Self-inflicted nail-gun injury with 12 cranial penetrations and associated cerebral trauma

2006 ◽  
Vol 104 (5) ◽  
pp. 828-834 ◽  
Author(s):  
Zachary N. Litvack ◽  
Matthew A. Hunt ◽  
Jason S. Weinstein ◽  
G. Alexander West
Keyword(s):  
Brain Injury ◽  
Clinical Decision Making ◽  
Relevant Literature ◽  
Ct Scanning ◽  
Clinical Decision ◽  
Middle Meningeal Artery ◽  
Common Mechanism ◽  
Penetrating Brain Injury ◽  
Rational Management ◽  
The Right

✓ In this case report, the authors describe a 33-year-old man who presented with headache due to the presence of 12 nail-gun nails impacted in his cranium and cerebral parenchyma. The authors also review the relevant literature regarding penetrating brain injury. The patient's physical examination revealed a Glasgow Coma Scale score of 15 and impairment of abduction of the right eye and abduction of the jaw producing dysarthria; the remaining results of the neurological examination were normal. Both x-ray films and computerized tomography (CT) scans of the head revealed the presence of 12 nails, the majority of which were located intracranially. A scattering artifact limited the ability of CT scanning to demonstrate any intracranial hemorrhage. Angiography did not demonstrate any evidence of traumatic vascular injury. After general anesthesia had been induced in the patient, the nails were removed in the operating room. Following removal of the final nail, a small left temporal craniotomy was performed to control hemorrhage from a tear in the left middle meningeal artery. Despite the development of a postoperative insular hematoma, the patient was discharged home with minimal deficits. This patient is the only known survivor of the largest number of foreign objects (12) to penetrate the skull intentionally. Overall, self-inflicted nail-gun injuries are less common than accidental discharges. A review of the literature, however, suggests that for penetrating brain injury, self-infliction is the more common mechanism. For those patients who survive such an injury, clinical decision making must focus on preventing further cortical or vascular damage. A rational management strategy should permit these patients to be discharged with no additional injury.

How to Evaluate Clinically Relevant Literature: Five Simple Rules for the Practicing Clinician in Stroke Neurorehabilitation

2020 ◽  
Author(s):  
Jonathan Sanching Tsay ◽  
Carolee Winstein
Keyword(s):  
Clinical Decision Making ◽  
Relevant Literature ◽  
Clinical Decision ◽  
Balance Sheets ◽  
Neural Connections ◽  
Recovery Processes ◽  
Immediate Recovery ◽  
Simple Rules ◽  
Busy Clinician ◽  
New Generation

Neurorehabilitation relies on core principles of neuroplasticity to activate and engage latent neural connections, promote detour circuits, and reverse impairments. Clinical interventions incorporating these principles have been shown to promote recovery while demoting compensation. However, many clinicians struggle to find evidence for these principles in our growing but nascent body of literature. Regulatory bodies and organizational balance sheets further discourage evidence-based, methodical, time-intensive, and efficacious interventions because practical needs often outweigh and dominate clinical decision making. Modern neurorehabilitation practices that result from these pressures favor strategies that encourage compensation over those that promote recovery. With a focus on helping the busy clinician evaluate the rapidly growing literature, we put forth five simple rules that direct clinicians toward intervention studies that value more enduring but slower biological recovery processes over the more alluring practical and immediate “recovery” mantra. Filtering emerging literature through this critical lens has the potential to change practice and lead to more durable long-term outcomes. This perspective is meant to serve a new generation of mechanistically minded clinicians, students, and trainees poised to not only advance our field but to also erect policy changes that promote recovery-based care of stroke survivors.

