Association between perceived coercion and perceived level of information in involuntarily admitted patients: Results from a multicenter observational study in Switzerland.

BACKGROUND: Involuntary admissions (IA) to psychiatric hospitals are controversial because they interfere with people's autonomy. In some situations, however, they appear to be unavoidable. Interestingly, not all patients perceive the same degree of coercion during IA. The aim of this study was to assess whether the level of knowledge about one's own IA is associated with perceived coercion. METHODS: This multicenter observational study was conducted on n = 224 involuntarily admitted patients. Interviews were conducted at five study centers from April 2021 to November 2021. The Macarthur Admission Experience Survey was administered to assess perceived coercion. Knowledge of involuntary admission, perceptions of information received, and attitudes towards legal aspects of involuntary admission were also assessed. RESULTS: We found that higher levels of knowledge about IA were negatively associated with perceived coercion at admission. Perceived coercion did not differ between study sites. Only half of the patients felt well informed about their IA, and about a quarter found the information they received difficult to understand. DISCUSSION: Legislation in Switzerland requires that patients with IA be informed about the procedure. Strategies to improve patients' understanding of the information given to them about IA might be helpful to reduce perceived coercion, which is known to be associated with negative attitudes towards psychiatry, a disturbed therapeutic relationship, avoidance of psychiatry, and the risk of further coercion.

Surgical anatomy of the lateral femoral cutaneous nerve for meralgia paraesthetica: A simple technical guide for surgeons and trainees alike.

Meralgia paraesthetica is an entrapment neuropathy of the lateral femoral cutaneous nerve, usually due to compression at the inguinal ligament as the nerve passes from the pelvis into the thigh. Surgical decompression of the lateral femoral cutaneous nerve is a simple and effective treatment option, but the surgical anatomy of the area is not always familiar to neurosurgeons and neurosurgical trainees alike. This paper is a simple review of the relevant surgical anatomy and the surgical steps of lateral femoral cutaneous nerve decompression, with the aim of providing the busy surgeon and trainee a quick and easy reference guide to the procedure.

Intracranial pressure waveform characteristics in idiopathic normal pressure hydrocephalus and late-onset idiopathic aqueductal stenosis.

BACKGROUND: Idiopathic normal pressure hydrocephalus (iNPH) and late-onset idiopathic aqueductal stenosis (LIAS) are two forms of chronic adult hydrocephalus of different aetiology. We analysed overnight intracranial pressure (ICP) monitoring to elucidate ICP waveform changes characteristic for iNPH and LIAS to better understand pathophysiological processes of both diseases. METHODS: 98 patients with iNPH and 14 patients with LIAS from two neurosurgical centres were included. All patients underwent diagnostic overnight computerised ICP monitoring with calculation of mean ICP, ICP heartbeat related pulse wave amplitude calculated in the frequency domain (AMP) and the time domain (MWA), index of cerebrospinal compensatory reserve (RAP) and power of slow vasogenic waves (SLOW). RESULTS: ICP was higher in LIAS than iNPH patients (9.3 ± 3.0 mmHg versus 5.4 ± 4.2 mmHg, p = 0.001). AMP and MWA were higher in iNPH versus LIAS (2.36 ± 0.91 mmHg versus 1.81 ± 0.59 mmHg for AMP, p = 0.012; 6.0 ± 2.0 mmHg versus 4.9 ± 1.2 mmHg for MWA, p = 0.049). RAP and SLOW indicated impaired reserve capacity and compliance in both diseases, but did not differ between groups. INPH patients were older than LIAS patients (77 ± 6 years versus 54 ± 14 years, p < 0.001). CONCLUSIONS: ICP is higher in LIAS than in iNPH patients, likely due to the chronically obstructed CSF flow through the aqueduct, but still in a range considered normal. Interestingly, AMP/MWA was higher in iNPH patients, suggesting a possible role of high ICP pulse pressure amplitudes in iNPH pathophysiology. Cerebrospinal reserve capacity and intracranial compliance is impaired in both groups and the pressure-volume relationship might be shifted towards lower ICP values in iNPH. The physiological influence of age on ICP and AMP/MWA requires further research.

