Audit of healthcare provision for UK prisoners with suspected epilepsy

SummaryPurposeTo describe the prevalence and nature of epileptic seizure disorders in a typical UK prison and compare the care offered to prisoners to the recommendations of the National Institute for Clinical Excellence (NICE).MethodsOver a 14-month period, all prisoners identified as having epilepsy were registered by prison primary healthcare services at a category ‘C’ prison holding 640 male adults. Prison and National Health Service health records were reviewed, prisoners were re-assessed by members of a specialist secondary care service based in the local general hospital NHS.ResultsTwenty-six prisoners were thought to have epilepsy. 61.5% of diagnoses had not been made by epilepsy specialists, 73.1% had uncontrolled seizures, only 19.2% had had computed tomography, none magnetic resonance imaging. At review, 30.8% of prisoners were thought to require neuroimaging, 19.2% cardiac investigations. The diagnosis of epilepsy was confirmed in only 57.9% of those prisoners considered to have the condition by prison healthcare services. 53.8% of those prisoners confirmed as having epilepsy had not had a medical review in the past 12 months; 63.2% required a change in their antiepileptic drugs (AEDs).ConclusionAlthough the prevalence of epilepsy in this prison population appeared high at first sight, a critical review of the diagnoses reduced the difference to the prevalence of epilepsy in the population at large. Fewer prisoners than expected achieved seizure control. Collaboration with specialist epilepsy services was poor. There were significant discrepancies between the healthcare provision in prison and the NICE epilepsy guidelines

Lost that lovin' feeling: The erosion of trust between small, high-distance partners

We investigate the role of high distance in trust erosion between small partners. High distance is known to hinder the formation of trust between potential partners, but its role in trust erosion in established partnerships is less understood by international business scholars. Through a qualitative longitudinal study, we extend current theory of how high distance effects the trust dynamics between cross-border partners. Specifically, we unearth three inter-related mechanisms that together explain how and why trust can erode due to high distance. We show that before a partnership is formed, high distance can lead partners to erroneously attribute cues to a potential partner’s high quality, leading to over-expectations of partner performance. Once the partnership is operational, high distance hinders actors’ ability to understand situational factors associated with disappointing outcomes, and so they are attributed to failings of the partner. At the same time, distance-related challenges of bounded reliability render partners reluctant to discuss partnership outcomes. This can result in a vicious cycle of inertia as partners strive to protect goodwill while abandoning efforts to produce partnership outcome because of doubts of the other’s quality. Thus, our theoretical model illustrates the limitations of trust and explains how, paradoxically, high distance can facilitate both trust formation and trust erosion

Emergency hospital care for adults with suspected seizures in the NHS in England 2007-2013: a cross-sectional study

Aims To quantify the frequency, characteristics, geographical variation and costs of emergency hospital care for suspected seizures. Design Cross-sectional study using routinely collected data (Hospital Episode Statistics). Setting The National Health Service in England 2007–2013. Participants Adults who attended an emergency department (ED) or were admitted to hospital. Results In England (population 2011: 53.11 million, 41.77 million adults), suspected seizures gave rise to 50 111 unscheduled admissions per year among adults (≥18 years). This is 47.1% of unscheduled admissions for neurological conditions and 0.71% of all unscheduled admissions. Only a small proportion of admissions for suspected seizures were coded as status epilepticus (3.5%) and there were a very small number of dissociative (non-epileptic) seizures. The median length of stay for each admission was 1 day, the median cost for each admission was £1651 ($2175) and the total cost of all admissions for suspected seizures in England was £88.2 million ($116.2 million) per year. 16.8% of patients had more than one admission per year. There was significant geographical variability in the rate of admissions corrected for population age and gender differences and some areas had rates of admission which were consistently higher than the average. Conclusions Our data show that suspected seizures are the most common neurological cause of admissions to hospital in England, that readmissions are common and that there is significant geographical variability in admission rates. This variability has not previously been reported in the published literature. The cause of the geographical variation is unknown; important factors are likely to include prevalence, deprivation and clinical practice and these require further investigation. Dissociative seizures are not adequately diagnosed during ED attendances and hospital admissions

Driving a motor vehicle and psychogenic nonepileptic seizures: ILAE Report by the Task Force on Psychogenic Nonepileptic Seizures

Objectives This International League Against Epilepsy (ILAE) Report: (a) summarizes the literature about “driving and psychogenic nonepileptic seizures (PNES)”; (b) presents the views of international experts; and (c) proposes an approach to assessing the ability of persons with PNES (PwPNES) to drive. Methods Phase 1: Systematic literature review. Phase 2: Collection of international expert opinion using SurveyMonkey®. Experts included the members of the ILAE PNES Task Force and individuals with relevant publications since 2000. Phase 3: Joint analysis of the findings and refinement of conclusions by all participants using email. As an ILAE Report, the resulting text was reviewed by the Psychiatry Commission, the ILAE Task Force on Driving Guidelines, and Executive Committee. Results Eight studies identified by the systematic review process failed to provide a firm evidence base for PNES‐related driving regulations, but suggest that most health professionals think restrictions are appropriate. Twenty‐six experts responded to the survey. Most held the view that decisions about driving privileges should consider individual patient and PNES characteristics and take account of whether permits are sought for private or commercial driving. Most felt that those with active PNES should not be allowed to drive unless certain criteria were met and that PNES should be thought of as “active” if the last psychogenic seizure had occurred within 6 months. Significance Recommendations on whether PwPNES can drive should be made at the individual patient level. Until future research has determined the risk of accidents in PwPNES a proposed algorithm may guide decisions about driving advice

