Soliciting stakeholders' views on the organization of child and adolescent mental health services: a system in trouble.

BACKGROUND: Despite a high prevalence of mental health problems among children and adolescents Belgium, like many other Western countries, does not have a clear strategy for the organization of child and adolescent mental healthcare services (CAMHS). METHODS: This paper describes stakeholders' views on the organization of CAMHS based on a qualitative study. Ten in-depth interviews with high profile stakeholders were complemented by roundtable discussions (n = 30). RESULTS: This diagnostic analysis illustrated that the system is in serious trouble characterized by fragmentation and compartmentalization. CONCLUSION: The findings create a sense of urgency that should be used to initiate a system reform of the Belgian CAMHS system.

A systematic review and meta-analysis of acute stroke unit care: what's beyond the statistical significance?

BACKGROUND: The benefits of stroke unit care in terms of reducing death, dependency and institutional care were demonstrated in a 2009 Cochrane review carried out by the Stroke Unit Trialists' Collaboration. METHODS: As requested by the Belgian health authorities, a systematic review and meta-analysis of the effect of acute stroke units was performed. Clinical trials mentioned in the original Cochrane review were included. In addition, an electronic database search on Medline, Embase, the Cochrane Central Register of Controlled Trials, and Physiotherapy Evidence Database (PEDro) was conducted to identify trials published since 2006. Trials investigating acute stroke units compared to alternative care were eligible for inclusion. Study quality was appraised according to the criteria recommended by Scottish Intercollegiate Guidelines Network (SIGN) and the GRADE system. In the meta-analysis, dichotomous outcomes were estimated by calculating odds ratios (OR) and continuous outcomes were estimated by calculating standardized mean differences. The weight of a study was calculated based on inverse variance. RESULTS: Evidence from eight trials comparing acute stroke unit and conventional care (general medical ward) were retained for the main synthesis and analysis. The findings from this study were broadly in line with the original Cochrane review: acute stroke units can improve survival and independency, as well as reduce the chance of hospitalization and the length of inpatient stay. The improvement with stroke unit care on mortality was less conclusive and only reached borderline level of significance (OR 0.84, 95% CI 0.70 to 1.00, P = 0.05). This improvement became statistically non-significant (OR 0.87, 95% CI 0.74 to 1.03, P = 0.12) when data from two unpublished trials (Goteborg-Ostra and Svendborg) were added to the analysis. After further also adding two additional trials (Beijing, Stockholm) with very short observation periods (until discharge), the difference between acute stroke units and general medical wards on death remained statistically non-significant (OR 0.86, 95% CI 0.74 to 1.01, P = 0.06). Furthermore, based on figures reported by the clinical trials included in this study, a slightly higher proportion of patients became dependent after receiving care in stroke units than those treated in general medical wards - although the difference was not statistically significant. This result could have an impact on the future demand for healthcare services for individuals that survive a stroke but became dependent on their care-givers. CONCLUSIONS: These findings demonstrate that a well-conducted meta-analysis can produce results that can be of value to policymakers but the choice of inclusion/exclusion criteria and outcomes in this context needs careful consideration. The financing of interventions such as stroke units that increase independency and reduce inpatient stays are worthwhile in a context of an ageing population with increasing care needs. One limitation of this study was the selection of trials published in only four languages: English, French, Dutch and German. This choice was pragmatic in the context of this study, where the objective was to support health authorities in their decision processes.

Does somatosensory discrimination activate different brain areas in children with unilateral cerebral palsy compared to typically developing children? An fMRI study.

