Forewarning of hypotensive events using a Bayesian artificial neural network in neurocritical care.

Traumatically brain injured (TBI) patients are at risk from secondary insults. Arterial hypotension, critically low blood pressure, is one of the most dangerous secondary insults and is related to poor outcome in patients. The overall aim of this study was to get proof of the concept that advanced statistical techniques (machine learning) are methods that are able to provide early warning of impending hypotensive events before they occur during neuro-critical care. A Bayesian artificial neural network (BANN) model predicting episodes of hypotension was developed using data from 104 patients selected from the BrainIT multi-center database. Arterial hypotension events were recorded and defined using the Edinburgh University Secondary Insult Grades (EUSIG) physiological adverse event scoring system. The BANN was trained on a random selection of 50% of the available patients (n = 52) and validated on the remaining cohort. A multi-center prospective pilot study (Phase 1, n = 30) was then conducted with the system running live in the clinical environment, followed by a second validation pilot study (Phase 2, n = 49). From these prospectively collected data, a final evaluation study was done on 69 of these patients with 10 patients excluded from the Phase 2 study because of insufficient or invalid data. Each data collection phase was a prospective non-interventional observational study conducted in a live clinical setting to test the data collection systems and the model performance. No prediction information was available to the clinical teams during a patient's stay in the ICU. The final cohort (n = 69), using a decision threshold of 0.4, and including false positive checks, gave a sensitivity of 39.3% (95% CI 32.9-46.1) and a specificity of 91.5% (95% CI 89.0-93.7). Using a decision threshold of 0.3, and false positive correction, gave a sensitivity of 46.6% (95% CI 40.1-53.2) and specificity of 85.6% (95% CI 82.3-88.8). With a decision threshold of 0.3, > 15 min warning of patient instability can be achieved. We have shown, using advanced machine learning techniques running in a live neuro-critical care environment, that it would be possible to give neurointensive teams early warning of potential hypotensive events before they emerge, allowing closer monitoring and earlier clinical assessment in an attempt to prevent the onset of hypotension. The multi-centre clinical infrastructure developed to support the clinical studies provides a solid base for further collaborative research on data quality, false positive correction and the display of early warning data in a clinical setting.

Early warning of EUSIG-defined hypotensive events using a Bayesian Artificial Neural Network.

BACKGROUND: Hypotension is recognized as a potentially damaging secondary insult after traumatic brain injury. Systems to give clinical teams some early warning of likely hypotensive instability could be added to the range of existing techniques used in the management of this group of patients. By using the Edinburgh University Secondary Insult Grades (EUSIG) definitions for -hypotension (systolic arterial pressure <90 mmHg OR mean arterial -pressure <70 mmHg) we collected a group of ∼2,000 events by analyzing the Brain-IT database. We then constructed a Bayesian Artificial Neural Network (an advanced statistical modeling technique) that is able to provide some early warning when trained on this previously collected demographic and physiological data. MATERIALS AND METHODS: Using EUSIG defined event data from the Brain-IT database, we identified a Bayesian artificial neural network (BANN) topology and constructed a series of datasets using a group of clinically guided input variables. This allowed us to train a BANN, which was then tested on an unseen set of patients from the Brain-IT database. The initial tests used a particularly harsh assessment criterion whereby a true positive prediction was only allowed if the BANN predicted an upcoming event to the exact minute. We have now developed the system to the point where it is about to be used in a two-stage Phase II clinical trial and we are also researching a more realistic assessment technique. KEY RESULTS: We have constructed a BANN that is able to provide early warning to the clinicians based on a model that uses information from the physiological inputs; systolic and mean arterial pressure and heart rate; and demographic variables age and gender. We use 15-min SubWindows starting at 15 and 30 min before an event and process mean, slope and standard deviations. Based on 10 simulation runs, our current sensitivity is 36.25% (SE 1.31) with a specificity of 90.82% (SE 0.85). Initial results from a Phase I clinical study shows a model sensitivity of 40.95% (SE 6%) and specificity of 86.46% (SE 3%) Although this figure is low it is considered clinically useful for this dangerous condition, provided the false positive rate can be kept sufficiently low as to be practical in an intensive care environment. CONCLUSION: We have shown that using advanced statistical modeling techniques can provide clinical teams with useful information that will assist clinical care.