Psychometric evaluation of the German version of the Opening Minds Stigma Scale for Health Care Providers (OMS-HC).

BACKGROUND: Healthcare professionals can be a source of stigma and discrimination for people with mental illness, and anti-stigma programs are needed for this target group. However, there is no validated German language scale to assess attitudes of healthcare professionals towards people with mental illness. This study had the aim to validate the German language version of the Opening Minds Stigma Scale for Health Care Providers (OMS-HC), a self-report measure of stigmatizing attitudes. METHODS: Staff (n = 392) on general psychiatric inpatient wards (excluding child, forensic and geriatric psychiatry) at five psychiatric hospitals in Switzerland (n = 3) and Germany (n = 2) participated in the study. The internal consistency of the OMS-HC was examined as well as its factor structure using exploratory and confirmatory factor analyses. To assess the scale's concurrent validity, we used the Social Distance Scale. RESULTS: Internal consistency for the OMS-HC total score was good (α = 0.74), acceptable for the subscales Attitudes (α = 0.62) and Social Distance (α = 0.69), and poor for the Disclosure subscale (α = 0.55). The original three-factor structure fit our data well. The OMS-HC total score and the Social Distance subscale score were significantly correlated with the Social Distance Scale, supporting concurrent validity. CONCLUSION: The German version of the OMS-HC demonstrated satisfactory psychometric properties and can be recommended for future research and intervention evaluation.

Psychiatric Emergencies in the Community: Characteristics and Outcome in Switzerland.

Psychiatric emergencies occur frequently in the community setting, e.g. the patient's home or public places. Little is known about the characteristics and outcome of these situations. This study describes psychiatric emergencies in the canton of Zurich, Switzerland, and examines determinants of their outcome. We retrospectively analyzed 620 medical records of consultations classified as psychiatric emergencies of a 24/7 service of community-based emergency physicians. Information on sociodemographic, clinical and situational factors was extracted. The observation period was 6 months in 2017. Binary logistic regression was used to examine predictors for involuntary admissions. Most emergency consultations (64.5%) took place at the patient's home, followed by police stations (31.0%), public places (3.2%), and somatic hospitals (1.3%). Patient characteristics and reasons for consultation varied considerably between the locations. The first involved person was commonly a relative. Of all consultations, 38.4% resulted in involuntary admissions, mainly in patients with psychosis, suicidality, aggression, refusal of necessary treatment and previous involuntary admissions. Situation-related factors and the involvement of relatives were no significant predictors of the outcome. Psychiatric emergencies occur in different places and in patients with a variety of psychiatric symptoms. Although half of the emergency situations were resolved in the community, the rate of involuntary admissions was still high. For additional reduction, the further development of quickly available alternatives to psychiatric inpatient treatment is required. These should be specifically geared towards acute situations in patients with the described risk factors. Additionally, the role of relatives during psychiatric emergencies should be further studied.

Transcranial Doppler-derived indices of cerebrovascular haemodynamics are independent of depth and angle of insonation.

Continuous measurement of cerebral blood flow velocity (CBFV) of the middle cerebral artery (MCA) using transcranial Doppler (TCD) and arterial blood pressure (ABP) monitoring enables assessment of cerebrovascular haemodynamics. Further indices describing cerebrovascular function can be calculated from ABP and CBFV, such as the mean index (Mxa) of cerebrovascular autoregulation, the 'time constant of the cerebral arterial bed' (tau), the 'critical closing pressure' (CrCP) and a 'non-invasive estimator of ICP' (nICP). However, TCD is operator-dependent and changes in angle and depth of MCA insonation result in different readings of CBFV. The effect of differing CBFV readings on the calculated secondary indices remains unknown. The aim of this study was to investigate variation in angle and depth of MCA insonation on these secondary indices. In eight patients continuous ABP and ipsilateral CBFV monitoring was performed using two different TCD probes, resulting in four simultaneous CBFV readings at different angles and depths per patient. From all individual recordings, the K-means clustering algorithm was applied to the four simultaneous longitudinal measurements. The average ratios of the between-clusters, sum-of-squares and total sum-of-squares were significantly higher for CBFV than for the indices Mxa, tau and CrCP (p < 0.001, p = 0.007 and p = 0.016) but not for nICP (p = 0.175). The results indicate that Mxa, tau and CrCP seemed to be not affected by depth and angle of TCD insonation, whereas nICP was.

