Intracranial pressure monitors in traumatic brain injury: a systematic review

We conducted a systematic review to examine the relationship between intracranial pressure monitors (ICP) monitors and mortality in traumatic brain injury (TBI). We systematically searched for articles that met the following criteria: (1) adults patients, (2) TBI, (3) use of an ICP monitor, (4) point estimate for mortality with ICP monitoring (5) adjustment for potential confounders. Six observational studies were identified with 11,371 patients. There was marked between-study heterogeneity that precluded a pooled analysis. Patients with ICP monitors had different clinical characteristics and received more ICP targeted therapy in the ICU. Four studies found no significant relationship between ICP monitoring and survival, while the other two studies demonstrated conflicting results. Significant confounding by indication in observational studies limits the examination of isolated TBI interventions. More research should focus on interventions that affect TBI careplan systems. Further research is needed to identify which subset of severe TBI patients may benefit from ICP monitoring.     

Measuring antiplatelet drug effects in the laboratory

This review discusses the advantages and disadvantages of currently available tests for the monitoring of antiplatelet therapy (especially aspirin and clopidogrel). Many tests of platelet function are now available for clinical use, and some of these tests have been shown to predict clinical outcomes after antiplatelet therapy. However, in most of these studies, the number of major adverse clinical events was low. No published studies address the clinical effectiveness of altering therapy based on the results of monitoring antiplatelet therapy. Therefore, the correct treatment, if any, of "resistance" to antiplatelet therapy is unknown and, other than in research trials, monitoring of antiplatelet therapy in patients is not generally recommended. A clinically meaningful definition of "resistance" to antiplatelet drugs needs to be developed, based on data linking drug-dependent laboratory tests to clinical outcomes in patients.     

Integrating unmet needs into dementia health-related quality of life research and care: Introduction of the Hierarchy Model of Needs in Dementia

Objectives: To make an inventory of needs assessment instruments in dementia, to explore the interaction between unmet needs and health-related quality of life (HRQoL) and to relate these to the conceptual model of Maslow's Hierarchy of needs in order to design a dementia-specific model.

Methods: Narrative review of literature on (measures of) needs of patients and caregivers and HRQoL determinants important in dementia. Relating these needs to individual goal setting instruments and Maslow's Hierarchy of needs model.

Results: The Camberwell Assessment of Needs for the Elderly (CANE) turns out to be a valid tool to assess needs of dementia patients, suitable for research and clinical use. The Carers’ Needs Assessment for Dementia (CNA-D) is a valid instrument to assess needs of caregivers. Patients identified significantly fewer needs than (in)formal caregivers. The most important needs, that also determine large part of HRQoL, are need for information; support with regard to symptoms of dementia; social contact and company; and for health monitoring and safety. Goal attainment scaling in dementia is an important but not yet valid outcome measure, with only few data on feasibility in dementia patients.

Conclusion: There are several instruments to assess needs of dementia patients and caregivers. Domains of unmet needs and HRQoL overlap. The Hierarchy Model of Needs in Dementia (HMND) offers a new theoretical framework to address the interplay between meeting of needs and improvement of HRQoL in dementia. By identifying unmet needs in dementia-research and focussing on unmet needs in dementia-care, much can be done to improve HRQoL.     

Implementing a clinical and research registry in obstetrics: overcoming the barriers

OBJECTIVE: This study aimed to describe the obstacles and solutions in developing and implementing a prospective obstetric database registry that collects biopsychosocial data on women during pregnancy and postpartum. The clinical goals of the registry were to improve both diagnosis of mental health and substance use problems and access to mental health care during pregnancy. The research goals were to examine the impact of psychiatric illness and substance use on birth outcomes. STUDY SETTING AND REGISTRY DESIGN: A questionnaire that contained validated instruments for mental health, substance use and psychosocial stressors was developed and administered to all pregnant women in an academic medical center obstetric clinic. Results were incorporated with reminder and decision support systems to ensure active follow-up of patients with mental health needs. Automated medical record information was collected for future analysis of outcomes. PROGRAM IMPLEMENTATION: Barriers to program implementation were overcome by a multifaceted intervention that included educational outreach to patients, providers and staff; integration of the registry into preexisting clinical protocols; reminder systems at workstations; provision of mental health decision support through perinatal social work and psychiatric consultation; and utilization of a "stepped-care" model to delivering mental health services. CONCLUSION: A mental health registry that merges clinical and research needs can be successfully integrated into the obstetric clinic setting.     

