Is two-staged gamma knife surgery a reasonable management option for very large cerebellar metastases? A case series of three patients.

OBJECTIVE: Two-staged gamma knife surgery (GKS) is a method that may extend the upper tumor volume limit for using GKS in the management of brain metastases. However, the safety of treating very large posterior fossa lesions with this technique has not been well demonstrated. Therefore, we analyzed our experience in treating cerebellar metastases larger than 12 cm3 with two-staged GKS. METHODS: Four consecutive patients harboring 12 to 30 cm3 cerebellar metastases scheduled two-staged GKS were included in the study, and all but one patient completed the treatment. The treatment doses were 10-13 Gy. All patients were followed with regular MR imaging and clinical assessments, and the tumor volumes were measured on all treatment and follow-up images. RESULTS: Tumor progression was not demonstrated in any of the patients. Tumor volumes decreased by, on average, more than half between the two stages. The median survival was 22 months, and no patient died due to intracranial tumor progression. Peritumoral edema at the first GKS resolved in all patients, replaced by asymptomatic mild T2 changes in two of them not requiring any treatment. No radiation-induced complication has developed thus far. CONCLUSION: Staged GKS seems to be a feasible management option for very large cerebellar metastases.

Healthcare Professionals' Experiences of Recovery-Oriented Collaboration Between Mental Health Centres and Municipalities: A Qualitative Study.

Collaboration within mental health centres and with municipalities in Western European healthcare has presented challenges due to structural and cultural disparities. The Danish healthcare system faces obstacles that impact mental healthcare services, particularly in cross-sectorial cooperation. Our aim was to investigate healthcare professionals' experiences of recovery-oriented collaboration within a mental healthcare setting across hospitals and municipalities to gather a deeper understanding of this issue. Twenty-four employees were purposively sampled from mental health centres in Copenhagen and focus group interviews were conducted to explore their perceptions of working together. Inductive content analysis was used to analyse the data and identify themes and categories. The participants emphasised challenges in communication and coordination to improve collaboration within across the two sectors. This study can contribute to a greater understanding of collaboration between mental health centres and municipalities. It aims to inspire improvements in communication, coordination, and the optimisation of mental health service delivery across sectors.

Patient Participation in Mental Health Care - Perspectives of Healthcare Professionals and Patients: A Scoping Review.

AIM: This scoping review aims to synthesize findings from fourteen selected articles to provide a comprehensive understanding of patient participation in mental healthcare. METHOD: The review analyzed articles employing various qualitative methodologies, including interviews and observations, to explore patient and healthcare professional perspectives. Articles were selected based on their relevance to the topic of patient participation in mental health care. RESULTS: The analysis revealed diverse perspectives on patient participation. Patients' preferences varied, with some preferring shared decision-making while others preferred minimal involvement. Barriers to shared decision-making included fear of judgment and substance misuse concerns. Strategies to manage disagreements and foster trusting relationships were identified. Challenges in implementing patient and public involvement in mental health services were noted, including stigma and inadequate professional training. Interprofessional collaboration was deemed fundamental, although fragmented care pathways and communication breakdowns persisted. Structural conditions and professional expectations significantly influenced patient participation, with a paternalistic approach perpetuating power imbalances. CONCLUSION: Despite challenges, the findings underscored the importance of empowering patients in treatment decision-making, promoting collaborative relationships, and addressing barriers to enhance patient-centered care in mental health settings. Insights from this review contribute to the discourse on patient-centered care, emphasizing the need for holistic approaches prioritizing patient dignity and well-being.

Perspectives on Recovery-Oriented Care in Mental Health Practices: Health Professionals Experiences.