Trigger characteristics of EUSIG-defined hypotensive events.

BACKGROUND: Hypotension is a recognized -secondary insult after traumatic brain injury (TBI). There are many definitions of hypotension, an often cited example being the Brain Trauma Foundation's current (2007) "Guidelines for the Management of Severe Traumatic Brain Injury," which defines hypotension as systolic pressure <90 mmHg. However, this same document declares "The importance of mean arterial pressure, as opposed to systolic pressure should also be stressed, …." Our work shows that when using the Edinburgh University Secondary Insult Grades (EUSIG) definitions, which require monitoring of both systolic and mean arterial pressures, that most hypotensive events are in fact triggered by a breach of the mean arterial level of 70 mmHg. We suggest that close monitoring of mean arterial pressure would enable clinical teams to avoid more potentially damaging hypotensive events. MATERIALS AND METHODS: An analysis of 100 patients from the Brain-IT database was performed. Using the EUSIG definitions, 2,081 events can be obtained by analyzing the systolic and mean blood pressures on a minute by minute basis. A software program was written to identify and classify the trigger pattern for each event. A categorical analysis of these triggering patterns has been carried out. KEY RESULTS: Our analysis shows that most events are triggered by a drop in mean arterial pressure. In fact a large number of events (91%) occur where the mean arterial pressure is below the threshold limits whereas the systolic pressure does not cross the 90 mmHg limit at all. CONCLUSION: We suggest that more emphasis should be placed on closely monitoring mean arterial pressure as well as systolic pressure when trying to guard against hypotensive problems in traumatically brain injured patients. In future work we will study the underlying physiological mechanisms and attempt to further classify concomitant conditions that may be contributing to the onset of a hypotensive event.

The use of hyperventilation therapy after traumatic brain injury in Europe: an analysis of the BrainIT database.

OBJECTIVE: To assess the use of hyperventilation and the adherence to Brain Trauma Foundation-Guidelines (BTF-G) after traumatic brain injury (TBI). SETTING: Twenty-two European centers are participating in the BrainIT initiative. DESIGN: Retrospective analysis of monitoring data. PATIENTS AND PARTICIPANTS: One hundred and fifty-one patients with a known time of trauma and at least one recorded arterial blood-gas (ABG) analysis. MEASUREMENTS AND RESULTS: A total number of 7,703 ABGs, representing 2,269 ventilation episodes (VE) were included in the analysis. Related minute-by-minute ICP data were taken from a 30 min time window around each ABG collection. Data are given as mean with standard deviation. (1) Patients without elevated intracranial pressure (ICP) (< 20 mmHg) manifested a statistically significant higher P(a)CO(2) (36 +/- 5.7 mmHg) in comparison to patients with elevated ICP (> or = 20 mmHg; P(a)CO(2): 34 +/- 5.4 mmHg, P < 0.001). (2) Intensified forced hyperventilation (P(a)CO(2) < or = 25 mmHg) in the absence of elevated ICP was found in only 49 VE (2%). (3) Early prophylactic hyperventilation (< 24 h after TBI; P(a)CO(2) < or = 35 mmHg, ICP < 20 mmHg) was used in 1,224 VE (54%). (4) During forced hyperventilation (P(a)CO(2) < or = 30 mmHg), simultaneous monitoring of brain tissue pO(2) or S(jv)O(2) was used in only 204 VE (9%). CONCLUSION: While overall adherence to current BTF-G seems to be the rule, its recommendations on early prophylactic hyperventilation as well as the use of additional cerebral oxygenation monitoring during forced hyperventilation are not followed in this sample of European TBI centers. DESCRIPTOR: Neurotrauma.

The effect of the results of the STICH trial on the management of spontaneous supratentorial intracerebral haemorrhage in Newcastle.