Identifying Unmet Rehabilitation Needs in Patients After Stroke With a Graphic Rehab-CompassTM

Background

Unmet rehabilitation needs are common among stroke survivors. We aimed to evaluate whether a comprehensive graphic “Rehab-Compass,” a novel combination of structured patient-reported outcome measures, was feasible and useful in facilitating a capture of patients' rehabilitation needs in clinical practice.

How to train residents to identify and treat dual diagnosis patients.

Medical training has failed to address the needs of patients with comorbid substance use and psychiatric disorders. Addiction teaching is limited and often fails to change the negative attitudes of many physicians. In many psychiatry residencies, addiction training occurs on inpatient or detoxification units and the focus is on screening, detoxification, and referral. Most residents do not gain adequate experience in the long-term management of dual-diagnosis patients. Successful clinical care is based on three critical elements (the "clinician's triad"): an adequate knowledge base, a positive attitude toward the patient and the benefits of treatment, and a sense of responsibility for the clinical problem. The Boston University Psychiatry Residency has designed an addiction training program to address these three issues. In addition to a comprehensive addiction seminar series, there are several unique features. The required clinical rotation occurs in an outpatient dual-diagnosis clinic and permits residents to follow a caseload of patients for 12 months. Extensive experience is gained in motivational interviewing, cognitive behavioral therapy, and pharmacotherapy. Self-directed learning approaches are used to maximize the educational experience on services that lack addiction faculty. Guidelines are provided for establishing a similar program and for more effective approaches to resident teaching.     

Point-of-care (POCT) prothrombin time monitors: is a periodical control of their performance useful?

Introduction

Point-of-care testing (POCT) prothrombin time monitors are now widely used to monitor oral anticoagulant treatment. Although portable coagulometers are extremely easy to use, checking the quality of their performance presents some difficulties.

Materials and Methods

The aims of this study were to investigate on a quarterly basis the performance of 95 Coagucheck S assigned to 99 anticoagulated patients at home. This was done checking the monitors versus a reference coagulometer in the laboratory at our Thrombosis Centre (TC). The other aims were to carry out an external quality assessment employing different sets of INR certified plasmas with 5 different ranges of anticoagulation and to assess the performance of the different lots of strips employed by the patients during the study.

Results

No difference between the PT INR obtained with both the systems at the first quarterly check was noted but a significant difference was found when the two systems were compared at the second and third quarterly checks. The Bland-Altman test showed increased disagreement between the first and the third controls. The percentage of INR values that showed a difference of more or less than 0.5 INR units in the PT values performed with both the systems was: 1.0% (first control), 7.5% (second control) and 11.5% (third control) (Chi-Square: 8.315, p = 0.0156). Lots with differences higher than 10% in terms of ± 0.5 INR Units at the first, second and third controls were 16%, 20.8% and 61%, respectively. Seven monitors (7.3%) failed to test one or two of the INR certified plasmas of one set but performed well using a second set of plasmas. Three monitors (3.1%) failed to test two sets of plasmas but performed well using a different lot of strips (from 279A to 483A). One monitor (1%) gave unsatisfactory results with different sets of plasmas and strips. All the other PT INR obtained with the monitors fell well within the different ranges of the INR certified plasmas.

Conclusions

Anticoagulated patient in self-testing or self-management should periodically bring their portable coagulometer to a reference Thrombosis Centre especially when the lot of strips have to be changed. The role of Thrombosis Centre appears therefore crucial in this regard.     

Measuring and Monitoring ICP in Neurocritical Care: Results from a National Practice Survey

Introduction

The use of intracranial pressure (ICP) monitors is nearly synonymous with Neurocritical Care. Recent studies in nursing literature have report high levels of practice variance associated with ICP monitoring and treatment. There are no recent practice surveys to describe how critical care physicians and nurses who are familiar with ICP management provide care to their patients.

Methods

A short survey was developed and disseminated electronically to the members of the Neurocritical Care Society.

Results

The summary from 241 professionals provides evidence that there is significant practice variation associated with ICP monitoring and management.

Conclusion

The results highlight the need to develop standardized approaches to measuring, monitoring, recording, and treating ICP.     

Incidence and mechanisms of cerebral ischemia in early clinical head injury.