Complications of elective intracranial pressure monitoring in adult hydrocephalus.

Continuous invasive monitoring of intracranial pressure (ICP) can be used in the diagnosis and management of various types of chronic cerebrospinal fluid (CSF) circulation disorders, such as hydrocephalus, shunt dysfunction and idiopathic intracranial hypertension. The risk profile and incidence of adverse events of this surgical procedure in this patient population is not well established. We aimed to investigate and describe the risks of ICP monitoring in adult patients with chronic CSF circulation disorders. We analysed 152 patients undergoing continuous ICP monitoring between 2010 and 2019, mainly for idiopathic normal pressure hydrocephalus. The average duration of ICP monitoring was 17 h 51 min. We observed no major adverse events, such as symptomatic intracranial haemorrhage, intracranial infection, or persistent neurological deficit. Minor complications were seen in 7% of patients and included accidental removal of the ICP probe in 4 patients, inability to remove the probe requiring surgical removal in 2 patients and single generalised seizures in 2 patients. In summary, the risk of serious adverse events and complications from invasive ICP monitoring in chronic CSF circulation disorders in adult patients appears to be low.

Tissue oxygenation indices of cerebrovascular autoregulation in healthy volunteers: a comparison of two NIRS devices.

BACKGROUND: Correlation coefficients between blood pressure and cerebral oxygen saturation measured using near-infrared spectrometry may be used to derive the tissue oximetry index of cerebral autoregulation. Cerebral oxygen saturations demonstrate poor agreement between near-infrared spectrometers however it is unclear if measurements of autoregulation are similarly specific to the equipment used. METHODS: Cerebral oxygen saturation was monitored bilaterally in 74 healthy volunteers using both the FORE-SIGHT and EQUANOX monitors in random order. The tissue oximetry index was calculated during changes in blood pressure induced by isometric handgrip manoeuvres and the mean bias and limits of agreement were calculated. RESULTS: Tissue oximetry index measured by FORE-SIGHT was higher than EQUANOX (0.21 ± 0.16 versus 0.15 ± 0.17, P < 0.001) and limits of agreement were -0.24 to 0.36. Baseline cerebral oxygen saturation by FORE-SIGHT was lower than EQUANOX by 1.48% (CI95% 0.63-2.33) and limits of agreement ranged from -11.8% to 8.8%. CONCLUSIONS: The substantial bias and wide limits of agreement for the tissue oximetry index as a measure of cerebral autoregulation indicate that values must be treated as specific to models of near-infrared spectrometers.

[Acceptance of Psychiatric and Somatic Advance Directives: A Comparison in Psychiatric Patients and Professionals]. / Akzeptanz von psychiatrischen und somatischen Patientenverfügungen: ein Vergleich unter psychiatrischen Patienten und Fachpersonen.

OBJECTIVE: Assessment of the attitudes towards somatic and psychiatric advance directives in the German speaking part of Switzerland. METHODS: Questionnaire for psychiatric patients, psychiatrists, psychologists, psychiatric nurses and peers assessing the attitudes towards three exemplary advance directives. RESULTS: The attitudes were mainly positive in all participating groups. Compared to professionals (79-100 %), the somatic advance directive found approval in significantly less patients (46 %). There were no significant group differences regarding the psychiatric advance directives, but patients (58 % and 84 %) were slightly more agreeing compared to professionals (31-50 % and 62-70 %). CONCLUSION: Psychiatric advance directives seem to be broadly accepted. The development of campaigns might help to raise the awareness about these instruments and increase their usage in clinical practice.

Psychiatric advance directives in Switzerland: Knowledge and attitudes in patients compared to professionals and usage in clinical practice.