Recently, the Surgical Trial in IntraCerebral Haemorrhage (STICH) was unable to show an overall benefit from 'early surgery' compared with a policy of 'initial conservative treatment'. Here, we evaluated the impact of the STICH results on the management of spontaneous supratentorial intracerebral haemorrhage (ICH) in the Newcastle upon Tyne Hospitals. The STICH results were released to the Neurosurgery Department at Newcastle General Hospital in November 2003; using ICD-10 data, we analysed ICH admissions before (2002) and after (2004, 2006, 2007) this. We assessed numbers of Neurosurgery and Stroke Unit admissions, numbers of clot evacuation procedures, and 30-day mortality rate (Neurosurgery vs. Stroke Unit admissions). Subarachnoid haemorrhage (SAH) admissions data were also collected to corroborate our findings. There were 478 spontaneous supratentorial ICH admissions in total; 156 in 2002, 120 in 2004, 106 in 2006 and 96 in 2007. SAH admissions remained remarkably constant over this period. Neurosurgery admissions decreased significantly across the four time periods, from 71% of total ICH admissions (n = 156) in 2002 to 55% (n = 96) in 2007, and Stroke Unit admissions increased significantly from 8% (n = 156) in 2002 to 30% (n = 96) in 2007 (chi(2) = 20.968, p < 0.001, df = 3). Clot evacuation procedures also decreased significantly from 32% (n = 111) of Neurosurgery admissions in 2002 to 17% (n = 53) in 2007 (chi(2) = 11.919, p = 0.008, df = 3). 30-day mortality increased in Neurosurgery from 14% of Neurosurgery admissions (n = 111) in 2002 to 26% (n = 53) in 2007, and decreased in the Stroke Unit, from 42% of Stroke Unit admissions (n = 12) in 2002 to 17% (n = 29) in 2007. The STICH results have significantly impacted ICH management in Newcastle, with a trend towards fewer Neurosurgery admissions and clot evacuations, and increased Stroke Unit admissions. The role of surgery for ICH remains controversial, and randomization continues in STICH II for patients with superficial lobar ICH.

Comparison of image quality, diagnostic confidence and interobserver variability in contrast enhanced MR angiography and 2D time of flight angiography in evaluation of carotid stenosis.

The aim of this study was to compare image quality, level of diagnostic confidence and interobserver agreement in assessment of carotid stenosis with contrast enhanced MR angiography (CE MRA) in comparison with 2D time of flight MR angiography (2D TOF MRA). 60 carotid arteries in 30 patients were examined by three observers. Image quality and diagnostic confidence were assessed on the basis of a visual analogue scale. Interobserver variability was assessed with the help of intraclass correlation coefficient. Median values on the visual analogue scale for image quality and diagnostic confidence were higher for CE MRA compared with 2D TOF MRA for all three observers. Higher intraclass correlation values were recorded for interobserver variability for CE MRA compared with 2D TOF MRA both for visual estimation of carotid stenosis as well as for measurement of carotid stenosis on the basis of North American Symptomatic Carotid Endarterectomy Trial (NASCET) and European Carotid Surgery Trial (ECST) criteria. CE MRA provides better image quality, higher level of diagnostic confidence and more interobserver agreement compared with 2D TOF MRA.

Intraventricular hemorrhage and hydrocephalus after spontaneous intracerebral hemorrhage: results from the STICH trial.

INTRODUCTION: Intraventricular hemorrhage (IVH), either independent of or as an extension of intracranial bleed, is thought to carry a grave prognosis. Although the effect of IVH on outcome in patients with subarachnoid hemorrhage has been extensively reviewed in the literature, reports of spontaneous intracerebral hemorrhage (ICH) in similar situations have been infrequent. The association of hydrocephalus in such situations and its influence on outcome is also uncertain. PATIENTS AND METHODS: As a sub-analysis of data obtained through the international Surgical Trial in Intracerebral Hemorrhage (STICH), the impact of IVH, with or without the presence of hydrocephalus, on outcome in patients with spontaneous ICH was analyzed. CT scans of randomized patients were examined for IVH and/or hydrocephalus. Other characteristics of hematoma were evaluated to see if they influenced outcome, as defined by the STICH protocol. RESULTS: Favorable outcomes were more frequent when IVH was absent (31.4% vs. 15.1%; p < 0.00001). The presence of hydrocephalus lowered the likelihood of favorable outcome still further to 11.5% (p = 0.031). In patients with IVH, early surgical intervention had a more favorable outcome (17.8%) compared to initial conservative management (12.4%) (p = 0.141). CONCLUSION: The presence of IVH and hydrocephalus are independent predictors of poor outcome in spontaneous ICH. Early surgery is of some benefit in those with IVH.