In several Western countries, mental health professionals work in accordance with the principles of recovery-oriented practices, but there is little research into what opportunities there are for fostering recovery-oriented practices in mental health settings. To investigate how central elements of recovery-oriented practices are reflected in health professionals experiences of care and treatment in mental health. Four focus group interviews with nurses and other health professionals are conducted and analysed using manifest content analysis to carry out a low-level analysis of the participants' experiences in mental healthcare. The study was designed in accordance with the ethical principles of the Helsinki Declaration (1) and Danish law (2). The participants gave informed consent after verbal and written information. The main theme, 'recovery-oriented practices framed within institutional structural conditions', was based on three subthemes: 1) users need help to find meaning during hospitalisation and find hope, 2) health professionals experience it as an obligation that users achieve personal recovery, and 3) user perspectives versus the mental health practices' structural logic. This study sheds light on health professionals experiences with a recovery-oriented practice. The health professionals believe in this as a positive approach and see it as an important obligation to help the user find their own aims and hopes. On the other hand, it can be difficult to work in recovery-oriented practices. It requires an active commitment from users; for many, this can be difficult to live up to.

'No service is an island': experiences of collaboration with crisis resolution teams in Norway.

Crisis resolution teams (CRTs) are a community-based service targeting adults experiencing acute mental health crises. The rationale for the development of CRTs is both value and efficacy based, suggesting that CRTs should contribute to the humanizing of mental health services and replace some acute hospital-based services with services in the community. Despite the collaborative nature of CRT work, how professionals from health and social services experience collaboration with CRTs is scantly explored. In the current study, semi-structured focus group interviews with eight different groups of 44 clinicians collaborating with CRTs in Norway were conducted. Data were analyzed using thematic analysis and categorized into four themes: (1) 'The accessible experts', (2) 'A broad and deep expertise', (3) 'Doing it together' and (4) 'Toward a new culture?'. The themes elaborate on issues related to the content and organization of CRT services, emphasizing the need for CRTs to be able to contribute their professional expertise in accessible, flexible and collaborative ways. A diversity in the knowledge base and in how services are organized may pose a challenge in interprofessional mental health crisis collaboration and mutual expectations. The study suggests that a shift toward a value-based and coherent mental health and social system could be a purposeful direction.

Recovery-Oriented Network Meetings in Mental Healthcare: A Qualitative Study.

Recovery-oriented cross-sectoral collaboration is a cornerstone of the debate concerning health professionals and users of mental health services and constitutes an objective in government health policy in Scandinavia and other Western countries. Users do not find that professionals communicate with each other across specific sectors regarding plans that have been prepared. They often experience that they have to start over again every time they switch between treatment locations. The aim of this study is to develop a recovery-oriented model for network meetings. Health professionals and users with experience from mental health services participated in three workshops to discuss and achieve a plan for recovery-oriented network meetings. Knowledge was generated in dynamic research cycles that were experiential, presentational, propositional, and practical. Themes were developed and framed by a content analysis.Recommendations are presented as a narrative from all the participants involved. The overall theme was 'more focus on personal recovery' with subthemes such as 'CHIME as a recovery-oriented approach'. In addition, other themes were generated such as 'open dialogical meetings', with subthemes such as 'meeting structures' and 'open dialogues'. This study concludes recommendations to promote a recovery-oriented approach in cross-sectoral network meetings inspired by theoretical perspectives along with the experiences and knowledge of co-researchers.

Dynamic radiation-induced imaging changes more than 20 years following gamma knife surgery.

Gamma knife radiosurgery (GKS), a technique which involves delivery of a high dose of radiation to a precisely defined target, has become the predominant treatment option for brain metastases (BM) because of its high effectiveness and relatively minimal toxicity. Herein, we report a case of late-onset radiation-induced edema around an asymptomatic cyst, more than 20 years after salvage GKS, with 27 years of imaging follow-up, allowing the description of the evolutionary trajectory of these relatively rare complications. Our reported case also demonstrated the benign nature of delayed cyst formation (DCF), emphasizing that observation alone is reasonable for asymptomatic patients.

Open Dialogue Approach: Exploring and Describing Participants' Experiences in an Open Dialogue Training Program.

