Laser Doppler monitoring of cerebral blood flow

Abstract

The clinical management of cerebral hemodynamic status has become more important, as well as more complex, in recent years. In response", monitoring systems for neurological patients have grown increasingly sophisticated. Unfortunately the capability of monitoring cerebral blood flow is absent in commercially available monitoring systems at this time. Various investigators have demonstrated that laser Doppler systems are capable of meeting this need. We present here a summary of laser Doppler technology and also a review of the progress in application of this technology to provide meaningful input for clinical decision making. Recent clinical experience and advances in instrumentation design suggest that laser Doppler monitoring of cerebral blood flow may soon become routine in neurological intensive care settings. [Neurol Res 1996; 18: 251–255]     

Candida tropicalis brain abscess in a neonate: An emerging nosocomial menace

Fungi are a relatively uncommon cause of brain abscess in neonates and early infancy. They are usually associated with predisposing factors like prematurity, low birth weight, use of broad-spectrum antibiotics, and prolonged stay in the intensive care unit. Candida tropicalis (C. tropicalis) is rapidly emerging as a nosocomial threat in the neonatal intensive care settings. This case report describes a neonate with C. tropicalis brain abscess who was diagnosed early and managed aggressively with a favorable outcome. Inadvertent use of intravenous antibiotics can have serious complications such as invasive fungal infection. Correct microbiological diagnosis is the key to successful treatment of deep-seated pyogenic infection. Fungal etiology should always be studied in relevant clinical settings.     

A comparison of assertive community treatment and intensive case management for patients in rural areas

OBJECTIVE: This article reviews the evidence for the effectiveness of community-based services for rural areas, specifically assertive community treatment and intensive case management. Service delivery to persons with severe mental illness in rural areas is challenged by low population densities, limited services, and shortages of professionals. METHODS: A comprehensive literature search identified six studies of rural assertive community treatment, only two of which were controlled studies, and four rural intensive case management studies, only one of which was a controlled study. Assertive community treatment would seem ideally suited to areas lacking services because of its self-contained multidisciplinary treatment team approach. However, rural programs have been forced to make several adaptations to the assertive community treatment model, including smaller teams, less comprehensive staff, and less intensive services. There is no published evidence that these adaptations are able to produce the same results as full-fidelity teams. Some believe that intensive case management may be an alternative to assertive community treatment in rural settings because intensive case management emphasizes individual caseloads, fewer staff, less intensive contacts, and brokered services. CONCLUSIONS: The evidence suggests that intensive case management programs are effective only in community settings where there is an ample supply of treatment and support services. To build the evidence base for the effectiveness of these models, much more attention needs to be focused on evaluating the current wave of assertive community treatment and intensive case management dissemination in rural areas.     

Factor structure and convergent validity of the inventory of interpersonal problems in an inpatient setting

The Inventory of Interpersonal Problems (IIP32) is a self-report measure designed to be used in clinical settings to assess interpersonal difficulties. However, it has been exclusively used in either outpatient or non-clinical settings, and psychometric data concerning its use in inpatients are limited. The current study examined the factor structure and construct validity of the IIP-32, and ways to optimally use this measure with inpatients at a private hospital providing intensive treatment. The original eight-factor structure was a poor fit to the data, whereas a five-factor structure provided a somewhat better fit. Although the five factors (Nonassertive, Detached, Intrusive, Self-Sacrificing, and Socially Inhibited) demonstrated adequate internal consistency, reliability, and limited convergent validity, the IIP is ultimately useful insofar as it engages patients in collaborative self-awareness during intensive psychotherapeutically oriented treatment.     

