National survey of psychological practices across rural and urban communities

The purpose of this study was to examine potential differences in the practice of psychology across urban and rural communities. The review of the rural literature suggests that psychologists in rural areas are likely to encounter numerous ethical dilemmas and problems that are related specifically to the characteristics of such communities. To date, however, much of this literature has been based on theory and the individual experiences of practitioners. This study sought to quantify any differences in the practice of psychology across communities for such ethical issues as multiple relationships, competency, burnout, confidentiality, and visibility in the community. A survey instrument was created based on previous surveys of ethical practices. A national sample of 1000 psychologists, stratified into urban and non-urban practitioners, was obtained from the American Psychological Association. After several mailings 447 usable surveys were returned. Data analysis revealed significant differences between urban/suburban and small town/rural groups, particularly for the dependent variables of multiple relationships and visibility. Significant differences were found across gender such that male psychologists are more likely than female psychologists to engage in a range of multiple relationship behaviors, and female psychologists are significantly more likely to make use of support from supervisors, colleagues, family and friends. Psychologists in private practice are significantly more likely than those in institutional settings to engage in multiple relationships, to find their work satisfying and rewarding, and to have control over their work environment; whereas practitioners in institutional settings are more likely to have support from colleagues and supervisors, and to work when too distressed to be effective. Psychologists with more experience are significantly more likely to engage in multiple relationship behaviors than those with less experience. Psychologists with a psychodynamic orientation are more likely to make use of supervision and to discuss case work with colleagues than other orientations. The most common concern listed, across community type and gender, is a lack of alternative referral sources. Results from this survey are compared to previous surveys of ethical practices. Qualitative results are categorized and discussed. Suggestions are made for future research based on these findings

Severe malaria in children leads to a significant impairment of transitory otoacoustic emissions--a prospective multicenter cohort study.

BACKGROUND: Severe malaria may influence inner ear function, although this possibility has not been examined prospectively. In a retrospective analysis, hearing impairment was found in 9 of 23 patients with cerebral malaria. An objective method to quickly evaluate the function of the inner ear are the otoacoustic emissions. Negative transient otoacoustic emissions are associated with a threshold shift of 20 dB and above. METHODS: This prospective multicenter study analyses otoacoustic emissions in patients with severe malaria up to the age of 10 years. In three study sites (Ghana, Gabon, Kenya) 144 patients with severe malaria and 108 control children were included. All malaria patients were treated with parental artesunate. RESULTS: In the control group, 92.6 % (n = 108, 95 % confidence interval 86.19-6.2 %) passed otoacoustic emission screening. In malaria patients, 58.5 % (n = 94, malaria vs controls p < 0.001, 95 % confidence interval 48.4-67.9 %) passed otoacoustic emission screening at the baseline measurement. The value increased to 65.2 % (n = 66, p < 0.001, 95 % confidence interval 53.1-75.5 %) at follow up 14-28 days after diagnosis of malaria. The study population was divided into severe non-cerebral malaria and severe malaria with neurological symptoms (cerebral malaria). Whereas otoacoustic emissions in severe malaria improved to a passing percentage of 72.9 % (n = 48, 95 % confidence interval 59-83.4 %) at follow-up, the patients with cerebral malaria showed a drop in the passing percentage to 33 % (n = 18) 3-7 days after diagnosis. This shows a significant impairment in the cerebral malaria group (p = 0.012 at days 3-7, 95 % confidence interval 16.3-56.3 %; p = 0.031 at day 14-28, 95 % confidence interval 24.5-66.3 %). CONCLUSION: The presented data show that 40 % of children have involvement of the inner ear early in severe malaria. In children, audiological screening after severe malaria infection is not currently recommended, but is worth investigating in larger studies