Aside from motor impairment, many children with unilateral cerebral palsy (CP) experience altered tactile, proprioceptive, and kinesthetic awareness. Sensory deficits are addressed in rehabilitation programs, which include somatosensory discrimination exercises. In contrast to adult stroke patients, data on brain activation, occurring during somatosensory discrimination exercises, are lacking in CP children. Therefore, this study investigated brain activation with functional magnetic resonance imaging (fMRI) during passively guided somatosensory discrimination exercises in 18 typically developing children (TD) (age, M=14 ± 1.92 years; 11 girls) and 16 CP children (age, M=15 ± 2.54 years; 8 girls). The demographic variables between both groups were not statistically different. An fMRI compatible robot guided the right index finger and performed pairs of unfamiliar geometric shapes in the air, which were judged on their equality. The control condition comprised discrimination of music fragments. Both groups exhibited significant activation (FDR, p<.05) in frontoparietal, temporal, cerebellar areas, and insula, similar to studies in adults. The frontal areas encompassed ventral premotor areas, left postcentral gyrus, and precentral gyrus; additional supplementary motor area (SMA proper) activation in TD; as well as dorsal premotor, and parietal operculum recruitment in CP. On uncorrected level, p<.001, TD children revealed more left frontal lobe, and right cerebellum activation, compared to CP children. Conversely, CP children activated the left dorsal cingulate gyrus to a greater extent than TD children. These data provide incentives to investigate the effect of somatosensory discrimination during rehabilitation in CP, on clinical outcome and brain plasticity.

How does brain activation differ in children with unilateral cerebral palsy compared to typically developing children, during active and passive movements, and tactile stimulation? An fMRI study.

The aim of the functional magnetic resonance imaging (fMRI) study was to investigate brain activation associated with active and passive movements, and tactile stimulation in 17 children with right-sided unilateral cerebral palsy (CP), compared to 19 typically developing children (TD). The active movements consisted of repetitive opening and closing of the hand. For passive movements, an MRI-compatible robot moved the finger up and down. Tactile stimulation was provided by manually stroking the dorsal surface of the hand with a sponge cotton cloth. In both groups, contralateral primary sensorimotor cortex activation (SM1) was seen for all tasks, as well as additional contralateral primary somatosensory cortex (S1) activation for passive movements. Ipsilateral cerebellar activity was observed in TD children during all tasks, but only during active movements in CP children. Of interest was additional ipsilateral SM1 recruitment in CP during active movements as well as ipsilateral S1 activation during passive movements and tactile stimulation. Another interesting new finding was the contralateral cerebellum activation in both groups during different tasks, also in cerebellar areas not primarily linked to the sensorimotor network. Active movements elicited significantly more brain activation in CP compared to TD children. In both groups, active movements displayed significantly more brain activation compared to passive movements and tactile stimulation.

Participating or not in a cardiac rehabilitation programme: factors influencing a patient's decision.

BACKGROUND: International research indicates that attendance of patients to a proposed cardiac rehabilitation (CR) programme varies between 21% and 75%. Addressing the reasons why cardiac patients are not participating will improve accessibility to CR. The objective of this study was to investigate patient compliance with cardiac rehabilitation and the reasons of refusing or abandoning the programme. METHODS: Twenty hospital centres were recruited to participate. Each centre was asked to recruit patients from three patient groups, namely: percutaneous coronary intervention patients, patients that underwent major cardiac surgery, and patients being admitted because of an acute myocardial infarction and not belonging to the other two groups. Patients were asked to fill out a questionnaire during a follow-up outpatient consultation after the cardiac intervention. RESULTS: In total, 226 patients participated in the survey. Most patients were proposed (86%) and accepted (81% out of proposed) to attend a CR programme. Of those who accepted, 77% completed the programme. The main reasons that led to patients' refusal to participate in a CR programme were distance to the CR centre, patients' belief they could handle their own problems, and lack of time. The main three reasons for not completing an initiated CR programme were other physical problems, patients' belief they could handle their own problems, and the cost of rehabilitation. CONCLUSION: Our findings demonstrate the importance of raising patients' awareness of the benefits of CR. Addressing potential barriers to attend a CR programme should be investigated with patients individually in order to ensure compliance.

Multidisciplinary outpatient rehabilitation following cardiac revascularization or valve surgery: patient-related factors for uptake.

