Barriers and enablers to implementing police mental health co-responder programs: A qualitative study using the consolidated framework for implementation research

Background

Police and mental health co-responder programs operate internationally and can be effective in providing timely and appropriate assessment, brief intervention, and referral services for people experiencing mental health crises. However, these models vary greatly, and little is known about how the design and implementation of these programs impacts their effectiveness.

Method

This study was a qualitative, post hoc implementation determinant evaluation of mental health co-responder units in Brisbane, Australia, comprising of verbal or written interviews with police and mental health staff with an on-road role in the co-responder units, and their managers. The Consolidated Framework for Implementation Research was used to identify barriers and enablers to the program's implementation and effectiveness.

Results

Participants (n = 30) from all groups felt strongly that the co-responder units are a substantial improvement over the usual police management of mental health crisis cases, and lead to better outcomes for consumers and the service. Enablers included an information-sharing agreement; the Mental Health Co-Responder (MHCORE) program's compatibility with existing police and mental health services; and the learning opportunity for both organizations. Barriers included cultural differences between the organizations, particularly risk-aversion to suicidality for police and a focus on least-restrictive practices for health; extensive documentation requirements for health; and a lack of specific mental health training for police.

Conclusions

Using an evidence-based implementation science framework enabled identification of a broad range of contextual barriers and enablers to implementation of police mental health co-responder programs. Adapting the program to address these barriers and enablers during the planning, implementation, monitoring, and evaluation phases increases the likelihood of the service's effectiveness. These findings will inform the spread and scale of the co-responder program across Queensland, and will be relevant to police districts internationally considering implementing a co-responder program.

“Always opening and never closing”: How dialogical therapists understand and create reflective conversations in network meetings

Tom Andersen’s reflecting team process, which allowed families to witness and respond to the talk of professionals during therapy sessions, has been described as revolutionary in the field of family therapy. Reflecting teams are prominent in a number of family therapy approaches, more recently in narrative and dialogical therapies. This way of working is considered more a philosophy than a technique, and has been received positively by both therapists and service users. This paper describes how dialogical therapists conceptualise the reflective process, how they work to engage families in reflective dialogues and how this supports change. We conducted semi-structured, reflective interviews with 12 dialogical therapists with between 2 and 20 years of experience. Interpretative Phenomenological analysis of transcribed interviews identified varying conceptualisations of the reflecting process and descriptions of therapist actions that support reflective talk among network members. We adopted a dialogical approach to interpretation of this data. In this sense, we did not aim to condense accounts into consensus but instead to describe variations and new ways of understanding dialogical reflecting team practices. Four themes were identified: Lived experience as expertise; Listening to the self and hearing others; Relational responsiveness and fostering connection; and Opening space for something new. We applied these themes to psychotherapy process literature both within family therapy literature and more broadly to understand more about how reflecting teams promote helpful and healing conversations in practice.

Prolonged disorders of consciousness: A response to a "critical evaluation of the new UK guidelines."

BACKGROUND

In 2020, The London Royal College of Physicians published "Prolonged disorders of consciousness following sudden-onset brain injury: national clinical guidelines". In 2021, in the journal Brain, Scolding et al. published "a critical evaluation of the new UK guidelines". This evaluation focussed on one of the 73 recommendations in the National Clinical Guidelines. They also alleged that the guidelines were unethical.

CRITICISMS

They criticised our recommendation not to use activation protocols using fMRI, electroencephalography, or Positron Emission Tomography. They claim these tests can (a) detect 'covert consciousness', (b) add predictive value and (c) should be part of routine clinical care. They also suggest that our guideline was driven by cost considerations, leading to clinicians deciding to withdraw treatment at 72 h.

EVIDENCE

Our detailed review of the evidence confirms the American Academy of Neurology Practise Guideline (2018) and the European Academy of Neurology Guideline (2020), which agree that insufficient evidence supports their approach.

