Emergency Care Handover (ECHO study) across care boundaries : the need for joint decision making and consideration of psychosocial history

Background: Inadequate handover in emergency care is a threat to patient safety. Handover across care boundaries poses particular problems due to different professional, organisational and cultural backgrounds. While there have been many suggestions for standardisation of handover content, relatively little is known about the verbal behaviours that shape handover conversations. This paper explores both what is communicated (content) and how this is communicated (verbal behaviours) during different types of handover conversations across care boundaries in emergency care. Methods: Three types of interorganisational (ambulance service to emergency department (ED) in ‘resuscitation’ and ‘majors’ areas) and interdepartmental handover conversations (referrals to acute medicine) were audio recorded in three National Health Service EDs. Handover conversations were segmented into utterances. Frequency counts for content and language forms were derived for each type of handover using Discourse Analysis. Verbal behaviours were identified using Conversation Analysis. Results: 203 handover conversations were analysed. Handover conversations involving ambulance services were predominantly descriptive (60%–65% of utterances), unidirectional and focused on patient presentation (75%–80%). Referrals entailed more collaborative talk focused on the decision to admit and immediate care needs. Across all types of handover, only 1.5%–5% of handover conversation content related to the patient's social and psychological needs. Conclusions: Handover may entail both descriptive talk aimed at information transfer and collaborative talk aimed at joint decision-making. Standardisation of handover needs to accommodate collaborative aspects and should incorporate communication of information relevant to the patient's social and psychological needs to establish appropriate care arrangements at the earliest opportunity

The degraded concept representation system in semantic dementia:damage to pan-modal hub, then visual spoke

The core clinical feature of semantic dementia is a progressive yet selective degradation of conceptual knowledge. Understanding the cognitive and neuroanatomical basis for this deficit is a key challenge for both clinical and basic science. Some researchers attribute the deficit to damage to pan-modal conceptual representations that are independent of any particular sensory-motor modality and are represented in the ventrolateral anterior temporal lobes. Others claim that damage to modality-specific visual feature representations in the occipitotemporal 'ventral stream' is responsible. In the present study, we tested the hypothesis that concept degradation in semantic dementia involves a combination of these pan-modal and modality-specific elements. We investigated factors influencing knowledge of object concepts by analysing 43 sets of picture-naming data from patients with semantic dementia. We found a strong influence of two pan-modal factors: highly familiar and typical items were named more accurately than less familiar/atypical items at all stages of the disorder. Items associated with rich sensory-motor information were also named more successfully at all stages, and this effect was present for sound/motion knowledge and tactile/action knowledge when these modalities were studied separately. However, there was no advantage for items rich in visual colour/form characteristics; instead, this factor had an increasingly negative impact in the later stages of the disorder. We propose that these results are best explained by a combination of (i) degradation of modality-independent conceptual representations, which is present throughout the disorder and is a consequence of atrophy focused on the ventrolateral anterior temporal lobes; and (ii) a later additional deficit for concepts that depend heavily on visual colour/form information, caused by the spreading of atrophy to posterior ventral temporal regions specialized for representing this information. This explanation is consistent with a graded hub-and-spoke model of conceptual knowledge, in which there is a gradual convergence of information along the temporal lobes, with visual attributes represented in the posterior cortex giving way to pan-modal representations in the anterior areas. © 2012 The Author

Deficits of knowledge versus executive control in semantic cognition: Insights from cued naming

Deficits of semantic cognition in semantic dementia and in aphasia consequent on CVA (stroke) are qualitatively different. Patients with semantic dementia are characterised by progressive degradation of central semantic representations, whereas multimodal semantic deficits in stroke aphasia reflect impairment of executive processes that help to direct and control semantic activation in a task-appropriate fashion [Jefferies, E., & Lambon Ralph, M. A. (2006). Semantic impairment in stroke aphasia vs. semantic dementia: A case-series comparison. Brain 129, 2132-2147]. We explored interactions between these two aspects of semantic cognition by examining the effects of cumulative phonemic cueing on picture naming in case series of these two types of patient. The stroke aphasic patients with multimodal semantic deficits cued very readily and demonstrated near-perfect name retrieval when cumulative phonemic cues reached or exceeded the target name's uniqueness point. Therefore, knowledge of the picture names was largely intact for the aphasic patients, but they were unable to retrieve this information without cues that helped to direct activation towards the target response. Equivalent phonemic cues engendered significant but much more limited benefit to the semantic dementia patients: their naming was still severely impaired even when most of the word had been provided. In contrast to the pattern in the stroke aphasia group, successful cueing was mainly confined to the more familiar un-named pictures. We propose that this limited cueing effect in semantic dementia follows from the fact that concepts deteriorate in a graded fashion [Rogers, T. T., Lambon Ralph, M. A., Garrard, P., Bozeat, S., McClelland, J. L., & Hodges, J. R., et al. (2004). The structure and deterioration of semantic memory: A neuropsychological and computational investigation. Psychological Review 111, 205-235]. For partially degraded items, the residual conceptual knowledge may be insufficient to drive speech production to completion but these items might reach threshold when they are bolstered by cues. (C) 2007 Elsevier Ltd. All rights reserved

