Matthew D Macfarlane

Striatal Atrophy in the Behavioural Variant of Frontotemporal Dementia: Correlation with Diagnosis, Negative Symptoms and Disease Severity

Introduction Behavioural variant frontotemporal dementia (bvFTD) is associated with changes in dorsal striatal parts of the basal ganglia (caudate nucleus and putamen), related to dysfunction in the cortico-striato-thalamic circuits which help mediate executive and motor functions. We aimed to determine whether the size and shape of striatal structures correlated with diagnosis of bvFTD, and measures of clinical severity, behaviour and cognition. Materials and Methods Magnetic resonance imaging scans from 28 patients with bvFTD and 26 healthy controls were manually traced using image analysis software (ITK-SNAP). The resulting 3-D objects underwent volumetric analysis and shape analysis, through spherical harmonic description with point distribution models (SPHARM-PDM). Correlations with size and shape were sought with clinical measures in the bvTFD group, including Frontal Behavioural Inventory, Clinical Dementia Rating for bvFTD, Color Word Interference, Hayling part B and Brixton tests, and Trail-Making Test. Results Caudate nuclei and putamina were significantly smaller in the bvFTD group compared to controls (left caudate 16% smaller, partial eta squared 0.173, p=0.003; right caudate 11% smaller, partial eta squared 0.103, p=0.023; left putamen 18% smaller, partial eta squared 0.179, p=0.002; right putamen 12% smaller, partial eta squared 0.081, p=0.045), with global shape deflation in the caudate bilaterally but no localised shape change in putamen. In the bvFTD group, shape deflations on the left, corresponding to afferent connections from dorsolateral prefrontal mediofrontal/anterior cingulate and orbitofrontal cortex, correlated with worsening disease severity. Global shape deflation in the putamen correlated with Frontal Behavioural Inventory scores—higher scoring on negative symptoms was associated with the left putamen, while positive symptoms were associated with the right. Other cognitive tests had poor completion rates. Conclusion Behavioural symptoms and severity of bvFTD are correlated with abnormalities in striatal size and shape. This adds to the promise of imaging the striatum as a biomarker in this disease.

Prevalence and symptomatology of catatonia in elderly patients referred to a consultation-liaison psychiatry service

Objectives: To determine the prevalence and clinical correlations of catatonia in patients aged over 65 years who are referred to a consultation-liaison service within a regional area of Australia. Additionally, to examine if the use of standardised screening tools is likely to change the rate of diagnosis of catatonia within the consultation-liaison service. Methods: One hundred and eight referrals from general hospital wards were assessed using the Bush-Francis Catatonia Screening Instrument (BFCSI) and associated examination; each consented patient was screened for catatonic symptoms. If two or more signs were present on the BFCSI, then severity was rated using the Bush-Francis Catatonia Rating Scale. These clinical characteristics were compared with their socio-demographic and medical data. Results: Prevalence of catatonia was 5.5%. The most common symptoms appeared to be rigidity, posturing and immobility (67% of cases), and were elicited through routine psychiatric examination. Conclusions: Routine psychiatric history and examination are likely sufficient to elicit catatonic signs in a consultation-liaison setting. Standardised screening examination may be more suited for conducting research or for use when examining for catatonia in psychiatric inpatient settings.

Assessing and managing suicidal patients in the emergency department

Objective: The objective of this article is to set out consensus guidelines for the assessment and management of “suicidal patients” in the emergency department. Conclusions: Clinicians should be respectful and reassuring. They should review old notes, conduct a full history and examination, and talk to friends, family and any practitioners already involved in the patient’s care. Management should be guided, where possible, by the patient’s preferences, not by notions of risk. Every negotiated management plan and its rationale should be carefully documented.

Comparison of consultation–liaison psychiatry services for inner-city, district or regional general hospitals using a common tool: Does one size fit all?