ETHICS

The ethical objections are based on unwarranted assumptions. Our guideline does not make any recommendations about management until at least four weeks have passed. We explicitly recommend that expert assessors undertake ongoing surveillance and monitoring; we do not suggest that patients be abandoned. Our recommendation will increase the cost We had ethicists in the working party.

CONCLUSION

We conclude the "critical evaluation" fails to provide evidence for their criticism and that the ethical objections arise from incorrect assumptions and unsupported interpretations of evidence and our guideline. The 2020 UK national guidelines remain valid.

104 Assessing for Delirium in A District General Emergency Department—Why are We Failing and How can We Improve?

Introduction

Delirium is among the most common of medical emergencies with a prevalence of 20% in adult acute general medical patients. Despite this delirium is underdiagnosed and treatment is variable. Assessment of delirium is missed or carried out unreliably in EDs.

Methodology

Using the Model for Improvement, we developed a driver diagram to plan our project. Assessing whether patients over 65 years old were assessed for delirium during their visit to the ED using a validated tool over a 6-month period. Evaluating the impact of our interventions using annotated run charts. Exclusion criteria—GCS under 13, NEWS2 greater than 5.

Aim

Identify current performance of delirium assessment in over 65 s in Weston General Hospital ED and improve to 100% of over 65 s screened. Assess whether this has been communicated in the discharge summary.

Results

Baseline data showed 22.2% (4/18) of patients meeting inclusion criteria were screened for delirium. We implemented multiple interventions over a 2-month period—discussing at ED handover, hospital wide email, presentation at grand round and displaying a poster in the ED. In the 6 weeks after the interventions were implemented there was increase to 45.4% (15/33) of patients over 65 screened. Delirium/cognitive impairment identified in 42.5% (48/113) of patients screened. This is higher than the national average of hospital admissions therefore it is likely people screen those who display signs of delirium. Cognitive impairment communicated in discharge letter in only 29.4% (33/113) of all patients.

Conclusion

There has been a great improvement in delirium screening. However, we did not meet our target of 100% of patients being screened. Interventions currently being implemented—addition of SQID tool to minors clerking document, addition of compulsory tick box delirium question on all discharge summaries. Further data will be collected to assess effectiveness of these interventions.

Fractal dimension of cortical functional connectivity networks & severity of disorders of consciousness

Recent evidence suggests that the quantity and quality of conscious experience may be a function of the complexity of activity in the brain and that consciousness emerges in a critical zone between low and high-entropy states. We propose fractal shapes as a measure of proximity to this critical point, as fractal dimension encodes information about complexity beyond simple entropy or randomness, and fractal structures are known to emerge in systems nearing a critical point. To validate this, we tested several measures of fractal dimension on the brain activity from healthy volunteers and patients with disorders of consciousness of varying severity. We used a Compact Box Burning algorithm to compute the fractal dimension of cortical functional connectivity networks as well as computing the fractal dimension of the associated adjacency matrices using a 2D box-counting algorithm. To test whether brain activity is fractal in time as well as space, we used the Higuchi temporal fractal dimension on BOLD time-series. We found significant decreases in the fractal dimension between healthy volunteers (n = 15), patients in a minimally conscious state (n = 10), and patients in a vegetative state (n = 8), regardless of the mechanism of injury. We also found significant decreases in adjacency matrix fractal dimension and Higuchi temporal fractal dimension, which correlated with decreasing level of consciousness. These results suggest that cortical functional connectivity networks display fractal character and that this is associated with level of consciousness in a clinically relevant population, with higher fractal dimensions (i.e. more complex) networks being associated with higher levels of consciousness. This supports the hypothesis that level of consciousness and system complexity are positively associated, and is consistent with previous EEG, MEG, and fMRI studies.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Development and validation of outcome prediction models for aneurysmal subarachnoid haemorrhage: the SAHIT multinational cohort study

OBJECTIVE

To develop and validate a set of practical prediction tools that reliably estimate the outcome of subarachnoid haemorrhage from ruptured intracranial aneurysms (SAH).