Prognostic Factors for Persistent Symptoms in Adults With Mild Traumatic Brain Injury: an Overview of Systematic Reviews

2021 ◽  
Author(s):  
Julien Déry ◽  
Béatrice Ouellet ◽  
Élaine de Guise ◽  
Ève-Line Bussières ◽  
Marie-Eve Lamontagne
Keyword(s):  
Traumatic Brain Injury ◽  
Prognostic Factors ◽  
Brain Injury ◽  
Mild Traumatic Brain Injury ◽  
Systematic Reviews ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Persistent Symptoms ◽  
Wide Range ◽  
Overview Of Systematic Reviews

Abstract Background: Mild traumatic brain injury (mTBI) is an increasing public health problem, because of its persistent symptoms and several functional consequences. Understanding the prognosis of a condition is an important component of clinical decision-making and can help to guide prevention of persistent symptoms following mTBI. Prognosis of mTBI has stimulated several empirical primary research papers and many systematic reviews leading to the identification of a wide range of factors. We aim to synthesize these factors to get a better understanding of their breadth and scope.Methods: We conducted an overview of systematic reviews. We searched in databases systematic reviews synthesizing evidence about prognosis of persistent symptoms after mTBI in the adult population. Two reviewers independently screened all references and selected eligible reviews based on eligibility criteria. They extracted relevant information using an extraction grid. They also rated independently the risk of bias using the ROBIS tool. We synthesized evidence into a comprehensive conceptual map to facilitate the understanding of prognostic factors that have an impact on persistent post-concussion symptoms.Results: From the 3857 references retrieved in database search, we included 25 systematic reviews integrating the results of 312 primary articles published between 1957 and 2019. We examined 35 prognostic factors from the systematics reviews. No single prognostic factor demonstrated convincing and conclusive results. However, age, sex and multiple concussions showed an affirmatory association with persistent post-concussion outcomes in systematic reviews.Conclusion: We highlighted the need of a comprehensive picture of prognostic factors related to persistent post-concussion symptoms. We believe that these prognostic factors would guide clinical decision and research related to prevention and intervention regarding persistent post-concussion symptoms.Systematic review registration: PROSPERO CRD42020176676

scholarly journals Factors Influencing Physicians' Clinical Decision-making at Upazila Health Complexes in Bangladesh

2020 ◽  
Vol 3 (4) ◽  
pp. 125-133
Author(s):  
M. Aminul Islam ◽  
M. Abdul Awal
Keyword(s):  
Decision Making ◽  
Social Networks ◽  
Clinical Decision Making ◽  
Average Length ◽  
Clinical Decision ◽  
Primary Data ◽  
Decision Making Process ◽  
Cross Sectional ◽  
The Right ◽  
Consultation Session

ABSTRACT Introduction Selecting the most appropriate treatment for each patient is the key activity in patient-physician encounters and providing healthcare services. Achieving desirable clinical goals mostly depends on making the right decision at the right time in any healthcare setting. But little is known about physicians' clinical decision-making in the primary care setting in Bangladesh. Therefore, this study explored the factors that influence decisions about prescribing medications, ordering pathologic tests, counseling patients, average length of patient visits in a consultation session, and referral of patients to other physicians or hospitals by physicians at Upazila Health Complexes (UHCs) in the country. It also explored the structure of physicians' social networks and their association with the decision-making process. Methods This was a cross-sectional descriptive study that used primary data collected from 85 physicians. The respondents, who work at UHCs in the Rajshahi Division, were selected purposively. The collected data were analyzed with descriptive statistics including frequency, percentage, one-way analysis of variance, and linear regression to understand relationships among the variables. Results The results of the study reveal that multiple factors influence physicians' decisions about prescribing medications, ordering pathologic tests, length of visits, counseling patients, and referring patients to other physicians or hospitals at the UHCs. Most physicians prescribe drugs to their patients, keeping in mind their purchasing capacity. Risk of violence by patients' relatives and better management are the two key factors that influence physicians' referral decisions. The physicians' professional and personal social networks also play an influential role in the decision-making process. It was found that physicians dedicate on average 16.17 minutes to a patient in a consultation session. The length of visits is influenced by various factors including the distance between the physicians' residence and their workplace, their level of education, and the number of colleagues with whom they have regular contact and from whom they can seek help. Conclusion The results of the study have yielded some novel insights about the complexity of physicians' everyday tasks at the UHCs in Bangladesh. The results would be of interest to public health researchers and policy makers.