Teaching Family Physicians About Mood Disorders: A Procedure Suite for Behavioral Medicine

BACKGROUND AND OBJECTIVES: One of the skills required of family physicians is the ability to recognize and treat individuals suffering from mood disorders. This study represents an interdisciplinary residency training approach that (1) is unique in family practice residencies; (2) trains faculty, residents, and students in mood disorder recognition and treatment; (3) has been evaluated by the Residency Review Committee and found compatible with psychiatry training guidelines; and (4) is adaptable to varied settings. METHOD: Existing psychiatric education at an urban family practice residency program was evaluated. A new curriculum was developed to emphasize clinical interactions that would allow residents to model the behavior of family physicians who demonstrate interest and expertise in psychiatry. The centerpiece of this curriculum is a family-physician-led, multidisciplinary, in-house consultation service known as a mood disorders clinic (MDC). Educational effectiveness was evaluated by comparing resident identification rates of mood disorders before and after training. Educational utility was evaluated by implementation in a variety of settings. RESULTS: Fifty-one residents rotated through 1 or more of 3 practice sites during a 60-month period. Psychiatric diagnoses for the 187 patients who remained in treatment for complete clinical assessment included all major mood and anxiety disorders outlined in the DSM-IV. A wide variety of associated psychosocial problems were also identified. A significant difference (p <.05) was seen between the number of continuity patients diagnosed with psychiatric conditions by resident physicians before and after the training experience. CONCLUSION: Implementation of this intensive training experience resulted in subjective as well as objective enhancement of resident education by providing an intensive, focused educational experience in primary care psychiatry. This concept is adaptable to a variety of practice sites and educational levels. The MDC could become the hub of an integrated delivery system for mental health services in an ambulatory primary care setting.     

Psychotherapy in psychiatry

The relationship between psychotherapy and psychiatry has become a beleagured one in recent years. The swing of the pendulum in the direction of biological psychiatry has led to a marginalization of psychotherapy within the discipline of psychiatry as a whole. However, psychotherapy continues to be a basic science of psychiatry with application in all clinical settings. It must be regarded as a biological treatment that works by changing the brain and is therefore just as important as pharmacotherapy in terms of overall treatment planning. The combined treatment of medication and psychotherapy has become the most common mode of psychiatric treatment planning in current practice. Both the two-treater model and the single-treater model have a set of advantages and disadvantages that are explicated. Further research is needed to identify clinical situations in which psychotherapy is essential, whether alone or in combination with medication. Moreover, as greater insights are gained into the brain mechanisms responsible for therapeutic changes, more specifically targeted psychotherapies can be developed.     

Cross-setting complementary staff- and parent-mediated Early Intensive Behavioral Intervention for young children with autism: A research-based comprehensive approach

Although, recent reviews and outcome research support empirical evidence for Early Intensive Behavior Intervention in University and community settings, research has also indicated that not all intensive behavioral service provisions are equally effective. Therefore, it was necessary to comprehend key variables that are common to empirically validated programs. This paper provides a research-based comprehensive EIBI model which has been recently implemented in Italy. Important components include post-diagnostic provision, complementary treatment in clinical setting by professionals and parent-mediated in the child's natural environment, treatment based on applied behavior analysis–verbal behavior, staff and parent training, as well as evaluation of progress.     

The premature demise of public child and adolescent inpatient psychiatric beds : Part II: challenges and implications

Psychiatric disorders are the leading reason for hospitalization among 5–19 year olds. Current data, however, suggest there are fewer than necessary available services for children and adolescents requiring intensive, inpatient psychiatric care. Children and adolescents with behavioral health problems, the majority of whom do not receive appropriate treatment, have increased risk of school failure, family disruption, out-of-home placements, poor employment opportunities, and poverty in adulthood. This paper will examine the challenges inherent in serving children and adolescents with serious emotional disturbances, avenues of financing for treatment and services, and various loci of intervention for high-risk children, including inpatient settings and systems of care. The goals of this paper are to illustrate the complexities of working with children and adolescents most in need of intensive psychiatric services, to explore how inpatient services “fit” into existing treatment approaches, and to discuss the efficacy of downsizing or closing inpatient psychiatric units for this population.     

