Quality of psychiatric care in the general hospital: referrer perceptions of an inpatient liaison psychiatry service

Aims

To explore the experience of senior staff on acute medical wards using an established inpatient liaison psychiatry service and obtain their views on clinically relevant performance measures.

Methods

Semistructured face-to-face interviews with consultants and senior nurses were taped, transcribed and analyzed manually using the framework method of analysis.

Results

Twenty-five referrers were interviewed. Four key themes were identified — benefits of the liaison service, potential areas of improvement, indices of service performance such as speed and quality of response and expanded substance misuse service. Respondents felt the liaison service benefited patients, staff and service delivery in the general hospital. Medical consultants wanted stepped management plans devised by consultant liaison psychiatrists. Senior nurses, who perceived themselves as frontline crisis managers, valued on-the-spot input on patient management.

Conclusions

Consultants and senior nurses differed in their expectations of liaison psychiatry. Referrers valued speed of response and regarded time from referral to definitive management plan as a key performance indicator for benchmarking services.     

Usefulness of Motor-Evoked Potentials Monitoring for Neurosurgical Treatment of an Unusual Distal Anterior Choroidal Artery Aneurysm

A 35 years old woman presented with an acute meningeal syndrome following an intra ventricular haemorrhage without subarachnoid haemorrhage. The angiography demonstrated a 6 mm partially thrombosed saccular aneurysm at the plexal point of the right anterior choroidal artery (AChoA). It was surgically approached inside the ventricle through a trans-temporal corticotomy. The aneurysm was excised after distal exclusion of the feeding artery under motor-evoked potentials monitoring. Of the 19 cases of distal AChoA aneurysm neurosurgical treatment, this is the only one performed under electrophysiology monitoring, a simple and safe method to detect and prevent motor tract ischemia. We discuss this rare case, along with a comprehensible review of the literature of the previous surgical cases of distal AChoA aneurysms.     

Anticoagulant therapy for sepsis‐associated disseminated intravascular coagulation: the view from Japan

The current management of disseminated intravascular coagulation (DIC) is based on aggressive treatment of the underlying condition and resuscitation with appropriate blood products. Anticoagulant therapy has appeared and disappeared in the different guidelines and important documents detailing the treatment of DIC. For example, Surviving Sepsis Campaign (SSC) guidelines, the ‘global standard’ for the management of severe sepsis, had recombinant activated protein C highly recommended in the original version, but this was withdrawn in the latest version due to the lack of evidence. In contrast, recent international guidance released from the International Society on Thrombosis and Haemostasis has introduced the potential efficacy of other agents. In sepsis‐related DIC, the basis for anticoagulant therapy comes from the mounting evidence for the anti‐inflammatory effects which these agents possess and can prove beneficial in septic situations. Several studies have clearly shown the important cross‐talk between coagulation and inflammation in patients with sepsis. More recently, neutrophil extracellular traps and damage‐associated molecular patterns (DAMPs), especially histones, have been demonstrated to play a crucial role in the coagulopathy of sepsis. Once again, the natural anticoagulants have an important function in neutralizing the effects of DAMPs and histones. In this review, in addition to examining the important role of anticoagulants in the septic milieu, the clinical studies examining antithrombin, recombinant thrombomodulin and plasma‐derived activated protein C are detailed. However, large‐scale randomized controlled trials are yet to be performed, with important consideration of the timing, dosage and duration of treatment.