DESIGN

Cohort study with logistic regression analysis to combine predictors and treatment modality.

SETTING

Subarachnoid Haemorrhage International Trialists' (SAHIT) data repository, including randomised clinical trials, prospective observational studies, and hospital registries.

PARTICIPANTS

Researchers collaborated to pool datasets of prospective observational studies, hospital registries, and randomised clinical trials of SAH from multiple geographical regions to develop and validate clinical prediction models.

MAIN OUTCOME MEASURE

Predicted risk of mortality or functional outcome at three months according to score on the Glasgow outcome scale.

RESULTS

Clinical prediction models were developed with individual patient data from 10 936 patients and validated with data from 3355 patients after development of the model. In the validation cohort, a core model including patient age, premorbid hypertension, and neurological grade on admission to predict risk of functional outcome had good discrimination, with an area under the receiver operator characteristics curve (AUC) of 0.80 (95% confidence interval 0.78 to 0.82). When the core model was extended to a "neuroimaging model," with inclusion of clot volume, aneurysm size, and location, the AUC improved to 0.81 (0.79 to 0.84). A full model that extended the neuroimaging model by including treatment modality had AUC of 0.81 (0.79 to 0.83). Discrimination was lower for a similar set of models to predict risk of mortality (AUC for full model 0.76, 0.69 to 0.82). All models showed satisfactory calibration in the validation cohort.

CONCLUSION

The prediction models reliably estimate the outcome of patients who were managed in various settings for ruptured intracranial aneurysms that caused subarachnoid haemorrhage. The predictor items are readily derived at hospital admission. The web based SAHIT prognostic calculator (http://sahitscore.com) and the related app could be adjunctive tools to support management of patients.

Paediatric neurorehabilitation: finding and filling the gaps through the use of the Institute for Manufacturing strategic roadmapping method

Introduction

Acquired brain injury (ABI) is a major cause of morbidity and mortality in childhood. Specialist rehabilitation services are often situated far from families and local services may be non-standardised and fragmented. A strategic level of understanding is needed to improve patient care and outcomes. Roadmapping techniques are commonly used in industry settings to discover and present a systematic understanding of structures; however, they are rarely used in the healthcare setting. With continuing pressures on healthcare systems worldwide, they provide an effective method for examining services.

Methods

The Institute for Manufacturing (IfM) strategic roadmapping method was used to identify areas of difficulty and opportunities in paediatric neurorehabilitation. Participants included stakeholders from a wide range of professions and sectors who have input with children after ABI.

Results

Delegates identified a range of ‘layers’ covering trends, drivers, current experience and unmet needs. From these layers, four priorities were identified and further expanded.These included: ‘access to medical and therapy expertise close(r) to home’, ‘shared understanding across family, school and health’, ‘family and professional awareness of resources and support’ and ‘establishing a centre for rehabilitation technology evaluation, advice and co-ordination of services and research’.

Conclusion

The IfM strategic roadmapping method identified and developed key areas for development in the field of paediatric neurological rehabilitation. Healthcare professionals looking at strategic level difficulties should strongly consider the use of such systematic tools when evaluating areas of practice.

Changes in Cerebral Partial Oxygen Pressure and Cerebrovascular Reactivity During Intracranial Pressure Plateau Waves

BACKGROUND

Plateau waves in intracranial pressure (ICP) are frequently recorded in neuro intensive care and are not yet fully understood. To further investigate this phenomenon, we analyzed partial pressure of cerebral oxygen (pbtO2) and a moving correlation coefficient between ICP and mean arterial blood pressure (ABP), called PRx, along with the cerebral oxygen reactivity index (ORx), which is a moving correlation coefficient between cerebral perfusion pressure (CPP) and pbtO2 in an observational study.

METHODS

We analyzed 55 plateau waves in 20 patients after severe traumatic brain injury. We calculated ABP, ABP pulse amplitude (ampABP), ICP, CPP, pbtO2, heart rate (HR), ICP pulse amplitude (ampICP), PRx, and ORx, before, during, and after each plateau wave. The analysis of variance with Bonferroni post hoc test was used to compare the differences in the variables before, during, and after the plateau wave. We considered all plateau waves, even in the same patient, independent because they are separated by long intervals.

