to reduce the prevalence of high-risk behaviours in acute care settings and paediatric hospitals, and to improve outcomes if behavioural emergencies occur. Further evaluation of this training format for managing high-risk behaviours (including aggression), in children with ASD and ID is required. As well as simulation education, features of provider and patient systems need to be considered when formulating solutions to this complex issue in the paediatric acute care setting.

The cancer community understands the value of blood profiling measurements in assessing and monitoring cancer. We describe an effort among academic, government, biotechnology, diagnostic, and pharmaceutical companies called the Blood Profiling Atlas in Cancer (BloodPAC) Project. BloodPAC will aggregate, make freely available, and harmonize for further analyses, raw datasets, relevant associated clinical data (e.g., clinical diagnosis, treatment history, and outcomes), and sample preparation and handling protocols to accelerate the development of blood profiling assays.

We report the incidence of and risk factors for complications after scoliosis surgery in patients with Duchenne muscular dystrophy (DMD) and compare them with those of other neuromuscular conditions. We identified 110 (64 males, 46 females) consecutive patients with a neuromuscular disorder who underwent correction of the scoliosis at a mean age of 14 years (7 to 19) and had a minimum two-year follow-up. We recorded demographic and peri-operative data, including complications and re-operations. There were 60 patients with cerebral palsy (54.5%) and 26 with DMD (23.6%). The overall complication rate was 22% (24 patients), the most common of which were deep wound infection (9, 8.1%), gastrointestinal complications (5, 4.5%) and hepatotoxicity (4, 3.6%). The complication rate was higher in patients with DMD (10/26, 38.5%) than in those with other neuromuscular conditions (14/84, 16.7% (p = 0.019). All hepatotoxicity occurred in patients with DMD (p = 0.003), who also had an increased rate of deep wound infection (19% vs 5%) (p = 0.033). In the DMD group, no peri-operative factors were significantly associated with the rate of overall complications or deep wound infection. Increased intra-operative blood loss was associated with hepatotoxicity (p = 0.036). In our series, correction of a neuromuscular scoliosis had an acceptable rate of complications: patients with DMD had an increased overall rate compared with those with other neuromuscular conditions. These included deep wound infection and hepatotoxicity. Hepatotoxicity was unique to DMD patients, and we recommend peri-operative vigilance after correction of a scoliosis in this group.

Aim. The purpose of this study was to determine the neuromuscular fatigue profiles during 100 s isometric (ISO), concentric (CON), and eccentric (ECC) activity.Methods. Twelve subjects (age 25.1+/-3.7 years, mass 70.1+/-8.2 kg, mean+/-SD) performed ISO, CON and ECC maximal voluntary contractions and 100 s endurance trials on an isokinetic dynamometer. Raw EMG data were recorded throughout each trial from the rectus femoris of the right limb. Corresponding data for integrated electromyography (IEMG), percentile frequency shifts (MPFS) and peak torque output were divided into five 5 s epochs and subsequently normalised with the first epoch being the reference point, in order to assess changes over time.Results. There were no significant differences between ECC, CON and ISO peak torque output (211+/-63 vs 169+/-41 vs 177+/-61 Nm; ECC, CON, ISO) and IEMG activity (280+/-143 vs 305+/-146 vs 287+/-143 mV; ECC, CON, ISO) during maximal contractions. Serial reductions in torque output were greatest in ISO in which torque output during the final epoch was 31+/-13% of initial values, similar to the final torque values in CON (58+/-15%), but significantly less than ECC (108.6+/-38.6%; P<0.001) values. In CON and ECC, IEMG was maintained (95+/-27% and 93+/-21%; CON and ECC), whereas IEMG for ISO decreased to 38+/-13% of initial values. The greatest reduction in MPFS occurred in CON (69+/-10%) compared to ISO (78+/-9%; P<0.05) and ECC (93+/-6%; P<0.001).Conclusion. These data demonstrate distinct neuromuscular fatigue profiles for the different types of muscle contraction. Whereas eccentric activity was largely fatigue resistant, isometric and concentric contractions displayed different neuromuscular fatigue profiles. (C) 2000 Elsevier Science Ltd. All rights reserved.

It is widely acknowledged that hospitalisation can be a stressful experience for children and their families. There is strong evidence in the literature that the utilisation of well-designed preparation programs can assist children to overcome their fear of hospitalisation and increase their ability to cope with medical procedures. A range of preparation programs have been described in the literature as have barriers to implementation including cost, access and flexibility. It is also important that the content presented is appropriate for the children undertaking the preparation in order to promote understanding. It is imperative that current and future research continues to focus on reducing children's fear of hospitalisation and draws upon previous knowledge to produce effective modes of preparation. The aim of this paper is to discuss how the use of multimedia technology can maintain the momentum in the development of effective preparation programs for children undergoing elective surgery. This paper will provide an overview of the instructional design process for a multimedia preparation program and present data to demonstrate that the program developed is a cognitively appropriate and an acceptable form of preparation for children aged 7-11 years who are scheduled for elective surgery.