BACKGROUND: Psychiatric advance directives (PAD) were shown to be effective in the reduction of coercion and strengthening of the patients` autonomy. Therefore, the Swiss legislation was revised and stipulates that PAD must be taken into account during involuntary hospitalization. This study aimed to analyze knowledge on and attitudes towards this instrument in patients and healthcare practitioners and their usage in clinical practice. METHODS: We developed a structured questionnaire and included patients (n = 110), psychiatrists (n = 205), psychologists (n = 85), nurses (n = 268) and peers (n = 16) to rate their knowledge on and attitudes towards PAD. We registered the existing PAD in patients and peers. The response rate varied between 17% (nurses), 19% (psychologists) 21% (psychiatrists), 33% (peers) and 56% (patients). RESULTS: Only 7% of the participating patients had a PAD. Compared to the other groups, patients had the least knowledge on PAD. Psychiatrists were significantly more critical towards PAD. Concerns that PAD impede necessary and adequate treatment, restrict professionals and result in conflicts between patients and HCP were most frequently named as reason for critical attitudes. CONCLUSIONS: Although being explicitly mentioned in the Swiss legislation the usage of PAD is small. Proactive information and training of psychiatrists might be helpful for a reduction of skeptical attitudes. This might improve the attitudes and lead to active support of patients during the preparation of PAD.

Involuntary admission of psychiatric patients: Referring physicians' perceptions of competence.

BACKGROUND: Involuntary admissions can be detrimental for patients. Due to legal, ethical and clinical considerations, they are also challenging for referring physicians. Nevertheless, not much is known about the subjective perceptions of those who have to decide whether to conduct an involuntary admission or not. AIMS: This study aimed at answering the question whether psychiatrists' perceptions of confidence during psychiatric emergency situations and consecutive involuntary admissions differ from those of physicians without a psychiatric training. METHOD: We assessed the professional background and subjective perceptions during psychiatric emergency situations in physicians who executed involuntary admissions to the University Hospital of Psychiatry Zurich. We used one-way analysis of variance (ANOVA) with Bonferroni-adjusted post hoc tests and chi-square tests to compare the responses of 43 psychiatrists with those of 64 other physicians. RESULTS: Psychiatrists felt less time constraints compared with non-psychiatric residents. The latter also had more doubts on the necessity of the involuntary admission issued. Psychiatrists considered themselves significantly more experienced in handling psychiatric emergency situations and in handling the criteria for involuntary admissions than other physicians. Psychiatrists and other physicians did not differ in their satisfaction concerning course and results of psychiatric emergency situations which was overall high. About half of all participants felt pressure from third parties. CONCLUSION: Psychiatric emergency situations are challenging situations not only for patients but also for the involved physicians. Physicians with a specialized training might be more confident in the handling of psychiatric emergency situations and exertion of involuntary admissions. Non-psychiatric physicians might benefit from specialized training programs.

Understanding outcome metrics of the revised NIOSH lifting equation.

The interpretation of the calculated result of the revised NIOSH Lifting Equation (RNLE) has been problematic because the relationship of the calculated result to back injury risk has not always been either well understood nor consistently interpreted. During the revision of the ISO standard 11228-1 (Manual lifting, lowering and carrying), an extensive literature review was conducted on validation studies of the RNLE. A systematic review of exposure-risk associations between the LI metrics and various low-back health outcomes from peer-reviewed epidemiological studies was conducted. Risk interpretations for different levels of calculated result of the RNLE are added to the ISO standard. Rationale for the risk interpretations is presented in this paper.

Clinical and socio-demographic characteristics associated with involuntary admissions in Switzerland between 2008 and 2016: An observational cohort study before and after implementation of the new legislation.