Delirium: Where do we stand?

Clinicians are likely to encounter delirium frequently, particularly in inpatient and intensive care settings. However, delirium is underrecognized and undertreated because of its heterogeneous and fluctuating presentation and due to the limitations in resources and training in contemporary clinical settings. Translation of current knowledge about delirium into clinical practice may improve patient care and benefit public health economics. Hence, this review comprehensively discusses the phenomenology and pathophysiology of delirium and its presenting features, risk factors, differential diagnoses, assessment, prognosis, and treatment with antipsychotics; the goal is to facilitate better prevention, recognition, and treatment of delirium. Available research is reviewed, limitations of the research are discussed, and future directions for further delirium research are identified.     

Debate: Inpatient units must enhance the system of care

Child or adolescent psychiatric inpatient units are expensive; therefore, a lot is expected of them. Short stay units are best used for diagnostic clarification, the initiation and supervision of complex treatment, and acute containment of risk. Longer stay units provide a recovery-focused programme to address mental health problems that have not responded to intensive treatment in other settings. Both types of unit form part of the wider system of care that supports young people with mental health problems. The operational characteristics of such units will ensure timely, safe and effective interventions to young people who will likely go on to receive most of their clinical care in the community.     

Six reports of children with autism spectrum disorder following intensive behavioral intervention using the Preschool Inventory of Repertoires for Kindergarten (PIRK®)

The current study presents case reports of six children diagnosed with autism spectrum disorder (ASD) who received intensive applied behavior analysis within the Comprehensive Application of Behavior Analysis to Schooling (CABAS^®) system and successfully integrated into mainstream education. The participants’ interventions followed curricular objectives from the Preschool Inventory of Repertoires for Kindergarten (PIRK^®), an empirically validated assessment tool and curriculum which improves outcomes for children with ASD and prepares for mainstream integration. Each case study presents acquisition of curricular objectives, rates of learning annually and results of independent psychological measures throughout the intensive behavioral intervention. This paper examines the variables (age of treatment onset, duration of treatment, presence of stereotypy or challenging behaviors prior to treatment) which may have influenced the successful integration of these participants into mainstream education settings.     

Neonatal intensive care neurology

The pediatric neurologist's role in the neonatal intensive care unit is described in four clinical settings: (1) assessment of outcome in neonatal encephalopathy, (2) treatment of seizures in full-term infants, (3) assessment and treatment of intraventricular hemorrhage with posthemorrhagic hydrocephalus, and (4) assessment of outcome in preterm infants. Emphasis is placed on the evidenced-based information available in these settings and on new therapies on the horizon. Using evidence-based information, the pediatric neurologist can accurately assess prognosis in the neonatal period, and this can provide the basis for a rational assessment of newer therapies in neonatal intensive care.     

Inpatient psychiatric care in the 21st century: the need for reform

Driven by financial pressures, the sole focus of psychiatric inpatient treatment has become safety and crisis stabilization. Data are lacking on outcomes of ultrashort-stay hospitalizations; however, such stays may diminish opportunities for a sustained recovery. In the absence of an evidence base to guide clinicians and policy makers, mental health professionals have an ethical obligation to promote what they consider to be best practice. This Open Forum focuses on the need to reconsider the current model of inpatient hospitalization in order to maximize positive outcomes and emphasize appropriate transition to the community and less intensive levels of care. A model of care is presented based on rapid formulation of diagnosis, goals, and treatment modalities before treatment begins. Three phases are described--assessment, implementation, and resolution--with specific principles to guide length-of-stay decisions and requirements for staffing.     

Neuromonitoring

Summary Neuromonitoring—the continuous or intermittent observation of nervous system functions—has become a field of interdisciplinary interest. Basically there are two major applications of neuromonitoring: in the operating theatre and the neurological or neurosurgical intensive care unit. Evoked potential recording, intracranial pressure measurement, serial EEG recording, cerebral blood flow measurement and ultrasound techniques have all been used as monitoring methods. The application of these techniques for operations, intensive care and the evaluation of brain death will be described.     