Open dialogue (OD) is a family-oriented approach that has demonstrated good outcomes in treatment of first-episode psychosis. OD focuses on communication as a joint process of constructing meaning among patients, their social networks, and professionals. The current study investigates how 42 participants experienced a training program in OD. The study comprises a cohort with a longitudinal design. Data were collected by means of semi-structured questionnaires and contained quantitative and qualitative data. Descriptive analysis was performed to analyze quantitative data and thematic analysis for qualitative data. Findings show that participants' learning outcomes and confidence with using OD with patients, social networks, and professionals increased significantly throughout the training program. Reflection and role play were essential learning methods. Participants defined themselves as in-progress and considered the training program educational, engaging, and varied. Three main themes arose from the data: Developing an OD Training Program, Competence Development "From Novice to Expert," and Participation and Commitments. [Journal of Psychosocial Nursing and Mental Health Services, 59(5), 38-47.].

Clinical outcome following cerebral AVM hemorrhage.

BACKGROUND: A significant difference exists between the published results reporting the clinical outcome following brain arteriovenous malformation (AVM) ruptures. Information about the outcome following hemorrhage in an AVM population treated with radiosurgery could provide additional information to assess the risk of mortality and morbidity following an AVM hemorrhage. METHODS: Clinical outcome was studied in 383 patients, the largest patient population yet studied, who suffered from a symptomatic hemorrhage after Gamma Knife® surgery (GKS) but before confirmed AVM obliteration. The impact of different patient, AVM, and treatment parameters on the clinical outcome was analyzed. The aim was to generate outcome predictions by comparing our data to and combining them with earlier published results. RESULTS: No relation was found between clinical outcome and treatment parameters, indicating that the results are applicable also on untreated AVMs. Twenty-one percent of the patients died, 45% developed or experienced worsening of neurological sequelae, and 35% recovered completely after the hemorrhage. Old age was a predictor of poor outcome. Sex, AVM location, AVM volume, and history of prior hemorrhage did not influence the outcome. The mortality rate was comparable to earlier published prospective data, but higher than that found in retrospective studies. CONCLUSIONS: The mortality rates in earlier published retrospective series as well as in studies focusing on clinical outcome following AVM hemorrhage significantly underestimate the risk for a mortal outcome following an AVM hemorrhage. Based on our findings, an AVM rupture has around 20% likelihood to result in mortality, 45% likelihood to result in a minor or major deficit, and 35% likelihood of complete recovery. The findings are probably applicable also for AVM ruptures in general. The cumulative mortality and morbidity rates 25 years after diagnosis were estimated to be around 40% in a patient with a patent AVM.

Twenty-three years follow-up after low-dose Gamma Knife surgery of a brainstem juvenile pilocytic astrocytoma: a case report and review of the literature.

Juvenile pilocytic astrocytoma (JPA) is a World Health Organization (WHO) grade I tumor that is the commonest to occur in the 0-19 age group, with an excellent prognosis of 96% 10-year survival in pediatric patients. Complete resection is the treatment of choice for JPAs. However, this is not always feasible due to the location of certain tumors, and the management following subtotal resection is controversial. Fractionated radiotherapy, chemotherapy, radiosurgery, and observation have all been used to treat tumor remnants. We report a young patient with good tumor control 23 years following low-dose Gamma Knife surgery (GKS) of a subtotally resected brainstem JPA and recommend that GKS may be a feasible treatment option to achieve long-term tumor control when subtotal resection cannot be achieved, even if the GKS prescription dose must be significantly reduced due to large tumor volume or proximity to critical structures sensitive to radiation.

European consensus conference on unruptured brain AVMs treatment (Supported by EANS, ESMINT, EGKS, and SINCH).

In December of 2016, a Consensus Conference on unruptured AVM treatment, involving 24 members of the three European societies dealing with the treatment of cerebral AVMs (EANS, ESMINT, and EGKS) was held in Milan, Italy. The panel made the following statements and general recommendations: (1) Brain arteriovenous malformation (AVM) is a complex disease associated with potentially severe natural history; (2) The results of a randomized trial (ARUBA) cannot be applied equally for all unruptured brain arteriovenous malformation (uBAVM) and for all treatment modalities; (3) Considering the multiple treatment modalities available, patients with uBAVMs should be evaluated by an interdisciplinary neurovascular team consisting of neurosurgeons, neurointerventionalists, radiosurgeons, and neurologists experienced in the diagnosis and treatment of brain AVM; (4) Balancing the risk of hemorrhage and the associated restrictions of everyday activities related to untreated unruptured AVMs against the risk of treatment, there are sufficient indications to treat unruptured AVMs grade 1 and 2 (Spetzler-Martin); (5) There may be indications for treating patients with higher grades, based on a case-to-case consensus decision of the experienced team; (6) If treatment is indicated, the primary strategy should be defined by the multidisciplinary team prior to the beginning of the treatment and should aim at complete eradication of the uBAVM; (7) After having considered the pros and cons of a randomized trial vs. a registry, the panel proposed a prospective European Multidisciplinary Registry.