BACKGROUND: Involuntary admission (IA) for psychiatric treatment has a history of controversial discussions. We aimed to describe characteristics of a cohort of involuntarily compared to voluntarily admitted patients regarding clinical and socio-demographic characteristics before and after implementation of the new legislation. METHODS: In this observational cohort study, routine data of 15'125 patients who were admitted to the University Hospital of Psychiatry Zurich between 2008 and 2016 were analyzed using a series of generalized estimating equations. RESULTS: At least one IA occurred in 4'560 patients (30.1%). Of the 31'508 admissions 8'843 (28.1%) were involuntary. In the final multivariable model, being a tourist (OR = 3.5) or an asylum seeker (OR = 2.3), having a schizophrenic disorder (OR = 2.1), or a bipolar disorder (OR = 1.8) contributed most to our model. Male gender, higher age, prescription of neuroleptics (all OR < 2.0) as well as having a depressive disorder, prescription of psychotherapy, prescription of antidepressants and admission after implementation of the new legislation (all OR > 0.6) were also weakly associated with IA. CONCLUSIONS: Besides schizophrenic or bipolar disorders, a small group of patients had an increased risk for IA due to non-clinical parameters (i.e. tourists and asylum seekers). Knowledge about risk factors should be used for the development of multi-level strategies to prevent frequent (involuntary) hospitalizations in patients at risk. On the organizational level, we could show that the new legislation decreased the risk for IA, and therefore may have succeeded in strengthening patient autonomy.

Attitudinal variance among patients, next of kin and health care professionals towards the use of containment measures in three psychiatric hospitals in Switzerland.

BACKGROUND: In psychiatric treatment containment measures are used to de-escalate high-risk situations. These measures can be characterized by their immanent amount of coercion. Previous research could show that the attitudes towards different containment measures vary throughout countries. The aim of this study was to compare the attitudes towards containment measures between three study sites in Switzerland which differ in their clinic traditions and policies and their actual usage of these measures. METHODS: We used the Attitude to Containment Measures Questionnaire (ACMQ) in three psychiatric hospitals in Switzerland (Zurich, Muensingen and Monthey) in patients, their next of kin (NOK) and health care professionals (HCP). Furthermore, we assessed the cultural specifics and rates of coercive measures for these three hospitals. RESULTS: We found substantial differences in the usage of and the attitudes towards some containment measures between the three study sites. The study site accounted for a variance of nearly zero in as needed medication to 15% in seclusion. The differences between study sites were bigger in the HCPs' attitudes (up to 50% of the variance), compared to NOK and patients. In the latter the study site accounted for up to 6% of the variance. The usage/personal experience of containment measures in general was associated with higher agreement. CONCLUSIONS: Although being situated in the same country, there are substantial differences in the rates of containment measures between the three study sites. We showed that the HCP's attitudes are more associated with the clinic traditions and policies compared to patients' and their NOKs' attitudes. One can conclude that patients' preferences depend less on clinic traditions and policies. Therefore, it is important to adapt treatment to the individual patients' attitudes. TRIAL REGISTRATION: The study was reviewed and approved by the Cantonal Ethics Commission of Zurich, Switzerland (Ref.-No. EK: 2016-01526, decision on 28.09.2016) and the Cantonal Ethics Commission of Bern, Switzerland (Ref.-Nr. KEK-BE: 2015-00074). This study has been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. The permission for conduction of the study was granted by the medical directors at the three study sites. The authors informed the respondents (patients, NOK, HCP) of their rights in the study in an oral presentation and/or a cover letter. They assured the participants of the confidentiality and anonymity of the data, and the voluntariness of participation. Patients were given an information sheet with the possibility to consent in the conduction of the study. Return of the completed questionnaires from HCP and NOK was constituted as confirmation of their consent. No identifying factors were collected to ensure privacy. This article does not contain any studies with animals performed by any of the authors.

Involuntary admission for psychiatric treatment: Compliance with the law and legal considerations in referring physicians with different professional backgrounds.