Antemortem demonstration of ischemia has proved elusive in head injury because regional CBF reductions may represent hypoperfusion appropriately coupled to hypometabolism. Fifteen patients underwent positron emission tomography within 24 hours of head injury to map cerebral blood flow (CBF), cerebral oxygen metabolism (CMRO2), and oxygen extraction fraction (OEF). We estimated the volume of ischemic brain (IBV) and used the standard deviation of the OEF distribution to estimate the efficiency of coupling between CBF and CMRO2. The IBV in patients was significantly higher than controls (67 +/- 69 vs. 2 +/- 3 mL; P < 0.01). The coexistence of relative ischemia and hyperemia in some patients implies mismatching of perfusion to oxygen use. Whereas the saturation of jugular bulb blood (SjO2) correlated with the IBV (r = 0.8, P < 0.01), SjO2 values of 50% were only achieved at an IBV of 170 +/- 63 mL (mean +/- 95% CI), which equates to 13 +/- 5% of the brain. Increases in IBV correlated with a poor Glasgow Outcome Score 6 months after injury (rho = -0.6, P < 0.05). These results suggest significant ischemia within the first day after head injury. The ischemic burden represented by this "traumatic penumbra" is poorly detected by bedside clinical monitors and has significant associations with outcome.     

Randomized controlled trials in evidence-based mental health care: getting the right answer to the right question

The purpose of clinical research is to answer this question: Would a new treatment, when added to the existing range of treatment options available in practice, help patients? Randomized controlled trials (RCTs)--in particular, double-blind RCTs--have important methodological advantages over observational studies for addressing this question. These advantages, however, come at a price. RCTs compare treatments using a particular allocation rule for assigning patients to treatments (random assignment) that does not mimic real-world practice. "Favorable" results from an RCT indicating that a new treatment is superior to existing treatments are neither necessary nor sufficient for establishing a "yes" answer to the question posed above. Modeled on an experimental design, RCTs are expensive in time and money and must compare simple differences in treatments. Findings have a high internal validity but may not address the needs of the field, particularly where treatment is complex and rapidly evolving. Design of clinical research needs to take account of the way treatments are allocated in actual practice and include flexible designs to answer important questions most effectively.     

Psychiatric Eclecticism: a cognitive view

Pluralism is necessary in psychiatry to compensate for the errors and biases characteristic of the equipment we use to appraise clinical "reality"--our own perceptual-cognitive apparatus. Our attention to clinical situations is skewed: we notice "data" consistent with past assumptions and formulations, and consequently, those views are reinforced by our perceptions. The eclectic posture involves approaching each clinical situation from multiple theoretical perspectives and settling on a perspective that most closely agrees with the patient's needs and wishes without sacrificing the best information available to the psychiatrist. Such eclecticism defines the psychiatrist's role as that of a broad-based scholar who can apply what he knows to the clinical situation. The author discusses the implications for clinical practice and psychiatric education.     

Issues in providing mental health services to hearing-impaired persons

Interest in the mental health service needs of hearing-impaired persons has expanded over the past 35 years, but the availability and accessibility of clinical services have lagged behind developments in research. Despite federal mandates, deaf Americans' psychiatric and psychosocial needs remain profoundly underserved. The author provides an overview of deaf culture and the deaf community and discusses issues in communication, including use of American Sign Language and interpreters in clinical settings. Diagnostic considerations, clinical assessment strategies, and inpatient, outpatient, educational, and early intervention treatment strategies are explored, and the needs of special populations, including mentally ill offenders, patients with multiple disabilities, and persons with hearing loss in later life are examined.     

Seizure detection at home: Do devices on the market match the needs of people living with epilepsy and their caregivers?

In patients with epilepsy, the potential to prevent seizure-related injuries and to improve the unreliability of seizure self-report have fostered the development and marketing of numerous seizure detection devices for home use. Understanding the requirements of users (patients and caregivers) is essential to improve adherence and mitigate barriers to the long-term use of such devices. Here we reviewed the evidence on the needs and preferences of users and provided an overview of currently marketed devices for seizure detection (medically approved or with published evidence for their performance). We then compared devices with known needs. Seizure-detection devices are expected to improve safety and clinical and self-management, and to provide reassurance to users. Key factors affecting a device’s usability relate to its design (attractive appearance, low visibility, low intrusiveness), comfort of use, confidentiality of recorded data, and timely support from both technical and clinical ends. High detection sensitivity and low false alarm rates are paramount. Currently marketed devices are focused primarily on the recording of non–electroencephalography (EEG) signals associated with tonic-clonic seizures, whereas the detection of focal seizures without major motor features remains a clear evidence gap. Moreover, there is paucity of evidence coming from real-life settings. A joint effort of clinical and nonclinical experts, patients, and caregivers is required to ensure an optimal level of acceptability and usability, which are key aspects for a successful continuous monitoring aimed at seizure detection at home.     