The significance of crossovers after randomization in the STICH trial.

INTRODUCTION: Of all forms of stroke, spontaneous intracerebral haemorrhage (ICH) causes the highest morbidity and mortality. The Surgical Trial in Intracerebral Haemorrhage (STICH) found no difference in outcomes between patients randomized to surgical or conservative treatment. PATIENTS AND METHODS: Of 530 patients randomized to initial conservative treatment, 140 crossed over to surgery. This study examines the variables associated with crossover. RESULTS: Dominant features of the crossover group were: male, (p = 0.04), right-sided clot (p = 0.03), lobar clot (p = 0.003), clot volume (median 64 mL for crossovers vs. 38 mL for others, p < 0.00001), midline shift (median 6 mm for crossovers vs. 3 mm for others, p < 0.00001), superficial clot (median 1.3 mm for crossovers vs. 11.5 mm for others, p < 0.00001), and randomization within 12 hours of ictus (p < 0.0005). Thalamic location (p = 0.002) was under-represented. Intraventricular haemorrhage, hydrocephalus, and focal deficits were not associated with crossover. Craniotomy was the method of evacuation in 85% of crossover patients. CONCLUSIONS: Crossover to surgery was more likely when ICH had these features: Right side, lobar location, superficial, large volume, big shift, and early randomization. Crossovers formed a worse prognostic group compared to non-crossovers. Surgery did not affect trial results, which were analyzed by intention-to-treat.

Variability in pupil size estimation.

BACKGROUND: The clinical estimation of pupil size and reactivity is central to the neurological assessment of patients, particularly those with or at risk of neurological damage. Health care professionals who examine pupils have differing levels of skill and training, yet their recordings are passed along the patient care pathway and can influence care decisions. The aim of this study was to determine if any statistical differences existed in the estimation of pupil size by different groups of health care professionals. METHODS: A total of 102 health care professionals working in the critical care environment were asked to estimate and record the pupil size of a series of 12 artificial eyes with varying pupil diameter and iris colour. All estimations were performed indoors under ambient lighting conditions. RESULTS: Our results established a statistically significant difference between staff groups in the estimation of pupil size. CONCLUSION: The demonstrated variability in pupil size estimation may not be clinically significant. However, it remains desirable to have consistency of measurement throughout the patient care pathway.

Treatment of poor-grade subarachnoid hemorrhage trial.

BACKGROUND AND PURPOSE: Management of poor-grade subarachnoid hemorrhage is based on limited evidence from small single-center retrospective observational studies. The purpose of this study was to undertake a single-center randomized controlled feasibility trial comparing a strategy of early endovascular aneurysm treatment with treatment after neurologic recovery in this group of patients. MATERIALS AND METHODS: Patients with poor-grade SAH were randomized within 24 hours of admission to early treatment or treatment after neurologic recovery. If a patient was randomized to early treatment, the aneurysm was treated endovascularly within 24 hours of randomization. Recruitment rate, safety profile, and functional outcome at the time of discharge and at 6 months were assessed. RESULTS: Fourteen of 51 patients screened were eligible for the trial. Of these 14, 8 patients were randomized (57%). All patients in the early coiling arm received treatment within 24 hours of randomization. There was no treatment-related complication. Overall, good outcome occurred in 25% of patients; the mortality rate was 75%. Patients in the early treatment arm (n = 5) had a good outcome rate of 20%, while those in treatment after neurologic recovery arm (n = 3) had a good outcome rate of 33.3%. CONCLUSIONS: This was a feasibility study that demonstrated that recruitment and randomization for comparing management strategies in poor-grade SAH are feasible. The recruitment rate among eligible patients was encouraging (57%), though a number of patients had to be excluded due to ineligibility. A multicenter study is necessary to recruit the numbers required to compare the clinical outcomes of these management strategies.