Update on traumatic brain injury in the ICU

Purpose of review:This review aims to summarize recent developments for the management of severe traumatic brain injury (TBI) in the ICU. Recent advancements in TBI ICU management emphasize a progression toward more multimodal approaches and mitigating secondary brain injury by increased focus on careful systemic management. Recent findings: Invasive monitoring techniques such as continuous intracranial pressure (ICP) and brain tissue oxygen pressure (PbtO2) monitoring are considered standard of care or may become crucial, respectively, for managing severe TBI. Technological advances in noninvasive techniques (e.g. quantitative pupillometry) are likely to advance our diagnostic and prognostic ability. Blood biomarkers, including glial fibrillary acidic protein, neurofilament light chain, and ubiquitin carboxy-terminal hydrolase L1, provide minimally invasive ways to better assess injury severity and predict outcomes. These advancements support personalized care, which will likely influence clinical management strategies in the future. Summary: ICP monitoring remains a key component of severe TBI management in ICU. Emerging evidence is slowly changing and improving intensive care and patient outcomes and include both brain-targeted therapies and careful systemic intensive care management.</p

EPA-EAN statement on Post-COVID syndrome.

We aimed to determine the role of the European Psychiatric Association (EPA) and the European Academy of Neurology (EAN) in the management of post-COVID conditions. This is a joint statement from the EAN and the EPA on post-COVID. It is published in the official journals of the two associations, the European Journal of Neurology and European Psychiatry

A survey on fever monitoring and management in patients with acute brain injury: the SUMMA study

Background: Fever is common in patients with acute brain injury and worsens secondary brain injury and clinical outcomes. Currently, there is a lack of consensus on the definition of fever and its management. The aims of the survey were to explore: (a) fever definitions, (b) thresholds to trigger temperature management, and (c) therapeutic strategies to control fever. Materials and Methods: A questionnaire (26 items) was made available to members of the European Society of Intensive Care Medicine via its website between July 2016 and December 2016. Results: Among 231 respondents, 193 provided complete responses to the questionnaire (84%); mostly intensivists (n=124, [54%]). Body temperature was most frequently measured using a bladder probe (n=93, [43%]). A large proportion of respondents considered fever as a body temperature >38.3°C (n=71, [33%]). The main thresholds for antipyretic therapy were 37.5°C (n=74, [34%]) and 38.0°C (n=86, [40%]); however, lower thresholds (37.0 to 37.5°C) were targeted in cases of intracranial hypertension and cerebral ischemia. Among first-line methods to treat fever, ice packs were the most frequently utilized physical method (n=90, [47%]), external nonautomated system was the most frequent utilized device (n=49, [25%]), and paracetamol was the most frequently utilized drug (n=135, [70%]). Among second-line methods, intravenous infusion of cold fluids was the most frequently utilized physical method (n=68, [35%]), external computerized automated system was the most frequently utilized device (n=75, [39%]), and diclofenac was the most frequently utilized drug (n=62, [32%]). Protocols for fever control and shivering management were available to 83 (43%) and 54 (28%) of respondents, respectively. Conclusions: In this survey we identified substantial variability in fever definition and application of temperature management in acute brain injury patients. These findings may be helpful in promoting educational interventions and in designing future studies on this topic

The continuum of spreading depolarizations in acute cortical lesion development: Examining Leão's legacy.

A modern understanding of how cerebral cortical lesions develop after acute brain injury is based on Aristides Leão's historic discoveries of spreading depression and asphyxial/anoxic depolarization. Treated as separate entities for decades, we now appreciate that these events define a continuum of spreading mass depolarizations, a concept that is central to understanding their pathologic effects. Within minutes of acute severe ischemia, the onset of persistent depolarization triggers the breakdown of ion homeostasis and development of cytotoxic edema. These persistent changes are diagnosed as diffusion restriction in magnetic resonance imaging and define the ischemic core. In delayed lesion growth, transient spreading depolarizations arise spontaneously in the ischemic penumbra and induce further persistent depolarization and excitotoxic damage, progressively expanding the ischemic core. The causal role of these waves in lesion development has been proven by real-time monitoring of electrophysiology, blood flow, and cytotoxic edema. The spreading depolarization continuum further applies to other models of acute cortical lesions, suggesting that it is a universal principle of cortical lesion development. These pathophysiologic concepts establish a working hypothesis for translation to human disease, where complex patterns of depolarizations are observed in acute brain injury and appear to mediate and signal ongoing secondary damage