Biomarkers in Neurocritical Care

The gold standard for assessing neurological function is the bedside clinical examination. However, in neurocritical patients, the signs and symptoms related to the severity of illness can often be ambiguous. It can be hard to distinguish between a severe but stable disease state and one that is dynamic and in a critical decline. Clinicians and family members alike may struggle with the uncertainty of functional outcome prediction. Intermediate biomarkers of brain injury can assist with ongoing clinical management of patients, and in some circumstances can guide prognosis. Used in the right setting, biomarkers in neurocritical care can also aid with decisions to intensify treatment or avoid prolonged and unnecessary therapy. The term biomarker is used in various ways, and here we use it to refer to 3 general types: 1) circulating blood macromolecules, 2) brain imaging, and 3) continuous invasive monitors. Despite its promise, biomarkers have several limitations and should be interpreted in the context of the overall clinical assessment.     

The assessment of need for mental health services

BACKGROUND: The field of psychiatric epidemiology has yielded several large and important studies of the prevalence of psychiatric disorders. These surveys have been enhanced by the inclusion of methodologies that reflect the needs for care of the population in question. Clinical studies of psychiatric disorders and unmet needs have focussed on identifying needs and correlating them with service evaluation and satisfaction measures. The association between prevalence, service use and unmet need requires review in order to establish whether there are trends and consistent findings. METHOD: Peer-reviewed studies involving the assessment of need up to the present were included. These were of two broad groups: population-based studies and clinical studies. Studies based on outcome measures, review articles, and child psychiatry, old age, and intellectual disability samples were excluded. We conducted a search of MEDLINE and PSYCHINFO using the key words, "mental health needs","assessment of need", and "needs assessment". In addition, we hand-searched key journals and sought personal communication with researchers in the field. RESULTS: A total of 14 population studies and 19 clinical studies were retrieved. The percentage of the general population who reported at least one need for care ranged from 9.5% to 13.8%. The numbers of needs in psychiatric patients ranged from 3.3 to 8.6. Correlates of unmet need include: unemployment, single status, low quality of life and high disability scores, and the presence of certain psychiatric diagnoses, such as affective psychosis and personality disorders. Higher rates of met need and service satisfaction are correlated with a longer duration of service contact. CONCLUSION: The assessment of need to date has been established either by service use data to make inferences about unmet need, by asking limited guided questions about needs, or by using established needs assessment instruments. The high prevalence of psychiatric disorders and the weak correlation between disorder and unmet need require a combined approach towards service development.     

A comparison between demographic and clinical characteristics of younger and older elderly new referrals to an out-patient psychogeriatric service

We compared the demographic and clinical characteristics of 37 subjects under and 41 subjects over 75 years of age who were consecutive new referrals to an out-patient psychogeriatric service in order to examine if an age-related dichotomy emerges in this population. Even though the groups were similar in most demographic (gender, education, years in Israel, family status) and some clinical aspects (number of physical diagnoses, medications taken) they differed significantly in some other clinical variables. "Functional" disorders, independence in performing household activities and Activities of Daily Living (ADL) and more recommendations for ambulatory follow-up were more prominent in the younger group. This profile has much in common with elderly patients newly referred to the general mental health services. The older group had more "organic" disorders, significant need for assistance in household activities and ADL, and more recommendations for follow-up in day-care centers, a profile more characteristic of patients who are treated in memory/dementia clinics. Thus, from a services organizational point of view, it is possible to subdivide out-patient elderly individuals with cognitive and emotional disturbances into separate groups, each with its own characteristics and needs.     

Programme spécialisé pour les premiers épisodes psychotiques : analyse d’une cohorte de 100 patients

Background

The emergence of specialized programs for the treatment of first-episode psychoses in non-research settings calls for a better definition of this group of patients and of the psychological interventions offered.

Aims

The aim of this study is to describe a specialized program for first-episode psychotic patients and to define the patients referred to, their different distinguishing characteristics and their relative use of the different services offered them.

Method

From an initial population of 127 patients, 100 agreed to have their data used to determine their detailed socio-demographic and symptomatological characteristics, their treatment delays (duration of untreated psychosis, referral delay) and their use of specific treatment modalities offered.

Results

The sample is similar to others described in the current literature in terms of socio-demographics, diagnostic distribution, and duration of untreated psychosis. The referral delay is 1.66 year. The symptomatological and neuropsychological portraits observed are characterized by heterogeneity. Services offered appear clinically indicated for most patients referred to (81%), with different characteristics observed across the groups of patients referred to in the different modalities.

Conclusion

The heterogeneity of the clinical presentation and of needs observed implies that such a program has to include a detailed assessment of each patient and a basic range of interventions. The implementation of such interventions in a non-research setting, and eventually on a large scale, should be accompanied by an evaluation process that could help guide clinical work and the organization of psychiatric services for patients suffering from psychosis.     