Surgery in intracerebral hemorrhage. The uncertainty continues.

BACKGROUND AND PURPOSE: Primary intracerebral hemorrhage (ICH) accounts for 10% to 20% of stroke but carries the highest rates of mortality and morbidity of all stroke subtypes. Current treatment, however, is varied and haphazard. The most recent Cochrane systematic review refers to 4 prospective, randomized controlled trials. We present a further meta-analysis to include 3 new trials. In addition, we review the trials of Chen et al and McKissock et al and discuss aspects of their quality that, we believe, prevent their inclusion in modern day meta-analysis. METHODS: Literature databases and articles were searched from 1966 to October 1999. Using the end points of death and dependency, the results of the 7 identified randomized trials were expressed as odds ratios. All available data were then analyzed with meta-analysis techniques. Analysis of relevant subsets of trials was also carried out. RESULTS: Meta-analysis of all 7 trials shows a trend toward a higher chance of death and dependency after surgery (OR 1.20; 95% CI 0.83 to 1.74). Meta-analysis was also carried out after exclusion of the Chen and McKissock trials for reasons discussed in the text. This meta-analysis suggests a benefit from surgery, with a reduction in the chances of death and dependency after surgical treatment by a factor of 0.63 (OR 0.63; 95% CI 0.35 to 1.14). CONCLUSIONS: When meta-analysis is restricted to modern-day, post-CT, well-constructed, balanced trials, a trend for surgery to reduce the chances of death and dependency is found. Perhaps, then, in the modern era of CT, good neuroanesthesia, intensive care, and the operating microscope, surgery has a role in the treatment of supratentorial intracerebral hemorrhage. The results of a large, multicenter, randomized controlled trial are urgently needed, and the ongoing International Surgical Trial of Intracerebral Hemorrhage should fulfill this objective.

Development of a measure of professional collaboration in primary health care.

STUDY OBJECTIVE: The aim was to develop indices of the degree of collaboration between district nurses, general practitioners, and health visitors. DESIGN: Semistructured interviews were conducted with each member of a pair of professionals who had patients in common. In each district a stratified random sample of six general practitioners and six community nurses was drawn, and for each a "partner" of the other profession was sampled. SETTING: A stratified random sample of 20 district health authorities in England. PARTICIPANTS: Complete interviews were obtained with 148 doctor-nurse and 161 doctor-health visitor pairs. MAIN RESULTS: Only 27% of general practitioners and district nurses with patients in common and 11% of general practitioners and health visitors collaborate. Stepwise logistic discriminant analysis was used to develop measures of collaboration between general practitioners and district nurses and between general practitioners and health visitors. The indices of collaboration were calculated from the responses of the community nurse to at most 10 questions. CONCLUSIONS: The indices developed here might be used as a measure of one aspect of the quality of service offered by a primary health care team or to assess the effect of changes in working patterns or the degree of collaboration within the organisation.

Issues of recruitment and maintaining high response rates in a longitudinal study of older hospital patients in England--pathways through care study.

STUDY OBJECTIVES: To describe and discuss the methods used to recruit and maintain an unbiased sample of older discharged hospital patients in a study of the process and outcomes of hospital care. DESIGN: Prospective longitudinal interview study of consecutive patients admitted to hospital over a 12 month period and followed up for six months. Interviews took place in hospital five days after admission, at home 10 days after discharge, and six months after admission. SETTING: Six hospital locations: three in the north of England and three in the south. PARTICIPANTS: People aged 65 and over admitted to hospital with a new stroke or fractured neck of femur, their significant other, and nursing staff caring for them. MAIN RESULTS: Of 3105 patients referred to the study, 2111 were eligible and 1671 (79%) were recruited. Recruited stroke patients were younger than those not recruited and rates differed between locations for both stroke and fractured neck of femur. By six months after admission 25% had died. Outcome data were obtained for 85% of the surviving patients. Patients who died were older and frailer before admission. Among survivors, outcome data for stroke patients were less likely to be obtained for men, those more able initially, and those who were married. Response rates to each interview differed according to respondent types. Interviews were more likely to be obtained with significant others than patients. Patients who were not able to be interviewed were older and frailer; significant others were less likely to be interviewed if the patients were younger and more able. CONCLUSIONS: High response rates can be achieved with very frail older people if strategies are adopted to maintain their interest and if self reported data are supplemented by interviewing significant others.