RESULTS

We found increases for ICP and ampICP according to our operational definitions for plateau waves. PRx increased significantly (p = 0.00026), CPP (p < 0.00001) and pbtO2 (p = 0.00007) decreased significantly during the plateau waves. ABP, ampABP, and HR remained unchanged. PRx during the plateau was higher than before the onset of wave in 40 cases (73 %) with no differences in baseline parameters for those with negative and positive ΔPRx (difference during and after). ORx showed an increase during and a decrease after the plateau waves, however, not statistically significant. PbtO2 overshoot after the wave occurred in 35 times (64 %), the mean difference was 4.9 ± 4.6 Hg (mean ± SD), and we found no difference in baseline parameters between those who overshoot and those who did not overshoot.

CONCLUSIONS

Arterial blood pressure remains stable in ICP plateau waves, while cerebral autoregulatory indices show distinct changes, which indicate cerebrovascular reactivity impairment at the top of the wave. PbtO2 decreases during the waves and may show a slight overshoot after normalization. We assume that this might be due to different latencies of the cerebral blood flow and oxygen level control mechanisms. Other factors may include baseline conditions, such as pre-plateau wave cerebrovascular reactivity or pbtO2 levels, which differ between studies.

Plateau Waves of Intracranial Pressure and Partial Pressure of Cerebral Oxygen

This study investigates 55 intracranial pressure (ICP) plateau waves recorded in 20 patients after severe traumatic brain injury (TBI) with a focus on a moving correlation coefficient between mean arterial pressure (ABP) and ICP, called PRx, which serves as a marker of cerebrovascular reactivity, and a moving correlation coefficient between ABP and cerebral partial pressure of oxygen (pbtO2), called ORx, which serves as a marker for cerebral oxygen reactivity. ICP and ICPamplitude increased significantly during the plateau waves, whereas CPP and pbtO2 decreased significantly. ABP, ABP amplitude, and heart rate remained unchanged. In 73 % of plateau waves PRx increased during the wave. ORx showed an increase during and a decrease after the plateau waves, which was not statistically significant. Our data show profound cerebral vasoparalysis on top of the wave and, to a lesser extent, impairment of cerebral oxygen reactivity. The different behavior of the indices may be due to the different latencies of the cerebral blood flow and oxygen level control mechanisms. While cerebrovascular reactivity is a rapidly reacting mechanism, cerebral oxygen reactivity is slower.

Borderline Intracranial Hypertension Manifesting as Chronic Fatigue Syndrome Treated by Venous Sinus Stenting

Chronic fatigue syndrome and cases of idiopathic intracranial hypertension without signs of raised intracranial pressure can be impossible to distinguish without direct measurement of intracranial pressure. Moreover, lumbar puncture, the usual method of measuring intracranial pressure, can produce a similar respite from symptoms in patients with chronic fatigue as it does in idiopathic intracranial hypertension. This suggests a connection between them, with chronic fatigue syndrome representing a forme fruste variant of idiopathic intracranial hypertension. If this were the case, then treatments available for idiopathic intracranial hypertension might be appropriate for chronic fatigue. We describe a 49-year-old woman with a long and debilitating history of chronic fatigue syndrome who was targeted for investigation of intracranial pressure because of headache, then diagnosed with borderline idiopathic intracranial hypertension after lumbar puncture and cerebrospinal fluid drainage. Further investigation showed narrowings at the anterior ends of the transverse sinuses, typical of those seen in idiopathic intracranial hypertension and associated with pressure gradients. Stenting of both transverse sinuses brought about a life-changing remission of symptoms with no regression in 2 years of follow-up. This result invites study of an alternative approach to the investigation and management of chronic fatigue.