Collaborative Goal Setting: A Clinical Approach for Adults With Mild Traumatic Brain Injury

2021 ◽  
pp. 1-20
Author(s):  
Jessica Brown ◽  
Kristen Ackley ◽  
Kelly Knollman-Porter
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Goal Setting ◽  
Mild Traumatic Brain Injury ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Models Of Care ◽  
Clinical Approach ◽  
Self Awareness ◽  
Clinical Resource

Purpose Speech-language pathologists (SLPs) have many available procedural options when setting treatment goals. Extant literature supports goal setting protocols that include and value the perspectives of the client; however, in practice, rehabilitation professionals may lean toward expert models of care when planning treatment. Our purpose is to describe a newly developed approach for SLPs and individuals with mild traumatic brain injury (mTBI) to work together to build meaningful, relevant goals. Method We utilized a multiple case study format to exemplify goal setting procedures. Specifically, we describe procedures and outcomes for a 29-year-old female 28 days postinjury and a 70-year-old male 9 months postinjury. Results Clients who engaged in this protocol worked collaboratively with a clinician to identify strengths and challenges postinjury, select and prioritize goal areas, and discuss and develop meaningful, personalized treatment activities. For both participants, use of the proposed protocol resulted in meaningful goals that addressed their self-reported deficits as well as their respective cognitive–linguistic deficits noted on objective, standardized measures. Conclusions Clinician and client collaboration during treatment goal development can facilitate increased client motivation and functional outcomes. The described approach is feasible from a clinical resource standpoint and promotes a systematic approach to placing the client at the forefront of clinical decision making to enhance therapeutic gains. Such client-centered approaches may be particularly valuable for individuals with mTBI who experience substantial cognitive and communicative challenges but may maintain high levels of self-awareness postinjury.

The Use of Artificial Intelligence Systems for Support of Medical Decision-Making

2011 ◽  
pp. 1017-1029
Author(s):  
William Claster ◽  
Nader Ghotbi ◽  
Subana Shanmuganathan
Keyword(s):  
Artificial Intelligence ◽  
Decision Making ◽  
Statistical Analysis ◽  
Medical Records ◽  
Clinical Decision Making ◽  
Ct Scanning ◽  
Clinical Decision ◽  
Radiology Department ◽  
Self Organizing Map ◽  
One Year

There is a treasure trove of hidden information in the textual and narrative data of medical records that can be deciphered by text-mining techniques. The information provided by these methods can provide a basis for medical artificial intelligence and help support or improve clinical decision making by medical doctors. In this paper we extend previous work in an effort to extract meaningful information from free text medical records. We discuss a methodology for the analysis of medical records using some statistical analysis and the Kohonen Self-Organizing Map (SOM). The medical data derive from about 700 pediatric patients’ radiology department records where CT (Computed Tomography) scanning was used as part of a diagnostic exploration. The patients underwent CT scanning (single and multiple) throughout a one-year period in 2004 at the Nagasaki University Medical Hospital. Our approach led to a model based on SOM clusters and statistical analysis which may suggest a strategy for limiting CT scan requests. This is important because radiation at levels ordinarily used for CT scanning may pose significant health risks especially to children.

scholarly journals Complexity of Clinical Decision Making: Consent, Capacity, and Ethics

2019 ◽  
Vol 40 (03) ◽  
pp. 162-169 ◽  
Author(s):  
Annette Askren ◽  
Paula Leslie
Keyword(s):  
Decision Making ◽  
Clinical Decision Making ◽  
Negative Charge ◽  
Clinical Decision ◽  
Informed Consent Process ◽  
Thickened Liquids ◽  
Medical Decisions ◽  
Social Media Platforms ◽  
The Right ◽  
Right To Refuse

AbstractSpeech–language pathologists (SLPs), and really their patients, are often faced with challenging clinical decisions to be made. Patients may decline interventions recommended by the SLP and are often inappropriately labeled “noncompliant.” The inappropriateness of this label extends beyond the negative charge; the patient's right to refuse is, in fact, protected by law. Anecdotal exchanges, social media platforms, and American Speech-Language-Hearing Association forums have recently revealed that many SLPs are struggling with the patient's right to decline. Many are not comfortable with the informed consent process and what entails patients' capacity to make their own medical decisions. Here, we discuss the basics of clinical decision-making ethics with intent to minimize the clinician's discomfort with the right to refuse those thickened liquids and eliminate the practice of defensive medicine.