Extended season for northern butterflies.

Butterflies are like all insects in that they are temperature sensitive and a changing climate with higher temperatures might effect their phenology. Several studies have found support for earlier flight dates among the investigated species. A comparative study with data from a citizen science project, including 66 species of butterflies in Sweden, was undertaken, and the result confirms that most butterfly species now fly earlier during the season. This is especially evident for butterflies overwintering as adults or as pupae. However, the advancement in phenology is correlated with flight date, and some late season species show no advancement or have even postponed their flight dates and are now flying later in the season. The results also showed that latitude had a strong effect on the adult flight date, and most of the investigated species showed significantly later flights towards the north. Only some late flying species showed an opposite trend, flying earlier in the north. A majority of the investigated species in this study showed a general response to temperature and advanced their flight dates with warmer temperatures (on average they advanced their flight dates by 3.8 days/°C), although not all species showed this response. In essence, a climate with earlier springs and longer growing seasons seems not to change the appearance patterns in a one-way direction. We now see butterflies on the wings both earlier and later in the season and some consequences of these patterns are discussed. So far, studies have concentrated mostly on early season butterfly-plant interactions but also late season studies are needed for a better understanding of long-term population consequences.

Strengthening practical wisdom: mental health workers' learning and development.

BACKGROUND: Practical wisdom, understood as knowing how to be or act in any present situation with clients, is believed to be an essential part of the knowledge needed to be a professional mental health worker. Exploring processes of adapting, extending knowledge and refining tacit knowledge grounded in mental health workers' experiences with being in practice may bring awareness of how mental health workers reflect, learn and practice professional 'artistry'. RESEARCH QUESTION: The aim of the article was to explore mental health workers' processes of development and learning as they appeared in focus groups intended to develop practical wisdom. The main research question was 'How might the processes of development and learning contribute to developing practical wisdom in the individual as well as in the practice culture?' RESEARCH DESIGN: The design was multi-stage focus groups, and the same participants met four times. A phenomenological hermeneutical method for researching lived experience guided the analysis. PARTICIPANTS AND CONTEXT: Eight experienced mental health workers representing four Norwegian municipalities participated. The research context was community-based mental health services. ETHICAL CONSIDERATIONS: The study was reported to Norwegian Social Data Services, and procedures for informed consent were followed. FINDINGS: Two examples of processes of re-evaluation of experience (Association, Integration, Validation, Appropriation and Outcomes and action) were explored. The health workers had developed knowledge in previous encounters with clients. In sharing practice experiences, this knowledge was expressed and developed, and also tested and validated against the aims of practice. Discussions led to adapted and extended knowledge, and as tacit knowledge was expressed it could be used actively. DISCUSSION: Learning to reflect, being ready to be provoked and learning to endure indecisiveness may be foundational in developing practical wisdom. Openness is demanding, and changing habits of mind is difficult. CONCLUSION: Reflection on, and confrontation with, set practices are essential to building practice cultures in line with the aims of mental health services.

A pragmatist approach to the hope discourse in health care research.

Hope is a central concept in nursing and other fields of health care. However, there is no consensus about the concept of hope. We argue that seeking consensus is futile given the multifaceted and multidimensional nature of the concept, but instead we encourage in-depth studies of the assumptions behind talk about hope in specific contexts. Our approach to the 'science of hope' is inspired by philosophical pragmatism. We argue that hope is a concept that opens different rooms for action in different contexts and that accordingly, all hope interventions are contextually sensitive. Careful attention to how the relative positions and power of nurses and patients influence what can be inferred from their different ways of talking about hope may make hopeful conversations more meaningful in health care relationships.