Brain Slump Caused by Jugular Venous Stenoses Treated by Stenting: A Hypothesis to Link Spontaneous Intracranial Hypotension with Idiopathic Intracranial Hypertension

Spontaneous intracranial hypotension, of which brain slump is an extreme expression, is caused by a cerebrospinal fluid leak. The reason the leak develops in the first place, however, is unknown, and some cases can be very difficult to manage. We describe a patient with severe symptoms of spontaneous intracranial hypotension and brain slump documented by magnetic resonance imaging whose clinical syndrome and structural brain anomaly resolved completely after treatment directed exclusively at improving cranial venous outflow. Diagnostics included computed tomography (CT) venography, catheter venography, and jugular venoplasty. CT venography showed narrowing of both internal jugular veins below the skull base. Catheter venography confirmed that these were associated with pressure gradients. Jugular venoplasty performed on two separate occasions as a clinical test gave temporary respite. Lasting remission (2 years of follow-up) was achieved by stenting the dominant internal jugular vein. These findings and this outcome suggest a mechanism for the development of spontaneous intracranial hypotension that would link it to idiopathic intracranial hypertension and have cranial venous outflow obstruction as the underlying cause.

Short pressure reactivity index versus long pressure reactivity index in the management of traumatic brain injury

OBJECT

The pressure reactivity index (PRx) correlates with outcome after traumatic brain injury (TBI) and is used to calculate optimal cerebral perfusion pressure (CPPopt). The PRx is a correlation coefficient between slow, spontaneous changes (0.003–0.05 Hz) in intracranial pressure (ICP) and arterial blood pressure (ABP). A novel index—the so-called long PRx (L-PRx)—that considers ABP and ICP changes (0.0008–0.008 Hz) was proposed.

METHODS

The authors compared PRx and L-PRx for 6-month outcome prediction and CPPopt calculation in 307 patients with TBI. The PRx- and L-PRx–based CPPopt were determined and the predictive power and discriminant abilities were compared.

RESULTS

The PRx and L-PRx correlation was good (R = 0.7, p < 0.00001; Spearman test). The PRx, age, CPP, and Glasgow Coma Scale score but not L-PRx were significant fatal outcome predictors (death and persistent vegetative state). There was a significant difference between the areas under the receiver operating characteristic curves calculated for PRx and L-PRx (0.61 ± 0.04 vs 0.51 ± 0.04; z-statistic = −3.26, p = 0.011), which indicates a better ability by PRx than L-PRx to predict fatal outcome. The CPPopt was higher for L-PRx than for PRx, without a statistical difference (median CPPopt for L-PRx: 76.9 mm Hg, interquartile range [IQR] ± 10.1 mm Hg; median CPPopt for PRx: 74.7 mm Hg, IQR ± 8.2 mm Hg). Death was associated with CPP below CPPopt for PRx (χ2 = 30.6, p < 0.00001), and severe disability was associated with CPP above CPPopt for PRx (χ2 = 7.8, p = 0.005). These relationships were not statistically significant for CPPopt for L-PRx.

CONCLUSIONS

The PRx is superior to the L-PRx for TBI outcome prediction. Individual CPPopt for L-PRx and PRx are not statistically different. Deviations between CPP and CPPopt for PRx are relevant for outcome prediction; those between CPP and CPPopt for L-PRx are not. The PRx uses the entire B-wave spectrum for index calculation, whereas the L-PRX covers only one-third of it. This may explain the performance discrepancy.

Stent-Mediated Redistribution of Cerebral Venous Outflow in the Treatment of Severe Intractable Headache: A Case Report

We describe a patient with multiple symptoms but whose primary complaint was of headache, in whom no firm diagnosis was made in two years, who was resistant to all treatment, until a markedly asymmetrical cranial venous outflow came to be regarded, not as normal variant anatomy but as fundamental to the clinical problem. Deliberately altering this anatomy in favour of a more symmetrical arrangement by stenting a hypoplastic transverse sinus brought about an immediate, profound and sustained clinical improvement. This result challenges the existing consensus on what is acceptable as normal in respect of cranial venous outflow. It raises intriguing questions about the relationship between neurological symptoms and the vagaries of cranial venous outflow anatomy. It suggests there may be new opportunities in the investigation of chronic headache.