Costs of formal care for frail older people in England: the resource implications study of the MRC cognitive function and ageing study (RIS MRC CFAS).

The aim of this paper is to quantify service use and costs of supporting frail older people at home in the community, using data collected in a longitudinal multicentre stratified randomised study for 1055 mentally frail, physically frail, and mentally and physically frail subjects. Average costs per person per week were found to total 64.45 Pounds Sterling, with a small number of services accounting for a large proportion of the total costs. The level of services offered by the nonstatutory voluntary and private sectors was found to be small. To highlight issues for policy makers, the extent of cost variations between a number of different subgroups were calculated. These bivariate analyses revealed substantial variation in costs, especially according to household structure, type of frailty, whether admission to continuing care accommodation occurred and survival. Multiple regression analysis demonstrated that 26% of the variation in log average weekly costs could be explained by a number of socio-demographic and health status variables. A particularly close relationship was observed between costs and whether admission to continuing care accommodation occurred, highlighting a need for policy-makers to examine the nature and scale of provision of alternative community based care packages. The results demonstrate that descriptive cost data such as those presented can provide information useful to the planning process, enabling more informed choices to be made over the provision of services for particular groups of people.

Predicting place of discharge from hospital for patients with a stroke or hip fracture on admission.

OBJECTIVES: To determine the predictive power of patient and service characteristics on place of discharge following hospital admission for an acute stroke and for hip fracture. METHODS: Prospective cohort of 440 acute stroke and 572 hip fracture patients aged 65 years or over admitted from home to six district general hospitals and associated community hospitals, three in the North and three in the South of England. RESULTS: Age, marital status, living arrangements, mental health status at admission, pre-admission self-rated disability, pre-admission use of home-care services, post-admission staff assessments of functional dependency as measured by Barthel Index and of confusion as measured by the modified Crichton Royal Behavioural Rating Scale and nursing staffs' expectation of place of discharge are all significantly related to place of discharge for stroke and hip fracture participants. Logistic regression correctly predicted discharge destination for 87% of stroke patients from data available at time of admission and 83% of hip fracture patients. Of the 30% of stroke patients discharged to an institution, the model correctly predicted 73%. However, of the 19% of hip fracture patients discharged to an institution, only 28% were correctly predicted. CONCLUSIONS: Data about older patients admitted to hospital with an acute condition should be routinely collected by hospital staff to inform clinical management and to permit risk-adjusted audit.

Continuous monitoring of ICP and CPP following ICH and its relationship to clinical, radiological and surgical parameters.

Sixty-two patients with a spontaneous supratentorial haemorrhage had continuous Intracranial Pressure (ICP) and Cerebral Perfusion Pressure (CPP) monitoring. In addition to the recordings of physiological data their past medical history, presenting neurological state, Computed Tomograph (CT) findings, daily Glasgow Coma Score (GCS) and outcome were noted. The mean age was 57.6 years (sd 13.3). Onset of recording, after ictus was at a mean of 32.6 hours (sd 26.0). Average length of recording was 62.0 hours (sd 39.8). Thirty-one patients had evacuation of haematoma, 6 insertion of External Ventricular Drain (EVD). Preoperative measures of ICP were significantly related to delayed neurological deterioration, death within three days and Glasgow Outcome Scale (GOS) at neurosurgical discharge. No such relationships existed with preoperative measures of CPP and neither ICP nor CPP was related to outcome at 6 months. Post-operative measures of both ICP and CPP demonstrated a significant relationship with death within three days of ictus and GOS at neurosurgical discharge. Again no relationship existed with these parameters and outcome at six months. Surgical evacuation of haematoma acted to significantly reduce ICP and improve CPP. Given that these factors seem to be related to deterioration, death and early outcome, it would seem that surgery could play a role in reducing mortality and improving outcome following Intra cerebral Haemorrhage (ICH).