BACKGROUND: Involuntary admission (IA) for psychiatric treatment is a massive restriction of human rights. Therefore, its execution is regulated by law. During executing IAs referring physicians find themselves in a dual role: support of patients in the recovery process but also safe-keeper of society. In Zurich, Switzerland the law stipulates that physicians regardless of their medical specialization may admit patients who suffer from a mental disorder, mental disability or severe neglect involuntarily if care cannot be provided otherwise, regardless of their decision-making capacity. The referring physician is obliged to examine the patients, hear their views on the IA, inform them about the following steps and about their right of appeal at the civil court. We aimed to assess whether referring physicians can comply with those legal requirements for an IA. Additionally, we examined whether legal considerations differed according to the physicians` professional backgrounds and attitudes towards coercion in general. METHODS: We invited physicians from different in- and outpatient settings who executed IAs to the University Hospital of Psychiatry Zurich to participate in a newly developed online survey. We used correlation analysis, chi-square and t-tests to analyze the responses of 43 psychiatrists with those of 64 other physicians. RESULTS: In about 1/3 of the IAs referring physicians were not able to hear the patients' views on the IA, to inform the patients about the following steps and about their right of appeal. Psychiatrists felt more certain with the legal basis of IA compared to physicians other than psychiatrists. Nevertheless, the latter stated that the assessment of the risk for suicide and danger should not be restricted only to psychiatrists. Both groups differed in their attitudes towards coercion with psychiatrists being more critical. CONCLUSIONS: Interventions should be developed to facilitate a compliance with legal requirements during IA. Physicians who execute IAs must have a thorough knowledge of the clinical and legal basis for their actions. We recommend specialized consultation teams for the assessment of PES and regular training including ethical discussions, especially for physicians other than psychiatrists.

Challenges and Opportunities in Building and Maintaining a Good Therapeutic Relationship in Acute Psychiatric Settings: A Narrative Review.

Background: The therapeutic relationship and its importance for psychotherapy outcome have been the subject of extensive research over the last decades. An acute psychiatric inpatient setting is a unique environment where severely ill patients receive intensive treatment over a limited, relatively short, period of time. This renders establishing a good therapeutic relationship difficult for various reasons. It seems likely, however, that the therapeutic relationship in such a setting plays a vital role on factors such as clinical outcome, patient satisfaction, and rehospitalization rates. Little information is available on special attributes and caveats of building and maintaining a good therapeutic relationship in an acute psychiatric setting, neither on its influence on therapy success. Methods: An extensive systematic literature search was performed using PubMed, science direct, psyc info, and google scholar databases. Keywords used were therapeutic alliance, therapeutic relationship, psychiatry, emergency, acute, coercion, autonomy, involuntary, closed ward. RCTs, observational studies, reviews, meta-analyses, and economic evaluations were included, case reports and opinion papers were excluded. Factors specific to an acute psychiatric setting were identified, and the available information was categorized and analyzed accordingly. The PRISMA statement guidelines were followed closely upon research and preparation of the present review. Results: A total of 48 studies were selected based on their relevance as well as design. They demonstrated that several factors related to setting, patient attributes, staff attributes, admission circumstances, and general situation, render building and maintaining a good therapeutic relationship difficult in an acute psychiatric setting compared to scheduled, long-term therapeutic sessions. The available literature on how to overcome this dilemma is scarce. Interventions involving staff and/or patients have been shown to be effective in terms of relevant outcome parameters. Conclusions: Increasing research efforts, as well as raising awareness and providing specific competencies amongst clinicians and patients in terms of nurturing a good therapeutic relationship in acute settings, are necessary to improve clinical outcome, economic factors, quality of patient care and patient as well as staff satisfaction.

Is cerebrovascular autoregulation associated with outcomes after major noncardiac surgery? A prospective observational pilot study.