Apraxia and motor dysfunction in corticobasal syndrome

Background: Corticobasal syndrome (CBS) is characterized by multifaceted motor system dysfunction and cognitive disturbance; distinctive clinical features include limb apraxia and visuospatial dysfunction. Transcranial magnetic stimulation (TMS) has been used to study motor system dysfunction in CBS, but the relationship of TMS parameters to clinical features has not been studied. The present study explored several hypotheses; firstly, that limb apraxia may be partly due to visuospatial impairment in CBS. Secondly, that motor system dysfunction can be demonstrated in CBS, using threshold-tracking TMS, and is linked to limb apraxia. Finally, that atrophy of the primary motor cortex, studied using voxel-based morphometry analysis (VBM), is associated with motor system dysfunction and limb apraxia in CBS.   Methods: Imitation of meaningful and meaningless hand gestures was graded to assess limb apraxia, while cognitive performance was assessed using the Addenbrooke's Cognitive Examination - Revised (ACE-R), with particular emphasis placed on the visuospatial subtask. Patients underwent TMS, to assess cortical function, and VBM.   Results: In total, 17 patients with CBS (7 male, 10 female; mean age 64.4+/2 6.6 years) were studied and compared to 17 matched control subjects. Of the CBS patients, 23.5% had a relatively inexcitable motor cortex, with evidence of cortical dysfunction in the remaining 76.5% patients. Reduced resting motor threshold, and visuospatial performance, correlated with limb apraxia. Patients with a resting motor threshold <50% performed significantly worse on the visuospatial sub-task of the ACE-R than other CBS patients. Cortical function correlated with atrophy of the primary and pre-motor cortices, and the thalamus, while apraxia correlated with atrophy of the pre-motor and parietal cortices.   Conclusions: Cortical dysfunction appears to underlie the core clinical features of CBS, and is associated with atrophy of the primary motor and pre-motor cortices, as well as the thalamus, while apraxia correlates with pre-motor and parietal atrophy

A questionable semantics: The interaction between semantic knowledge and autobiographical experience in semantic dementia

In our earlier article, we proposed that recent episodic experiences in patients with semantic dementia support the production of nongeneralisable, autobiographically constrained, "semantic-like" facts (Graham, Lambon Ralph, &amp;, Hodges, 1997). We argued that this type of "semantic-like" knowledge was distinguishable from true semantic information because our two patients with semantic dementia showed no facilitatory effect of recent autobiographical experiences on their knowledge of golf and bowls; information which was presumably learnt prior to the onset of their disease. In this paper, we discuss the implications of these results for current views relating to the nature and organisation of long-term memory. © 1999 Psychology Press Ltd

Determining the Impact of Autobiographical Experience on "Meaning": New Insights from Investigating Sports-related Vocabulary and Knowledge in Two Cases with Semantic Dementia

Snowden, Griffiths, and Neary (1994, 1995) have proposed thatautobiographical experience helps to maintain the integrity of semantic memory in patients with semantic dementia. We investigated this hypothesis by testing knowledge related to golf and bowls in two case studies. If Snowden and colleagues' hypothesis is correct, our two patients should have better semantic knowledge for the sport that they regularly experience, compared with knowledge of other sports. In keeping with Snowden et al's hypothesis, we found that autobiographical experience influenced the ability of the patients to match up a surname with a first name: The names of personally and currently relevant golf bowls partners were more likely to be matched correctly than such personally relevant names from the past, or the names of famous sports celebrities. Unlike Snowden et al., however, we found that knowledge of people, in all categories, was severely impoverished and that any semantic information was produced as part of an autobiographical memory. Likewise, detailed study of each patient's understanding of their favourite sportrevealed no significanteffectof autobiographical experience on true semantic knowledge. We propose that the ability of semantic dementia patients to encode, albeit temporarily, recent autobiographical memories via a spared hippocampal complex supports the production of highly autobiographically constrained semantic-like facts and, to a lesser extent, frequently encountered names. There is, however, no direct effect of autobiographical experience on previously established semantic memory, i.e. knowledge of golf, bowls, and people, presumably stored within the temporal neocortex. These results are discussed with respect to current anatomically based computational models of long-term memory

A questionable semantics: The interaction between semantic knowledge and autobiographical experience in semantic dementia

In our earlier article, we proposed that recent episodic experiences in patients with semantic dementia support the production of nongeneralisable, autobiographically constrained, “semantic-like” facts (Graham, Lambon Ralph, & Hodges, 1997). We argued that this type of “semantic-like” knowledge was distinguishable from true semantic information because our two patients with semantic dementia showed no facilitatory effect of recent autobiographical experiences on their knowledge of golf and bowls; information which was presumably learnt prior to the onset of their disease. In this paper, we discuss the implications of these results for current views relating to the nature and organisation of long-term memory