2-COM: presentation of an instrument facilitating communication between physicians and carers in daily practice

Communication between the patient and the professional carer lies at the heart of all decisions regarding diagnosis and treatment. However, patients and doctors often have divergent views on care needs; 2-COM (for 2-communication) is a simple patient-completed self-report instrument designed in order to facilitate patient-professional carer communication. Aims - To present 2-COM and to examine whether providing patients with an opportunity to identify and discuss their needs would improve communication and induce changes in care. Methods - The 2-COM is a simple list of 20 common problems, or areas of perceived need, that might be experienced by patients with severe mental illness. The list includes problems with housing, relationships, money, lack of activities, psychological distress, sexuality, symptoms and treatment side effects; 2-COM has shown adequate test-retest reliability and is well accepted by patients as a valued aid to communication with their doctor; 134 patients in a clinical diagnosis of schizophrenia or schizoaffective disorder were recruited at seven European centres: Maastricht, Oviedo, Gijon, Hamburg, Copenhagen, Milan and Nice. The assessment took place over 3 out patient clinic visits; at visit 1, the clinician recorded a list of all current interventions, including medication and non-medical treatments, together with demographic information and an assessment of current level of functioning, using the Global Assessment of Functioning scale. Prior to the second visit, patients were randomised to receive either 2-COM or "standard care" - a routine appointment without 2-COM. Immediately after the interview, all patients, whether they had completed 2-COM or not, completed a confidential questionnaire in which they could indicate the perceived quality of communication. Similarly, clinicians completed a repeat of the list of all current interventions, together with an assessment of any changes to the treatment plan implemented after the interview with the patient. Four to six weeks after clinic visit 2, patients attended the clinic for a third, "routine" clinical interview. Both patients and clinicians then completed the same set of post-interview assessments as at visit 2. The 2-COM induced a stable improvement of patient-reported quality of patient-doctor communication (B=0.33, P=0.031), and induced changes in management immediately after the intervention. Treatment change was more likely in patients with more reported needs at the 2-COM and needs most likely to induce treatment changes. In conclusion, the study showed that 2-COM is a useful instrument to expose and subsequently bridge, patient-professional carer discordance on patient needs.     

Treatment needs, diagnoses and use of services for acutely admitted psychiatric patients in northwest Russia and northern Norway

Background

We compared demography, diagnoses and clinical needs in acutely admitted psychiatric hospital patients in northwest Russia and northern Norway.

Method

All acutely admitted psychiatric patients in 1 psychiatric hospital in north-west Russia and 2 in northern Norway were in a three months period assessed with HoNOS and a Norwegian form developed to study acute psychiatric services (MAP). Data from a total of 841 patients were analysed (377 Norwegian, 464 Russian) with univariate and multivariate statistics.

Results

Russian patients were more often males who had paid work. 2/3 were diagnosed with alcohol and organic disorders, and 70% reported problems related to sleep. Depression was widespread, as were problems associated with occupation. Many more Norwegian patients were on various forms of social security and lived in community supported homes. They had a clinical profile of affective disorders, use of drugs, suicidality and problems with activities involved of daily life. Slightly more Norwegian patients were involuntary admitted.

Conclusion

Acutely admitted psychiatric patients in North West Russia and Northern Norwegian showed different clinical profiles: alcohol, depression and organic disorders characterised Russian patients, affective disorders, suicidality and use of drugs characterised the Norwegians. Whereas Norwegian patients are mainly referred from GPs the Russians come via 1.line psychiatric services (“dispensaries”). Average length of stay for Russian patients was 2.5 times longer than that of the Norwegian.     

Craniocerebral disproportion: a topical review and proposal toward a new definition, diagnosis, and treatment protocol

Introduction

At some point in their lives, patients previously shunted for hydrocephalus may experience chronic, debilitating headaches, despite the fact that their shunts are functioning properly. Previously published reports have suggested that a subset of these patients may be suffering from an iatrogenic craniocerebral disproportion (CCD) and, therefore, may benefit from procedures that expand the available intracranial space. A unified definition of this disorder, however, is lacking.

Discussion

Here, the authors chart the history (including historical terminology) of CCD, review its incidence, describe its signs, symptoms, and associated radiologic findings, and expound upon its pathophysiology. Next, a concise clinical definition of CCD based on the temporal correlation of headaches with the appearance of plateau waves on intracranial pressure (ICP) monitoring is proposed. The authors conclude with a discussion of the various therapeutic strategies employed previously to treat this disorder and present their individualized treatment strategy based upon the simultaneous utilization of ICP monitors and gradual external cranial vault expansion.