The Wolfson Assessment Matrix: a potential tool to support clinicians in establishing access to specialized neuro rehabilitation by capturing important prognostic factors. Sharing more equitable and transparent criteria.

BACKGROUND: Specialized Rehabilitation Services (SRSs) are designed to offer intensive multidisciplinary rehabilitation to patients with complex needs, who are expected to make significant functional gains in their ADLs over a relatively limited period of time. Although national guidelines offer a guidance on how to band patients by complexity, there is no consensus on how to screen patients with regard to rehabilitation prognosis. AIM: The aim of this study was to improve the selection of patients admitted to an SRS, defining transparent and equitable prognostic criteria to guide clinicians' decision making. DESIGN: This is a retrospective observational study SETTING: an SRS in the UK. POPULATION: We included 121 patients affected by a neurological condition consecutively admitted for multidisciplinary rehabilitation. METHODS: Rehabilitation Complexity Scale Extended is used to describe rehabilitation complexity. A short list of potential barriers to rehabilitation was analysed to predict the functional outcome measured by the Functional Independent Measure and the Barthel Index. RESULTS: Older age, a heavier burden of co-morbidities, pre-morbid cognitive difficulties or dementia and a lower function level at admission were the most important variables to predict a lower functional gain. CONCLUSIONS: We have used this list of barriers to create the Wolfson Assessment Matrix as a potential support tool to guide clinicians navigating through the different rehabilitation service options when assessing complex patients for eligibility to an SRS. CLINICAL REHABILITATION IMPACT: SRSs are highly expensive services representing a possible step along the rehabilitation pathway for patients with complex needs. A tool such as the Wolfson Assessment Matrix would represent a step forward to help consistency in decision making regarding appropriateness for SRSs. It would also help to set realistic long-term goals with patients and families and support Health Services in the further development of alternative rehabilitation settings.

Difficulties in Management of Functional Movement Disorders: Three Illustrative Cases.

BACKGROUND: Some patients with FND and FEVD cannot re-establish walking ability with standard treatment alone. CASES: Novel invasive treatment of FEVD trialed in three females, aged 19, 30 and 33 years with >18 month history of FND. None could walk and all were wheelchair-dependent needing home carers. Standard treatment plus novel step-wise escalation of invasive "intervention+" was individually tailored to correct FEVD; functional electrical stimulation, botulinum toxin injections, tibial nerve block, serial casting, and for Case 3, manipulation under anesthetic and surgical tendon lengthening. All regained walking ability and discontinued carers. Case 1 resumed dancing and Case 3 returned to employment. Improvements were largely maintained at 3 and 6 month follow-up. CONCLUSIONS: As a last resort, invasive adjuncts may be considered in a very small proportion of FND patients who fail to regain walking ability with standard treatment alone and reach a "dead end" where no further progress is feasible.

A Retrospective Case Series Analysis of the Relationship Between Phenylalanine: Tyrosine Ratio and Cerebral Glucose Metabolism in Classical Phenylketonuria and Hyperphenylalaninemia.

We retrospectively examined the relationship between blood biomarkers, in particular the historical mean phenylalanine to tyrosine (Phe:Tyr) ratio, and cerebral glucose metabolism. We hypothesized that the historical mean Phe:Tyr ratio would be more predictive of cerebral glucose metabolism than the phenylalanine (Phe) level alone. We performed a retrospective case series analysis involving 11 adult classical phenylketonuria/hyperphenylalaninemia patients under the care of an Inherited Metabolic & Neuropsychiatry Clinic who had complained of memory problems, collating casenote data from blood biochemistry, and clinical [18F]fluorodeoxyglucose positron emission tomography ([18F]FDG PET). The Phe:Tyr ratio was calculated for individual blood samples and summarized as historical mean Phe:Tyr ratio (Phe:Tyr) and historical standard deviation in Phe:Tyr ratio (SD-Phe:Tyr), for each patient. Visual analyses of [18F]FDG PET revealed heterogeneous patterns of glucose hypometabolism for eight patients. [18F]FDG PET standardized uptake was negatively correlated with Phe in a large cluster with peak localized to right superior parietal gyrus. Even larger clusters of negative correlation that encompassed most of the brain, with frontal peaks, were observed with Phe:Tyr, and SD-Phe:Tyr. Our case series analysis provides further evidence for the association between blood biomarkers, and cerebral glucose hypometabolism. Mean historical blood Phe:Tyr ratio, and its standard deviation over time, appear to be more indicative of global cerebral glucose metabolism in patients with memory problems than Phe.

Re-audit of physical examination on admission.

Re-audit of the physical examination of older adults admitted to one of two inpatient Older Adult wards at the Maudsley Hospital found that on admission, only 58% of patients had a brief physical examination and 43% had a full physical examination, and after 72 hours only 65% had a full physical examination. This is a slight improvement on the previous audit but still falls short of the target of 90% of patients having a full physical examination within 72 hours of admission. Recommendations include education of junior and senior doctors of the need for physical examination via presentation of audit and distribution of results, consideration of the use of a proforma to gather information on physical examination which may have been done in an acute hospital and a further re-audit to see if outcomes have improved.

Screening for depression in post stroke patients.

BACKGROUND: depression has a significant prevalence in patients following a stroke. Studies have found rates to be between 25-54%. AIMS: Within this audit we aimed to ascertain the proportion of patients who have been identified as having depression, and explore the methods employed to identify depressed patients. We also looked to assess the number of these patients who have been treated for depression and to explore the medications used for the treatment of depression. METHODS: this audit was conducted in two phases. Initially an audit was conducted to establish the current prevalence, screening and management of depression in post-stroke patients. Following this, we introduced the PHQ-9 as a screening tool for depression and a re-audited at four months. In phase 2, All patients admitted to the stoke ward in Bedford hospital between 10/9/09 and 13/12/09 were included in the audit. Patients were screened for depression using the PHQ-9 questionnaire two weeks after admission. RESULTS: the incidence of depression within the phase one group was 28%. In 9 of these cases there was no record of mood assessment or diagnosis of depression in the medical notes. Thirteen out of 60 patients were prescribed psychotropic agents during their stay. In phase 2, Of the 18 patients screened, 10 patients (56%) scored 5 or above, which according to the scoring system of the PHQ-9 is indicative of depression. One patient scored 10 indicative of moderate depression and one patient scored 19 indicative of moderately severe depression. DISCUSSION: phase 1 of this audit revealed that there was no formal screening tool in use to identify depression in post stroke patients. Consequently we found the prevalence to be 28%. This correlates with the lower end of the rate expected within this group according to the literature. As no screening tool was being used, practice was not in accordance with the standards set by NICE guidelines. This led us to introduce the PHQ-9 screening tool in phase 2. Following this, we found the prevalence of depression had increased from 28% to 56%. CONCLUSIONS: these results highlight the importance of formal screening in order to reliably identify patients who have signs of depression.