Vestibular dysfunction in acute traumatic brain injury.

Traumatic brain injury (TBI) is the commonest cause of disability in under-40-year-olds. Vestibular features of dizziness (illusory self-motion) or imbalance which affects 50% of TBI patients at 5 years, increases unemployment threefold in TBI survivors. Unfortunately, vestibular diagnoses are cryptogenic in 25% of chronic TBI cases, impeding therapy. We hypothesized that chronic adaptive brain mechanisms uncouple vestibular symptoms from signs. This predicts a masking of vestibular diagnoses chronically but not acutely. Hence, defining the spectrum of vestibular diagnoses in acute TBI should clarify vestibular diagnoses in chronic TBI. There are, however, no relevant acute TBI data. Of 111 Major Trauma Ward adult admissions screened (median 38-years-old), 96 patients (87%) had subjective dizziness (illusory self-motion) and/or objective imbalance were referred to the senior author (BMS). Symptoms included: feeling unbalanced (58%), headache (50%) and dizziness (40%). In the 47 cases assessed by BMS, gait ataxia was the commonest sign (62%) with half of these cases denying imbalance when asked. Diagnoses included BPPV (38%), acute peripheral unilateral vestibular loss (19%), and migraine phenotype headache (34%), another potential source of vestibular symptoms. In acute TBI, vestibular signs are common, with gait ataxia being the most frequent one. However, patients underreport symptoms. The uncoupling of symptoms from signs likely arises from TBI affecting perceptual mechanisms. Hence, the cryptogenic nature of vestibular symptoms in TBI (acute or chronic) relates to a complex interaction between injury (to peripheral and central vestibular structures and perceptual mechanisms) and brain-adaptation, emphasizing the need for acute prospective, mechanistic studies.

Adverse drug reactions: managing the risk.

AIM: This study aims to assess the need to formalize medication monitoring strategies in electronic records in two crisis resolution home treatment (CRHT) teams in one UK NHS Trust. BACKGROUND: The management and monitoring of prescribed medications has long been a cause for concern. As a result of the potential adverse drug reactions associated with commonly prescribed medication, clients of mental health teams are vulnerable to iatrogenic risk linked to physical health problems. METHOD: Electronic records for all clients receiving care in two CHRT teams in one UK mental health Trust in November 2007 were examined for evidence of monitoring for potential adverse drug reactions. Findings were compared with the sample of paper records submitted to a national audit. RESULTS: Electronic records omitted important aspects of medication monitoring, for example: 14 out of 57 clients had blood pressure recorded; 15 out of 57 had heart rate recorded; 13 out of 57 had weight recorded. However, the teams' paper records were significantly better than both the electronic records and a national audit sample at recording blood pressure and obesity. We found few differences between our two teams. CONCLUSIONS: The format of our electronic records requires modification to ensure that systems are in place to document adverse drug reactions and the physical health of those with mental illness. IMPLICATIONS FOR NURSING MANAGEMENT: The transition to electronic records needs to be carefully managed to ensure that information on adverse drug reactions is included. The West Wales Adverse Drug Reaction profile, version II, is one strategy to achieve this in mental health.