BACKGROUND: There are concerns in Europe regarding the service provision and accessibility of multidisciplinary cardiac rehabilitation (MDCR) in general, and particularly in ambulatory settings. This paper analyses the utilization of outpatient MDCR and its determinants after cardiac revascularization or valve surgery in Belgium. METHODS: Claims rehabilitation data for all patients discharged in 2007 after a percutaneous cardiac intervention or cardiac surgery were available from the Belgian Common Sickness Funds Agency. Logistic regressions were performed to identify patients demographic and socioeconomic characteristics associated with the uptake of outpatient MDCR during the year following the hospital discharge. RESULTS: A total of 29,021 patients were included. During the hospitalization for the cardiac procedure, 44% were offered inpatient MDCR. After discharge, only 15.6% followed at least one session of outpatient MDCR. The chance of attending outpatient MDCR was lower for female, disabled, and older patients, as well as unemployed patients. The absence of an authorized MDCR centre in the neighbourhood of the patient's residence decreased the chance of attending outpatient MDCR, while living in a neighbourhood with a high education and income level increased this probability. CONCLUSION: These results confirm the low rates of MDCR attendance found in a previous study performed by the European Association of Cardiovascular Prevention and Rehabilitation. The study shows specific patient groups that should be targeted in priority, i.e. women, elderly, unemployed patients, disabled persons, and patients with a low socioeconomic status.

Relation between neuroradiological findings and upper limb function in hemiplegic cerebral palsy.

The relation between neuroradiological findings and upper limb function was examined in 53 children with hemiplegic cerebral palsy (CP). CT and MRI images of the children were classified into four groups (malformations, periventricular lesions, congenital cortical-subcortical lesions and postnatally acquired lesions). Additionally, each single affected neuroanatomical structure was noted. Clinical assessments included measures of activity (Melbourne Assessment of Unilateral Upper Limb Function and House Classification) and body functions (motor and sensory impairments). Comparative statistics and correlation analysis were used. Three children had a malformation, 28 a periventricular lesion, 14 a cortical-subcortical lesion and eight a postnatally acquired lesion. Children with periventricular lesions obtained the best motor functioning. Within this group, children with pure periventricular lesions performed significantly better compared to mixed lesions. The differences between congenital cortical-subcortical lesions and acquired lesions were not significant. Results further showed that middle cerebral artery infarctions and basal ganglia/thalamic lesions were significantly correlated to a worse performance. The type of lesion determined by the timing of the brain insult, and the location of the lesion distinguish children with hemiplegic CP regarding upper limb function. These insights are valuable for prognosis and may contribute to a better delineation of therapeutic interventions.

Quantitative diffusion tensor imaging in cerebral palsy due to periventricular white matter injury.

Periventricular white matter injury (PWI) is a major form of brain injury observed in congenital hemiparesis. The aim of this study is to determine the usefulness of diffusion tensor imaging (DTI) and fibre tracking in delineating the primary and secondary degenerative changes in cerebral white matter and deep grey matter in patients with spastic cerebral palsy due to PWI and to look for any possible reorganization of the axonal architecture. Five hemiparetic cerebral palsy patients (median age 14 years) with known PWI were prospectively studied with DTI of the brain at 1.5T and quantitatively compared with five age and sex matched controls. Fibre tracts for various corticofugal, thalamocortical and association tracts were generated and analysed for the DTI fibre count and for diffusion parameters. A region of interest based analysis was performed for the directionally averaged mean diffusivity (D(av)) and fractional anisotropy (FA) values in various white matter locations in the brain and the brainstem and in the deep grey matter nuclei. Group statistics were performed for these parameters using Mann-Whitney U-test comparing the affected sides in patients with either side in controls and the unaffected side in hemiparetics. There was significant reduction in DTI fibre count on the lesional side involving corticospinal tract (CST), corticobulbar tract (CBT) and superior thalamic radiation in the patient group compared with controls. Also there was an increase in DTI fibre count in the unaffected side of the hemiparetic patients in CST and CBT, which reached statistical significance only in CBT. The corpus callosum, cingulum, superior longitudinal fasciculus and middle cerebellar peduncle failed to show any significant change. ROI measurements on the primary site of white matter lesion and the thalamus revealed a significant increase in D(av) and decrease in FA, suggesting primary degeneration. The CST in the brainstem, the body of corpus callosum and the head of caudate and lentiform nuclei showed features of secondary degeneration on the affected side. The CST on the unaffected side of hemiparetics was found to have a significant decrease in D(av) and an increase in FA. Thus the degeneration of various motor and sensory pathways, as well as deep grey matter structures, appears to be important in determining the pathophysiological mechanisms in patients with congenital PWI. Also evidence suggesting the reorganization of sensorimotor tracts in the unaffected side of spastic hemiparetic patients was noted.