The Elderly Psychiatric Patient with Positive Syphilis Serology: The Problem of Neurosyphilis

1998 ◽  
Vol 28 (3) ◽  
pp. 333-339 ◽  
Author(s):  
Ishwer L. Bharwani ◽  
Charles O. Hershey
Keyword(s):  
Elderly Patients ◽  
Clinical Decision Making ◽  
Relevant Literature ◽  
Clinical Decision ◽  
The Elderly ◽  
Illustrative Case ◽  
Positive Serology ◽  
Important Indicator ◽  
Syphilis Serology ◽  
Latent Syphilis

Objective: Older patients have a high prevalence of neurological and psychiatric disorders. They also have a baseline prevalence of late latent syphilis or positive syphilis serology. Thus the clinical question arises as to whether a neuropsychiatric disorder in a geriatric patient is neurosyphilis or if the positive serology is incidental. Method: An illustrative case example is used to illustrate this dilemma. The relevant literature is reviewed. Results: The cerebrospinal fluid (CSF) protein is an important indicator of inflammatory activity in the central nervous system and is used as a clinical guide in the diagnosis. Elderly patients have higher values of normal CSF protein than younger patients. Conclusions: Given the importance of CSF protein in the diagnosis of neurosyphilis, physicians must include this knowledge, that elderly patients have higher CSF protein values, in their clinical decision making in the differentiation between neurosyphilis and late latent syphilis in the elderly patient.

Pharmacological management of acute severe behavioural disturbance: a survey of current protocols

2017 ◽  
Vol 25 (4) ◽  
pp. 395-398 ◽  
Author(s):  
Nick O’Connor ◽  
John Corish
Keyword(s):  
Clinical Decision Making ◽  
Relevant Literature ◽  
Clinical Decision ◽  
Evidence Base ◽  
Clinical Knowledge ◽  
Behavioural Disturbance ◽  
Treatment Protocols ◽  
Pharmacological Management ◽  
New Evidence ◽  
Careful Assessment

Objectives: The investigators reviewed protocols for the pharmacological management of acute severe behavioural disturbance (ASBD) used in Australasian psychiatric settings. Relevant literature was also examined, with a focus on Australian research. Methods: All Fellows of the RANZCP were emailed on two occasions in 2014 requesting a copy of the guidelines for pharmacological management of the ASBD patient used in their workplace. A literature search was also undertaken. Results: Thirty-six pharmacological management protocols for the ASBD patient were received. Twenty-six of these referred to patients aged 18–65 years and were selected for analysis. A number of recent publications provided new evidence in relation to the safe and effective management of patients with ASBD. Conclusions: ASBD is a heterogeneous, transnosological set of presentations requiring careful assessment and rational clinical decision making. Treatment protocols arising from an evolving evidence base provide safe and effective pathways for the majority of patients. However, sound clinical knowledge and a careful assessment of each presentation is required to enable the clinician to tailor treatment individually.

Use of Templates for Clinical Documentation in Psychiatric Evaluations—Beneficial or Counterproductive for Residents in Training?

2012 ◽  
Vol 43 (1) ◽  
pp. 99-103 ◽  
Author(s):  
Joanna Bajgier ◽  
James Bender ◽  
Rose Ries
Keyword(s):  
Health Care ◽  
Decision Making ◽  
Clinical Decision Making ◽  
Relevant Literature ◽  
Health Care Financing ◽  
Clinical Decision ◽  
Third Party ◽  
Clinical Documentation ◽  
Advantages And Disadvantages ◽  
Valid Data

In psychiatry, as in other disciplines, electronic templates are replacing handwritten records to meet health care financing regulations and requirements of third-party payers. We address whether these checklists are helpful for residents, especially those beginning training, in learning the foundational skills of their discipline and in recording a comprehensive set of patient data. An informal survey of our residents suggests that residents find the templates useful, though they have advantages and disadvantages. We also review relevant literature from psychiatry and other fields on the use of electronic templates and pose questions about how we might gauge the usefulness of the templates in residents' training and in obtaining valid data for clinical decision-making.

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