NICU Fingerprint Access Control

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We offer parents the opportunity of signing up for having fingerprint access to our Neonatal Intensive Care Unit (NICU).

Being the first Trust in the South West to introduce this biometric technology, the fingerprint access will enable you to come and see your baby whenever you wish without needing to wait for the door to the unit to be opened by a member of our staff, allowing you unrestricted access to your baby.

The fingerprint access is an electronic device which scans and captures a digital image of your fingerprint patterns. When your finger is put on the scanning area, a digital image of fingerprint patterns is read by the sensor. A biometric template is generated which is then stored in a database.

The image of the fingerprint taken by the biometric system is only recognisable by the system itself and would only be able to generate information such as check-in times. It is very near impossible to recreate a fingerprint and no risk to their identity if there were a data breach.

We do kindly ask all parents to ensure they do not let anyone else onto the unit. All our members of staff wear badges and will not be offended if you ask to see it.

To sign up to NICU fingerprint access control, please speak to a member of the NICU team.

Risks of Bariatric Surgery

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The complication rates for weight loss surgery are low. Approximately 1 in 100 may have a problem after gastric band surgery, and 1 in 1000 may not survive the operation. Following gastric bypass and sleeve gastrectomy operations the risk of complications are approximately 3 in 100, and 1 in 500 may not survive the operation. These are historical figures and may in fact be much lower. Patients at higher risk are those who are heavier, older, those with other significant health problems or if they have had previous operations in that area.

The risks of gastric band surgery are low, but the band can occasionally slip, become infected or erode into the stomach. The oesophagus (gullet) can also stretch above the band if you overeat. If these complications occur, generally the band will need to be removed.

Gastric bypass and sleeve gastrectomy operations involve cutting the stomach, so leaks can occur. Should this happen then further surgery is usually required to deal with the leak. Bleeding from the staple lines can also happen and may require a blood transfusion. Internal twisting of the bowel can happen at a later stage following gastric bypass.

One of the major risks of this type of surgery is of blood clots within the legs (DVT), which can occasionally dislodge and get stuck in the lung (PE). We cannot completely get rid of this risk, but we can try to reduce it by giving you compression stockings to wear during and after the operation, giving blood thinning injections during your stay and getting you up and about as soon as possible after surgery. The risk of clots doesn’t go away for a few weeks, so it is important to keep wearing the stockings at home and being as active as possible.

Before being discharged from hospital you will be given information as to what to look out for when you get home, as well as what to do and who to contact  if you are worried.

M.E./CFS Rehabilitation Checklist

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What is rehabilitation?

The World Health Organisation has defined rehabilitation as:

“A process aimed at enabling people to reach and maintain their optimal physical, sensory, intellectual, psychological and social functional levels. Rehabilitation provides people with the tools they need to attain independence and self-determination.”
Access to rehabilitation is a human right.

The Bristol M.E. Service aims to support people living with M.E./CFS in developing optimal self-management and rehabilitation. However, surveys carried out by patient charities have found that some rehabilitation approaches have been problematic for some people living with M.E./CFS. We wanted to learn more about this, so that these problems could be avoided. We therefore worked with the national charity Action for ME on their detailed survey of patient experiences of rehabilitation which was carried out in 2010. A detailed analysis of the responses to the ‘free text’ sections of the survey was carried out which encouraged respondents to write about their experiences of these therapies. We published the findings from this research in a peer-reviewed journal [1] as we think that it is important to share knowledge about what works well, and what the problems can be, especially as these problems can be avoided.

We found that key issues for a number of survey participants included:

  • difficulties setting a sustainable baseline for exercise or activity (see below)
  • the importance of good quality therapist-patient communication and collaboration.

Based on our clinical experience and the feedback analysed in Action for M.E.’s patient survey, we devised the following checklist to help people living with M.E./CFS to ensure that they receive the best advice and support from their rehabilitation therapist.

Rehabilitation checklist

1. Have you been fully assessed?

A full assessment should take into account the history of your condition, your symptoms, factors which aggravate your symptoms, your current functional ability, sleep pattern, any medication and any other medical conditions. All of these factors can influence your self-management plan. If you and your therapist understand the factors which aggravate your symptoms, and your current activity level, you will be able to develop a more appropriate self-management and rehabilitation plan.