Lumbar puncture, chronic fatigue syndrome and idiopathic intracranial hypertension: a cross-sectional study

OBJECTIVE

Unsuspected idiopathic intracranial hypertension (IIH) is found in a significant minority of patients attending clinics with named headache syndromes, if it is specifically sought out. Chronic fatigue syndrome is frequently associated with headache. Could the same be true of chronic fatigue? Moreover, there are striking similarities between the two conditions. Could they be related? Attempting to answer these questions, we describe the results of a change in clinical practice aimed at capturing patients with chronic fatigue who might have IIH.

DESIGN

Cross-sectional.

SETTING

Hospital outpatient and radiology departments.

PARTICIPANTS

Patients attending a specialist clinic with chronic fatigue syndrome and headache who had lumbar puncture to exclude raised intracranial pressure.

MAIN OUTCOME MEASURES

Intracranial pressure measured at lumbar puncture and the effect on headache of cerebrospinal fluid drainage.

RESULTS

Mean cerebrospinal fluid pressure was 19 cm H2O (range 12-41 cm H2O). Four patients fulfilled the criteria for IIH. Thirteen others did not have pressures high enough to diagnose IIH but still reported an improvement in headache after drainage of cerebrospinal fluid. Some patients also volunteered an improvement in other symptoms, including fatigue. No patient had any clinical signs of raised intracranial pressure.

CONCLUSIONS

An unknown, but possibly substantial, minority of patients with chronic fatigue syndrome may actually have IIH. An unknown, but much larger, proportion of patients with chronic fatigue syndrome do not have IIH by current criteria but respond to lumbar puncture in the same way as patients who do. This suggests that the two conditions may be related.

Looking for idiopathic intracranial hypertension in patients with chronic fatigue syndrome

INTRODUCTION

Headache is common in chronic fatigue syndrome, a condition of unknown cause in which there are no clinical signs. Fatigue is common in idiopathic intracranial hypertension, a headache condition of unknown cause in which the only clinical signs are those of raised intracranial pressure, signs which may be absent. Might, therefore, idiopathic intracranial hypertension be present in some patients diagnosed with chronic fatigue syndrome? Could the two conditions be related?

PATIENTS AND METHODS

From June 2007, patients attending a specialist clinic who fulfilled the diagnostic criteria for chronic fatigue syndrome and in whom headache was an especially prominent symptom were offered CT venography and lumbar puncture, looking for evidence of raised intracranial pressure.

RESULTS

Of the 20 patients who accepted lumbar puncture, eight had pressures of 20 cm H₂O or greater, including three who had pressures of 25 cm H₂O or greater. Mean pressure was 19 cm H₂O.

CONCLUSIONS

Some patients with headache and a diagnosis of chronic fatigue syndrome have unrecognised and occult idiopathic intracranial hypertension. The possibility that the two conditions are related cannot be excluded.

The rate, risk factors and cost of surgical site infections in primary breast surgery

Although breast surgery involving clean wounds is expected to be associated with a low risk of surgi-cal site infection (SSI) and minimal associated costs, estimates of infection could be affected by intensity of case finding and choice of follow-up methods. A broad range of post-discharge follow-up methods is more likely to estimate true SSI rates and costs. This prospective systematic study used 30 day surveillance with active data collection methods to identify the rate and cost of surgical site infection in patients having primary breast surgery. Ten per cent of patients (16/159) had a surgical site infection. The additional average cost of treating each infected patient was £1443. Hierarchical sequential regression identified high body mass index, operations lasting more than two hours and smoking as significant independent risk factors.