The selectin superfamily: the role of selectin adhesion molecules in delayed cerebral ischaemia after aneurysmal subarachnoid haemorrhage.

Cerebral ischaemia and reperfusion injury may be exacerbated by leukocyte recruitment and activation. Adhesion molecules play a pivotal role in leukocyte recruitment. We report a prospective study of the potential role of the selectin family of adhesion molecules (E-, P- and L-selectin) in delayed cerebral ischaemia (DID) following aneurysmal subarachnoid haemorrhage. In patients with good grade SAH, we have compared serum concentrations of E-, P- and L-selectin, between patients who do, and do not develop delayed cerebral ischaemia. There was no difference in E-selectin concentration between the two groups (44.0 ng/ml vs. 37.4 ng/ml). Serum P-selectin concentration was significantly higher in patients with DID compared to those patients without DID (149.5 ng/ml vs. 112.9 ng/ml, p = 0.039). Serum L-selectin concentrations were significantly lower in patients with DID (633.8 ng/ml vs 897.9 ng/ml, p = 0.013). We conclude that P- and L-selectin are involved in the pathogenesis of DID following aneurysmal subarachnoid haemorrhage. The results of this study do not elucidate the exact role of each selectin in DID.

A review of the literature on women's views on their maternity care in the community in the UK.

OBJECTIVES: to review the UK literature relating to women's views on community-based maternity care between 1970 and 1998. DESIGN: UK research studies examining community-based maternity care were identified by searching several electronic databases using defined search terms. Data extraction was carried out by two or more independent reviewers using a pro-forma. Findings are summarised in this paper. FINDINGS: a total of 624 papers were retrieved and 241 met inclusion criteria. Only 40 papers included some form of comparison group. Examples from more recent and relevant papers focusing on women's views of their maternity care are described and discussed. Women expressed high levels of satisfaction with care. However, there are serious gaps in the research evidence. CONCLUSION AND POLICY IMPLICATIONS: most of the papers included in the review were descriptive and few studies were of a size and quality to enable findings to be generalised to other groups and settings. More information is needed on the care process. There is a need for research studies to examine consumer views where different groups of women experience different care processes.

A review of the literature on the midwife and community-based maternity care.

OBJECTIVE: to review the UK literature relating to community-based maternity care. DESIGN: all UK research studies published between 1970 and 1998 relating to community-based maternity care were included. Searches were made via a number of electronic databases using defined search terms. All papers included were independently reviewed by a minimum of two researchers. Study findings were tabulated using a pro-forma. Findings are summarised in this paper. FINDINGS: a total of 241 papers were deemed to meet all inclusion criteria. The majority of studies used descriptive methods with only 11 papers reporting findings from randomised controlled trials. Findings are reported relating to clinical outcomes, the care process and the views of women and health professionals. CONCLUSION AND POLICY IMPLICATIONS: the overall quality of the evidence in the papers reviewed was very mixed. What limited evidence there is suggests that, for the majority of women, care in community settings is as safe and as acceptable to women as care provided in hospital. Despite a large volume of literature, the amount that is known about midwives' contribution to care, and what women think about it, is limited. There is a need for controlled studies to compare outcomes for different patterns of care and for well-designed observational studies to provide information on the care process.

Are older people satisfied with discharge information?

In this article we report the views of older discharged patients who have had a stroke or have fractured the neck of their femur on the information they were given about their condition and treatment while in hospital. Structured face-to-face interviews carried out 10 days after discharge contained some open-ended questions. Responses to a question on information were coded according to whether they were indicative of satisfaction. These responses were also analysed qualitatively to identify themes: 41% reported satisfaction with information and 40% dissatisfaction. The responses of the remaining 19% could not be coded either way. Views indicative of dissatisfaction were more likely to be expressed by subjects with the poorest outcomes and those who had experienced most ward moves. All staff should be vigilant in ensuring that information is always clearly conveyed to the most frail patients.