2. Do you have significant "ups and downs" in your symptoms and ability from day to day?

If so, it will probably help you to spend some time on stabilising your patterns of activity before considering the pros and cons of exploring an increase any activity. This focus on stability may be called pacing, activity management, energy management or baseline setting.

3. Have you spent time with your therapist discussing your baselines for activities?

A "baseline" is a manageable amount of physical or mental activity which can be achieved on most days of the week, without provoking a setback. A baseline is not your "personal best", but it is a lower, sustainable level of activity.

4. Are you able to work to your baselines in practice?

It is one thing to know what your baseline for activity is: it is another thing to stick to it! It is tempting to do more on a good day, but this can feed into a pattern of overdoing and then recovering: "boom and bust". If you find yourself doing a lot of "booming and busting" (also known as activity cycling) then you would probably do well to focus on stabilising your activity levels before considering any increases.

5. Have you discussed strategies to increase your exercise or activity level with your therapist?

For M.E./CFS rehabilitation, small increases, for example 10% from the baseline are commonly used. This is typically followed by a period of days or weeks before the next increase is considered.

6. Do you understand that you may experience a mild, acceptable increase in symptoms following your increase in exercise?

This increase in symptoms is common, but should settle after a week or two at your slightly higher level of activity. This increase in symptoms should feel acceptable to you. It is important to realise that rehabilitation is not aimed at relieving symptoms in the short term: it is aimed at making gentle progress with function.

7. Have you discussed a setback plan with your therapist?

Setbacks or relapses are fairly common for people with M.E./CFS, and can be triggered by a range of factors including too-rapid increases in physical activity, cognitive or emotional activity, stress, poor sleep, acute infection, seasonal and environmental factors. If you experience a setback during your rehabilitation, have you agreed a plan with your therapist about how you will adapt/reduce your activity?

8. Is your rehabilitation focused on your personal goals?

Rehabilitation works best if the activity is linked with making progress in your rehabilitation goals. Rehabilitation goals are personal, and may include a range of activities such as walking, housework, gardening, exercise, socialising, and voluntary or paid employment.

9. Do you understand that not everyone makes progress with rehabilitation?

Research suggests that people who plan to slowly increase their activities are more likely to make moderate improvements. However, we know that a significant proportion of people with M.E./CFS who try to slowly build up their activity don't manage to make significant progress. If you are one of these people, try not to be disheartened: at least you know that you have tried to gradually build up your activities, and you have done the best you can to make progress at this stage. Your therapist should understand that not everyone makes progress with rehabilitation.

10. Are you seeing a therapist who has had success with rehabilitation for people with CFS/ME?

If your therapist doesn't have experience of rehabilitation for people with M.E./CFS, then you could ask to see a specialist who has. Or, you could ask your therapist to seek advice and supervision from a specialist therapist. 

At the heart of rehabilitation is an empathic interaction between the person and the therapist which gives rise to the process of building confidence and gently restoring function whilst managing what can often be a very challenging health condition.

References:

  1. Gladwell, P.W. et al. Use of an online survey to explore positive and negative outcomes of rehabilitation for people with CFS/ME. Disability and Rehabilitation, 2014. 36(5): p. 387-394.

Clinical Biochemistry Clinics

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Patients with Inherited Metabolic Disease

A clinical advisory service regarding the investigation and management of patients with Inherited metabolic disease is available by telephone, letter or email. 

An adult metabolic clinic is held twice a month. Referral can be organised after discussion with Dr Helena Kemp.        

    

Dr Helena Kemp
Telephone: 0117 4148423
Email: helena.kemp@nbt.nhs.uk

Lipid Clinic

Patients can be referred directly to Dr G Bayly or Dr A Day (lipid clinic at University Hospitals Bristol NHS Trust), for more information visit www.uhbristol.nhs.uk/patients-and-visitors/your-hospitals/bristol-royal-infirmary/what-we-do/laboratory-medicine/lipid-clinic Clinics are usually held twice a week (Monday and Wednesday).

Clinical Biochemistry Clinics

Functional Neurological Symptoms

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Functional neurological symptoms are neurological symptoms that are genuine, but not due to a disease of the nervous system.