BACKGROUND: Studies have identified multiple risk factors for development of cognitive decline after surgery. Impaired cerebrovascular autoregulation may be a contributor to postoperative cognitive decline. METHODS: One hundred and forty patients admitted for major elective noncardiac surgery were recruited. Near-infrared spectroscopy was used to calculate the tissue oxygenation index of dynamic autoregulation (TOx). The primary endpoint was Day 3 cognitive recovery as assessed using the Postoperative Quality of Recovery Scale. The secondary endpoint was a combined major adverse event of death, acute myocardial infarction, cardiac arrest, stroke, pulmonary embolism, sepsis, and acute kidney injury at Day 30. RESULTS: Higher optimal TOx values, signifying impaired autoregulation, were associated with worse outcomes. Patients who cognitively recovered at Day 3 (n = 47) had lower optimal TOx values (TOxopt ) than patients who did not recover (n = 22): 0.06 (0.24) vs 0.18 (0.16) (mean [SD]), P = 0.02. Patients who did not suffer a major adverse event (n = 102) had lower TOxopt than patients who did (n = 17): 0.09 (0.21) vs 0.20 (0.27), P = 0.04. When dichotomized as having impaired or intact autoregulation based on TOxopt levels, a value of TOxopt ≥0.1 correctly identified 72.7% of patients who did not cognitively recover, OR 3.3 (1.1-9.9) (Odds ratio, [95% CI]), P = 0.03. TOxopt ≥0.1 correctly identified 82.4% of patients who suffered a major adverse event, OR 4.7 (1.3-17.2), P = 0.02. CONCLUSIONS: In older and higher risk patients having major noncardiac surgery, impaired cerebrovascular autoregulation was associated with failure of cognitive recovery in the early postoperative period and with 1-month mortality and morbidity.

Noninvasive Monitoring of Dynamic Cerebrovascular Autoregulation and 'Optimal Blood Pressure' in Normal Adult Subjects.

BACKGROUND: Cerebrovascular autoregulation can be continuously monitored from slow fluctuations of arterial blood pressure (ABP) and regional cerebral oxygen saturation (rSO2). The purpose of this study was to evaluate the index of dynamic cerebrovascular autoregulation (TOx) and the associated 'optimal' ABP in normal adult healthy subjects. METHODS: Twenty-eight healthy volunteers were studied. TOx was calculated as the moving correlation coefficient between spontaneous fluctuations of ABP and rSO2. ABP was measured with the Finometer photoplethysmograph. The ABP with optimal autoregulation (ABPOPT) was also determined as the ABP level with the lowest associated TOx (opt-TOx). RESULTS: Average rSO2 and TOx was 72.3 ± 2.9% and 0.05 ± 0.18, respectively. Two subjects had impaired autoregulation with a TOx > 0.3. The opt-TOx was - 0.1 ± 0.26. ABPOPT was 87.0 ± 16.7 mmHg. The difference between ABP and ABPOPT was - 0.3 ± 7.5 mmHg. In total, 44% of subjects had a deviation of ABP from ABPOPT exceeding 5 mmHg. ABPOPT ranged from 57 to 117 mmHg. CONCLUSIONS: TOx in healthy volunteers on average displays intact autoregulation and ABP close to ABPOPT. However, some subjects have possible autoregulatory dysfunction or a significant deviation of ABP from ABPOPT, which may confer a susceptibility to neurological injury.

Comparing Attitudes to Containment Measures of Patients, Health Care Professionals and Next of Kin.

Background: In clinical psychiatric practice, health care professionals (HCP) must decide in exceptional circumstances after the weighing of interests, which, if any, containment measures including coercion are to be used. Here, the risk for patients, staff, and third parties, in addition to therapeutic considerations, factor into the decision. Patients' preference and the inclusion of relatives in these decisions are important; therefore, an understanding of how patients and next of kin (NOK) experience different coercive measures is crucial for clinical decision making. The aim of this study is to compare how patients, HCP, and NOK assess commonly used coercive measures. Methods: A sample of 435 patients, 372 HCP, and 230 NOK completed the Attitudes to Containment Measures Questionnaire (ACMQ). This standardized self-rating questionnaire assessed the degree of acceptance or rejection of 11 coercive measures. Results: In general, HCPs rated the coercive measures as more acceptable than did NOK and patients. The largest discrepancy in the ratings was found in regard to the application of coercive intramuscular injection of medication (effect size: 1.0 HCP vs. patients). However, the ratings by NOK were significantly closer to the patients' ratings compared to patients and HCP. The only exception was the acceptance of treatment in a closed acute psychiatric ward, which was deemed significantly more acceptable by NOK than by patients. Also, patients who had experienced coercive measures themselves more strongly refused other measures. Conclusion: Patients most firmly rejected intramuscular injections, and the authors agree that these should only be used with reservation considering a high threshold. This knowledge about the discrepancy of the ratings should therefore be incorporated into professional training of HCP.