Breaking the myths: new treatment approaches for chronic depression.

BACKGROUND: Chronic depressive disorders are common, accounting for approximately one-third of all cases of depression and posing a major public health problem. In the past, chronic depression has been thought to be treatment-resistant, and evidence suggests that it is currently underdiagnosed, misdiagnosed, and suboptimally treated. OBJECTIVES: To review the subtypes of chronic depression and the evidence-base concerning their optimal treatment and to discuss some key clinical issues and areas of future research. METHODS: We identified key studies and randomized controlled trials (RCTs) by systematically searching electronic databases and hand searching specialist journals and bibliographies. RESULTS: Chronic depressive disorders respond well to standard pharmacologic interventions in the acute and maintenance phases of treatment. Standard psychotherapies alone may not be efficacious for chronic depression (especially dysthymia). Recent evidence suggests that treatment combining psychotherapy and medications may be superior to either treatment alone. CONCLUSIONS: Chronic depressive disorders are amenable to treatment, provided that intervention is both thorough and intensive. Although our knowledge about the optimal treatment of chronic depression has developed rapidly, changes in clinical practice have been slower to evolve. Further research is required to assess the effectiveness of multimodal interventions for chronic depression in more naturalistic settings.     

An intensive outpatient program for patients with borderline personality disorder

Intensive outpatient programs are designed to promote patients' functioning in the community by offering a more intensive level of structure and support than was previously available for outpatients. This paper describes the intensive outpatient program at McLean Hospital in Belmont, Massachusetts, which is tailored for patients with borderline personality disorder. These patients are susceptible to control struggles and regressive behaviors in more restrictive treatment settings. Through frequent contact with clinicians and other patients in this group-oriented program, patients with borderline personality disorders appear to feel sufficiently "held" and understood to develop their functional capacities as outpatients.     

Psychological debriefing in cross-cultural contexts: ten implications for practice

Crisis interventions following exposure to traumatic events have become common in most western and in some non-western countries. The literature regarding early interventions, specifically the use of Psychological Debriefing (PD), is grounded in a western context. Little has been written of its use in different cultural settings. This article focuses on the use of PD in different cultural settings, as well as some of the conceptual issues related to cross-cultural trauma research and practice, which inevitably have implications for the use of early intervention. Ten key implications for practice are suggested.     

Linezolid: implications for neurosurgical infections

Nosocomial infections affect a significant number of intensive care unit (ICU) patients including those in the neurosurgical ICU. Gram-positive organisms are responsible for many of these infections and often these pathogens are resistant to some of the older antimicrobial agents. Two new classes of antibiotics have been developed: streptogramins and oxazolidinones. Linezolid is an oxazolidinone, which has been shown to be effective against methicillin- and vancomycin-resistant Gram-positive pathogens. It may be administered orally or parenterally, and displays favorable pharmacokinetic properties, with rapid and complete absorption after oral administration. Linezolid is generally well tolerated with mild gastrointestinal related adverse effects. Linezolid provides a useful alternative in the treatment of Gram-positive infections, particularly those caused by resistant organisms. It has tremendous clinical utility, especially in the ICU where infections and multi-drug resistant rates are high and treatment options become limited.     

The Questions About Behavioral Function (QABF): current status as a method of functional assessment

Functional assessment has now entered the mainstream for evaluation and to aid in the treatment of challenging behaviors, while experimental functional analysis was at the forefront of this movement, this particular methodology has proven to be impractical, and thus has limited utility in real world settings. As a result of these factors standardized test have become a popular alternative for making a functional assessment. The most extensively studied of these scales to date is the Questions About Behavioral Function (QABF). This paper reviews the available research on this scale, its current status, and future directions.