They are called functional symptoms because they affect the “function” of the body rather than being caused by damage to the “structure”.

This problem has been around for a long time, for most of history it was called “hysteria”, though it is common in men as well as women. More recently, psychiatrists called it “conversion disorder” because patients were thought to be “converting” stress into physical symptoms.

However not all patients experience significant psychological problems. A lot of patients just have an accident or a period of illness and then get functional symptoms afterwards.

Symptoms can include:

  • Loss of motor control
  • Sensory symptoms
  • Speech problems
  • Attacks or seizures
  • Visual symptoms
  • Cognitive problems

These symptoms are common, affecting around a third of people attending neurology outpatient clinics.
They can resolve quickly and of their own accord, and sometimes a clear, reassuring explanation and some time is all a patient needs to get better.

The following websites have a lot of very useful information:
www.neurosymptoms.org
www.nonepilepticattacks.info

When symptoms become more chronic they can cause a lot of problems, with a third of affected patients not being able to work. Patients are often very distressed by their symptoms. In this case we tend to diagnose “Functional Neurological Symptoms Disorder” (FND). 

When patients are affected by FND they can benefit from specialist help including physiotherapy and psychological therapy.

At the Rosa Burden Centre we have psychiatrists, therapists and nurses with lots of experience working with patients with these symptoms.

We have an outpatient clinic in which we carry out assessments and provide guidance. We provide outpatient psychological treatment (CBT) for suitable patients.

For patients who have tried all the other available treatment and are still very affected by their symptoms we have a three week inpatient rehabilitation program:

Our inpatient program is “multidisciplinary” meaning it involves assessment and treatment from professionals with different expertise:

  • Nursing staff trained in physical and mental health
  • Psychological therapy
  • Physiotherapy
  • Occupational therapy
  • Psychiatry

Through 1:1 assessments with different professionals, and weekly team meetings involving the patients, we aim to get a good understanding of your symptoms, how they affect you and how you understand them.

Part of the assessment involves us getting to understand you as an individual, because these symptoms are complex and can be affected by lots of different aspects of a person’s history. We will challenge you to try different techniques and learn new skills, to enable you to manage your symptoms more effectively.

By the time the three weeks are over we hope that your symptoms will have improved, your ability to manage the activities of daily life will have improved, and you will have confidence that you can continue to recover at home.

Functional Neurological Symptoms Referral

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Our service is modelled on the stepped care approach recommended in the 2012 document “Stepped Care for Functional Neurological Symptoms” by Health Improvement Scotland. For more information download Stepped care for functional neurological symptoms PDF.

Our current pathway is:

Step 1: Diagnosis and explanation made by a local neurologist, patient education material provided
Step 2: Brief intervention by local services as able e.g. liaison psychiatry team, IAPT, physiotherapy
Step 3: Chronic symptoms following steps 1 and 2: Referral to outpatient neuropsychiatry for assessment and guidance +/- CBT.
Step 4: MDT inpatient programme.

Outcomes

We currently use the outcome measures from the liaison psychiatry PLAN protocol for our inpatient program, namely the CGI (Clinician Rated) and the CORE 10 (Patient rated)
For 68 consecutive cases in 2017-2018 our outcomes were as follows:

CORE 10 (Patient rated outcome measure):

  • Mean 4.7/10 at admission, Mean 2.0/10 at discharge.
  • Effect size (Cohens d, no control group) = 2.1.

CGI (Clinician rated outcome measure):

  • Mean 19.9 at admission, 11.1 at discharge.
  • Effect size (Cohens d, no control group) = 1.2.

Sleep Disorders Referral

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Sleep Disorders Clinic

We offer an outpatient clinic for neuropsychiatric sleep disorders, which includes:

  • Assessment by a sleep specialist clinician
  • Sleep investigations such as polysomnography and actigraphy where these are indicated
  • Diagnosis and recommendations for outpatient treatment.

Polysomnography is carried out during a brief inpatient stay at the Rosa Burden centre.
We accept referrals from GP’s by e-referral and secondary care clinicians by letter to the address below.