Health professionals' perceptions of user involvement in a mental health centre: A critical discourse analysis.

The objective of this study was to investigate the engagement between healthcare professionals and users of mental healthcare at the individual level in a mental health hospital. A qualitative research design with purposive sampling was adopted. Five audio-recorded focus group interviews were conducted with nurses and other health professionals at a mental health hospital in Copenhagen and were explored using Fairclough's discourse analysis framework. This study shows how users can be subject to paternalistic control despite the official aim that user involvement be an integral part of the care and treatment offered. As evidenced in discussions by health professionals, the users were involved in plans based on conditions determined by the health professionals who were predominantly focused on treating diseases and enabling the users to live a life independent of professional help. Our results can contribute to dealing with the challenges of incorporating user involvement as an ideology in mental health hospitals.

Is Gamma Knife surgery, omitting adjunct whole brain radiation treatment, feasible for patients with 20 or more brain metastases?

Background: The importance of the number of brain metastases (BM) when deciding between whole brain radiation treatment (WBRT) and radiosurgery is controversial. We hypothesized that the number of BM is of limited importance when deciding radiation strategy, and offered Gamma Knife surgery (GKS) also for selected patients with 20 or more BM. Methods: The outcome following single session GKS for 75 consecutive patients harboring 20 or more (20+) BM was analyzed. Data was collected both retro- and prospectively. Results: The median survival time was 9 months. Two grade 3 complications occurred, 1 resolved and 1 did not. Sex and clinical condition at the time of GKS (ECOG value) were the only parameters significantly related to survival time. Eighteen patients developed leptomeningeal dissemination with or without distant recurrences (DR), and another 32 patients developed DR a total of 73 times. DR was managed with GKS 24 times, with WBRT 3 times and with systemic treatment or best supportive care 46 times. The median time to developing DR was unrelated to the number of BM, but significantly longer for patients older than 65 years, as well as for patients with NSCLC. Conclusions: GKS is a reasonable treatment option for selected patients with 20 or more BM. It is better to decide the optimal management of post-GKS intracranial disease progression once it occurs rather than trying to prevent it by using adjunct WBRT.

"We are all fellow human beings": mental health workers' perspectives of being in relationships with clients in community-based mental health services.

Stable, trusting relationships are at the core of Norwegian community-based mental health services. Being acknowledged and respected may promote a client's recovery. The aim of this study was to explore mental health workers' experiences of relating to clients. The design involved multi-stage focus groups based on a participatory approach and using interpretative phenomenological analysis. Acknowledging the personhood of a client appears to offer opportunities for growth and development in the client as well as in the health worker, based on reciprocal processes of each person affecting the other and the health workers' openness to understanding the other person.

Healthcare Professionals' Experiences with Patient Participation in a Mental Healthcare Centre: A Qualitative Study.

INTRODUCTION: Patient participation is a cornerstone of the debate concerning healthcare professionals and patients of mental health centres. It constitutes an objective in government health policy in Scandinavia and other Western countries. However, little is known about the experiences of healthcare professionals in mental healthcare practices involving patients under their treatment and care. OBJECTIVE: This study aimed to explore the experiences of healthcare professionals with patient participation in the context of a mental health centre. METHODOLOGICAL DESIGN: Four focus group interviews with healthcare professionals reflected differing experiences with unfolding patient participation in clinical practices in four wards of a mental health centre. A content analysis developed and framed themes. RESULTS: Patient participation was based on structural conditions, which shows that predetermined structural methods predominantly control involvement. The structural methods are seen as promoting participation from the patient's perspective. At the same time, the methods also enable taking account of the individual patient's wishes and needs for involvement. DISCUSSION AND CONCLUSION: This study illuminates the meaning of patient participation in a mental health centre based on the social interactions among nurses and other healthcare professionals. The approach can contribute to dealing with the challenges of incorporating patient participation as an ideology for all patients in a psychiatric context, which is important knowledge for healthcare professionals.