Mapping traumatic axonal injury using diffusion tensor imaging: correlations with functional outcome

BACKGROUND

Traumatic brain injury is a major cause of morbidity and mortality worldwide. Ameliorating the neurocognitive and physical deficits that accompany traumatic brain injury would be of substantial benefit, but the mechanisms that underlie them are poorly characterized. This study aimed to use diffusion tensor imaging to relate clinical outcome to the burden of white matter injury.

METHODOLOGY/PRINCIPAL FINDINGS

Sixty-eight patients, categorized by the Glasgow Outcome Score, underwent magnetic resonance imaging at a median of 11.8 months (range 6.6 months to 3.7 years) years post injury. Control data were obtained from 36 age-matched healthy volunteers. Mean fractional anisotropy, apparent diffusion coefficient (ADC), and eigenvalues were obtained for regions of interest commonly affected in traumatic brain injury. In a subset of patients where conventional magnetic resonance imaging was completely normal, diffusion tensor imaging was able to detect clear abnormalities. Significant trends of increasing ADC with worse outcome were noted in all regions of interest. In the white matter regions of interest worse clinical outcome corresponded with significant trends of decreasing fractional anisotropy.

CONCLUSIONS/SIGNIFICANCE

This study found that clinical outcome was related to the burden of white matter injury, quantified by diffusivity parameters late after traumatic brain injury. These differences were seen even in patients with the best outcomes and patients in whom conventional magnetic resonance imaging was normal, suggesting that diffusion tensor imaging can detect subtle injury missed by other techniques. An improved in vivo understanding of the pathology of traumatic brain injury, including its distribution and extent, may enhance outcome evaluation and help to provide a mechanistic basis for deficits that remain unexplained by other approaches.

Ethical issues in consenting vulnerable patients for neuroscience research

Many subjects cannot give fully informed consent to take part in research by virtue of age or mental capacity. However, it is unacceptable to deny these patients involvement in research by virtue of a lack of capacity to consent to such research. Further, this would hinder the advancement of medical science and technologies that might ultimately benefit these patients. Conversely, it is as unacceptable to discriminate against these patients and their condition as it is to exploit them or expose them to undue risk. Neuroscientific research raises a number of specific ethical issues in this patient population, in particular issues of consent, potential benefits of research, management of incidental findings and the assignment of appropriate controls. This paper examines the dilemmas that surround such ethical issues, and demonstrates that various procedures including informed consent, deferred consent and consent by proxy can be used to consent patients in both the standard medical and research arenas. Researchers, clinicians and regulatory authorities must work together to understand the benefits, limitations, risks and obligations of any research study involving these patients in order to advance medical care.

Developing the Role of a Health Information Professional in a Clinical Research Setting

Objective - This paper examines the role of a health information professional in a large multidisciplinary project to improve services for head injury. Methods - An action research approach was taken, with the information professional acting as co-ordinator. Change management processes were guided by theory and evidence. The health information professional was responsible for an ongoing literature review on knowledge management (clinical and political issues), data collection and analysis (from patient records), collating and comparing data (to help develop standards), and devising appropriate dissemination strategies. Results - Important elements of the health information management role proved to be 1) co-ordination; 2) setting up mechanisms for collaborative learning through information sharing; and 3) using the theoretical frameworks (identified from the literature review) to help guide implementation. The role that emerged here has some similarities to the informationist role that stresses domain knowledge, continuous learning and working in context (embedding). This project also emphasised the importance of co-ordination, and the ability to work across traditional library information analysis (research literature discovery and appraisal) and information analysis of patient data sets (the information management role). Conclusion - Experience with this project indicates that health information professionals will need to be prepared to work with patient record data and synthesis of that data, design systems to co-ordinate patient data collection, as well as critically appraise external evidence.

Psychiatric, cognitive and behavioural outcomes following craniopharyngioma and pituitary adenoma surgery

In order to determine the cognitive and behavioural changes in patients following craniopharyngioma surgery, all patients over the age of 16 years who had an operative intervention for craniopharyngioma between 1983 and 1998 were identified. Those consenting were interviewed using standardized instruments to assess for the presence of a psychiatric disorder, disturbance of behaviour or altered cognitive function. A control group of age- and sex-matched patients who had undergone pituitary adenoma excision were identically assessed. Eighteen people, of a total of 44, were interviewed. There were some differences in the subjective experience of appetite and the degree of control exercised over eating behaviour. Otherwise outcomes in cases and controls were similar. In the domains assessed, these two groups have similar outcomes from surgery.