We will consider referrals for:

  • Hypersomnias e.g. Narcolepsy, Idiopathic Hypersomnia, Klein Levine Syndrome
  • Parasomnias e.g. Sleep terrors, Sexsomnia, REM sleep behaviour disorder
  • Sleep related movement disorders e.g. Periodic Limb Movement Disorder
  • Circadian rhythm sleep-wake disorders e.g. delayed sleep-wake phase disorder

We don’t accept referrals for:

  • Insomnia
  • Sleep related breathing disorders (please refer to your local respiratory sleep centre)
  • Sleep problems due to a primary medical, psychiatric or substance use problem.

 

Contact Neuropsychiatry

Rosa Burden Centre for Neuropsychiatry
Southmead Hospital
Southmead Road
Bristol
BS10 5NB

New referrals 
Stacey Blunsden    
01174140459

Reception
01174140450

Medical secretaries
Yvonne Munn
01174140452

Non Epileptic Attack Disorder (NEAD)

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NEAD is a condition which presents mainly as collapses or episodes of unconsciousness, which are frequently mistaken for epilepsy.

NEAD can exist alongside or in absence of epilepsy, thus requiring the need for detailed psychological assessment and treatment.

  • 20% of "intractable epilepsy“
  • But 20% of frontal epilepsies misdiagnosed as NEAD
  • 50% of “Status Epilepticus” in A&E is NEAD
  • NEAD most commonly occur in people with epilepsy
  • Confirm diagnosis with EEG if possible

Treatment:

  • Reduce AEDs if possible
  • View video/EEG if possible
  • Explore psychotherapeutic issues
  • CBT and family education

 

Neuropsychiatric Aspects of Epilepsy

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Psychosis

Ictal Psychoses - include non-convulsive status:

  • Prolonged automatisms
  • Confusion
  • Episodic hallucinations  
  • Mood changes
  • Paroxysmal EEG changes
  • Clearly episodic, rarely >1 hour

Post-ictal Psychoses- Fugues:

  • Wandering
  • Altered behaviour
  • Amnesia
  • ?“dissociative”
  •  EEG usually “normal”

Twilight states:

  • Abnormal subjective experience (cognitive and affective)
  • Perseveration
  • Subtle cognitive impairments
  • Paranoid hallucinatory experiences
  • May be associated with deep EEG changes or with “forced normalization”

Chronic Inter-ictal Psychoses: 

  • 3% risk - especially if left temporal lobe

Chronic paranoid hallucinatory:

  • “Schizophreniform”
  • Onset 10-15 years after epilepsy
  •  Less Family history
  •  Pre-morbid personality
  •  Warmer affect
  •  Less personality deterioration

Affective disorder and Epilepsy

Ictal emotion:  

  • Fear, also depression,                            
  • Rarely elation                          
  • Can be prodromal, partial status, post ictal                      
  • Lack precipitant                                                                        
  • Sudden onset and ending                           
  • Have a primitive, unvarying quality

Inter-ictal depression and anxiety:

  • 15-45% prevalence
  •  Major Affective Disorder 11% (cf 4.9% gen pop)
  •  62% lifetime prevalence (cf 17% gen pop)
  •  High anxiety and hostility scores
  •  Risk after surgery: 2yrs=10%(successful or not)
  •  Multi-factorial causation (biological,  personal, family and societal factors)
  •  Treatment: attend to these factors:
    SSRIs, can use ECT
    A range of interactions, mostly “academic”

Personality and Epilepsy

A long and misleading history of prejudice

  • Possibly a "Temporal lobe personality syndrome”
  • Bear and Fedio 1977 :
    • Humourless sobriety
    • Circumstantiality
    • Viscosity
    • Religiosity
    • Emotionality (Rt)
    • Hypergraphia (Rt)
    • Ruminative intellectual (Lt)
  • However, “current data do not support or refute any consistent clustering of behavioural traits in epilepsy” Devinsky 1996
  • But may show extremes and diversity.

Aggression and Epilepsy

  • Aggression - ictal, possibly ictal, not ictal
  • Ictal:  usually part of confusion, poor handling etc
  • Very rare as part of an automatism
  • Poorly directed, fragmentary, simple, brief,
  • Repetitive, lack of concealment, remorse after
  • Possibly ictal: ? “Episodic Dyscontrol”
  • Not ictal: statistical relationship between epilepsy and
  • Violence for various epidemiological reasons.