Strangeness nuclear physics: a critical review on selected topics

Selected topics in strangeness nuclear physics are critically reviewed. This includes production, structure and weak decay of $\Lambda$--Hypernuclei, the $\bar K$ nuclear interaction and the possible existence of $\bar K$ bound states in nuclei. Perspectives for future studies on these issues are also outlined.Comment: 63 pages, 51 figures, accepted for publication on European Physical Journal

Entrepreneurial education: reflexive approaches to entrepreneurial learning in practice

Even though entrepreneurial education is quite a new phenomenon in higher education, as a field of inquiry it is one of the most rapidly growing areas of research However there is a wide spread consensus that traditional pedagogical methods of learning alone are insufficient to adequately develop entrepreneurs to deal with the complexities of running and creating innovating business opportunities. There is a wide spread consensus that traditional pedagogical “instructional methods” alone are insufficient to adequately develop entrepreneurs to deal with the complexities of running and creating business opportunities. As a consequence there is a growing need to cultivate innovative ways of thinking and new modes of pedagogy to fully enhance and develop entrepreneurial approaches to education and learning. It is argued that traditional approaches to entrepreneurial education tend to ignore, and not address, the ambiguities and uncertainties which surround the entrepreneurial process. The historical pre-occupation with an individualistic approach to entrepreneurial learning has continued to marginalise and de-value the broader social context in which the entrepreneur functions, (Goss, 2005). Current writing on entrepreneurial learning has shifted attention towards “learning for” as opposed to “learning about” entrepreneurship. The authors adopt a social constructionist perspective which draws recognition to the importance of inter-subjective knowledge exchange as a means of developing entrepreneurial learning. While there are numerous approaches to a social constructionist paradigm, the critical features of the perspective provide the manner by which “we” come to experience the social world. The approach suggests towards developing a pedagogical approach which explores the social processes that constitute entrepreneurial undertakings and thus shifts the focus away from the traditional positivist approaches to entrepreneurial learning. The paper seeks to contribute to a growing need to cultivate innovating ways of thinking, diverse skills and new modes of behaviour to fully enhance and develop entrepreneurial approaches to education. The paper sets out to address this problem by examining the role reflexivity can play in entrepreneurial education, as a method of critiquing what it means to practice as an entrepreneur

Machine learning as a diagnostic decision aid for patients with transient loss of consciousness

Background: Transient loss of consciousness (TLOC) is a common reason for presentation to primary/emergency care; over 90% are because of epilepsy, syncope, or psychogenic non-epileptic seizures (PNES). Misdiagnoses are common, and there are currently no validated decision rules to aid diagnosis and management. We seek to explore the utility of machine-learning techniques to develop a short diagnostic instrument by extracting features with optimal discriminatory values from responses to detailed questionnaires about TLOC manifestations and comorbidities (86 questions to patients, 31 to TLOC witnesses). Methods: Multi-center retrospective self- and witness-report questionnaire study in secondary care settings. Feature selection was performed by an iterative algorithm based on random forest analysis. Data were randomly divided in a 2:1 ratio into training and validation sets (163:86 for all data; 208:92 for analysis excluding witness reports). Results: Three hundred patients with proven diagnoses (100 each: epilepsy, syncope and PNES) were recruited from epilepsy and syncope services. Two hundred forty-nine completed patient and witness questionnaires: 86 epilepsy (64 female), 84 PNES (61 female), and 79 syncope (59 female). Responses to 36 questions optimally predicted diagnoses. A classifier trained on these features classified 74/86 (86.0% [95% confidence interval 76.9%–92.6%]) of patients correctly in validation (100 [86.7%–100%] syncope, 85.7 [67.3%–96.0%] epilepsy, 75.0 [56.6%–88.5%] PNES). Excluding witness reports, 34 features provided optimal prediction (classifier accuracy of 72/92 [78.3 (68.4%–86.2%)] in validation, 83.8 [68.0%–93.8%] syncope, 81.5 [61.9%–93.7%] epilepsy, 67.9 [47.7%–84.1%] PNES). Conclusions: A tool based on patient symptoms/comorbidities and witness reports separates well between syncope and other common causes of TLOC. It can help to differentiate epilepsy and PNES. Validated decision rules may improve diagnostic processes and reduce misdiagnosis rates. Classification of evidence: This study provides Class III evidence that for patients with TLOC, patient and witness questionnaires discriminate between syncope, epilepsy and PNES