Spontaneous cerebrospinal fluid rhinorrhoea as the presenting feature of an invasive macroprolactinoma

A 29-year-old male university student, with no prior history of trauma, presented with a 1 year history of clear fluid leaking intermittently from his left nostril. His past medical history included bilateral gynaecomastia since age 12, and recent low libido. β2-transferrin analysis of the nasal fluid confirmed a diagnosis of cerebrospinal fluid (CSF) rhinorrhoea. The serum prolactin was grossly elevated at 42 700 mU/l and brain magnetic resonance imaging (MRI) revealed a large parasellar/sellar mass. A diagnosis of invasive macroprolactinoma complicated by spontaneous CSF rhinorrhoea was made. The patient was commenced on treatment with cabergoline, but while awaiting surgery to repair the CSF leak he developed streptococcus mitis and sanguis meningitis. He made an uncomplicated recovery with antibiotic treatment. Immediately following this episode, the CSF rhinorrhoea resolved spontaneously. Subsequently, a repeat MRI scan revealed dramatic involution of the pituitary mass and the serum prolactin had fallen to 604 mU/l.

Analysis of leukocyte rolling in vivo and in vitro

Leukocyte rolling is an important step for the successful recruitment of leukocytes from blood to tissues mediated by a specialized group of glycoproteins termed selectins. Because of the dynamic process of leukocyte rolling, binding of selectins to their respective counter-receptors (selectin ligands) needs to fulfill three major requirements: (1) rapid bond formation, (2) high tensile strength, and (3) fast dissociation rates. These criteria are perfectly met by selectins, which interact with specific carbohydrate determinants on selectin ligands. This chapter describes the theoretical background, technical requirements, and analytical tools needed to quantitatively assess leukocyte rolling in vivo and in vitro. For the in vivo setting, intravital microscopy allows the observation and recording of leukocyte rolling under different physiological and pathological conditions in almost every organ. Real-time and off-line analysis tools help to assess geometric, hemodynamic, and rolling parameters. Under in vitro conditions, flow chamber assays such as parallel plate flow chamber systems have been the mainstay to study interactions between leukocytes and adhesion molecules under flow. In this setting, adhesion molecules are immobilized on plastic, in a lipid monolayer, or presented on cultured endothelial cells on the chamber surface. Microflow chambers are available for studying leukocyte adhesion in the context of whole blood and without blood cell isolation. The microscopic observation of leukocyte rolling in different in vivo and in vitro settings has significantly contributed to our understanding of the molecular mechanisms responsible for the stepwise extravasation of leukocytes into inflamed tissues.

Monitoring emergence from coma following severe brain injury in an octogenarian using behavioural indicators, electrophysiological measures and metabolic studies: a demonstration of the potential for good recovery in older adults

This case study describes a multi-disciplinary investigation of the emergence from coma of an 80-year old female (KE) following severe traumatic brain injury. The relationship between cognitive/behavioural ability and the integrity of cerebral function was assessed using neuropsychological measures, positron emission tomography, electroencephalography, somatosensory evoked potentials and trans-cranial magnetic stimulation. These investigations were performed as KE was beginning to emerge from coma (4 weeks) and, again, approximately 1 year following brain injury, when she was judged to have achieved her maximum level of recovery. Neuropsychological measures revealed improvement during the first year post-injury in KE's speed of information processing, memory and executive abilities. Electrophysiological and metabolic studies indicated a restoration of functional integrity that was consistent with the gradual recovery in higher brain function documented using behavioural procedures. This case study demonstrates the rehabilitation potential of pre-morbidly healthy older adults following severe traumatic brain injury.