OBJECTIVE Consultation-liaison psychiatry (CLP) services vary in terms of structure, function and responsiveness. It is not known whether evaluation measurements can be meaningfully compared across different CLP services to assess value and efficiency. The aim was to develop and test a common tool for measuring process and outcome measures in CLP. METHODS A data collection tool was developed using the literature and consultation with CLP clinicians. The tool was used to prospectively gather referral data, response times, health utilisation data and functional outcomes for individuals referred over seven months to three different CLP teams, servicing inner city, district and regional areas. RESULTS The structure, staffing, liaison attachments and scope of practice varied between the services. The regional CLP service attended seven hospitals and had the highest referral rate and largest inpatient population pool. The three services received referrals for similar reasons and made similar diagnoses. Multimodal management was the norm, and CLP facilitated follow-up arrangements upon discharge. Only the district CLP service saw all emergency referrals within an hour. Age and need for an interpreter did not affect response times. CONCLUSION Despite local differences in geography, CLP roles, hospital and community mental health service pathways and patient populations, the CLP data collection tool was applicable across sites. Staff resourcing and referral demand are key determinants of CLP response times.

Getting started in research: research questions, supervisors and literature reviews

Objectives: Research can seem daunting, especially for trainees and early career researchers. This paper focuses on how to formulate and begin a research project such as the RANZCP Scholarly Project. Methods: We outline an approach to framing a research question, developing theses and hypotheses, choosing a supervisor and conducting a literature review. Conclusions: Through systematic planning early career researchers and other clinicians can plan and conduct research suitable for the Scholarly Project or other research activity.

A guide to clinical research supervision for psychiatrists: a mentoring approach.

Objectives: To provide a guide for clinically-based psychiatrist supervisors of research projects for early career researchers. Methods: This paper will describe a mentoring framework for supervision, for psychiatrist clinical research supervisors and early career researchers. Results: The domains discussed include, across various aspects of a study: the role of the supervisor, project management, and where and when to seek advice. Conclusions: Supervision of clinical research can be a professionally rewarding experience for psychiatrists, as well as early career researcher supervisees.

Getting started in research: systematic reviews and meta-analyses

Objectives: Systematic reviews are one of the major building blocks of evidence-based medicine. This overview is an introduction to conducting systematic reviews and meta-analyses. Conclusions: Systematic reviews and meta-analyses of randomised controlled trials (RCTs) represent the most robust form of design in the hierarchy of research evidence. In addition, primary data do not have to be collected by the researcher him/herself, and there is no need for approval from an ethics committee. Systematic reviews and meta-analyses are not as daunting as they may appear to be, provided the scope is sufficiently narrow and an appropriate supervisor available.

The rites of writing papers: steps to successful publishing for psychiatrists

Objective: To encourage psychiatrists to publish high-quality articles in peer-reviewed journals by demystifying the publishing process. Methods: This paper will describe the publishing process and outline key factors that ensure that publishing is an achievable goal for psychiatrists. Results: The publishing process can be long and often this is related to delays associated with obtaining reviewers and their comments. Negative reviewer comments often relate to grammatical and typographical errors, an insufficient literature review, failure to adequately discuss limitations and conclusions that are not adequately supported by the results. Authors who systematically respond to their paper’s reviewer comments are usually successful in having their papers accepted. Success in publishing is usually determined by a topic that appeals to the readership of a journal, a credible methodology and a paper that is well-written. Conclusions: Publishing is achievable for all psychiatrists providing they can write a paper that delivers a clear and concise message, are willing to address reviewer comments and that their paper is tailored to the readership of the journal.

Getting started in research: Designing and preparing to conduct a research study

Objective: To discuss common pitfalls and useful tips in designing a quantitative research study, the importance and process of ethical approval, and consideration of funding. Conclusions: Through careful planning, based on formulation of a research question, early career researchers can design and conduct quantitative research projects within the framework of the Scholarly Project or in their own independent projects.

Measuring movement into residential care institutions in Haiti after Hurricane Matthew: A pilot study

Background Governments have an ethical imperative to safeguard children in residential care institutions at all times, including in the aftermath of an emergency. Yet, a lack of accurate data about how the magnitude and characteristics of this population may change due to an emergency impedes leaders’ ability to formulate responsive policies and services, mobilize resources and foster accountability. The purpose of this study was therefore to determine the feasibility of evaluating movement of children into residential care following an emergency. Methods The pilot study took place in Les Cayes commune in the Sud Department of Haiti in April 2017. Six months prior to the pilot, the area was severely affected by Hurricane Matthew, with widespread devastation to property, livestock and livelihoods. Using a two-stage process, the team created a comprehensive list of residential care institutions in Les Cayes. At each facility, the data collectors attempted to administer four separate tools: a group count tool, a record review tool, interviews with staff, and interviews with children 10 years of age and older. Results Out of 27 known institutions in Les Cayes, 22 institutions consented to participate in the research. Within these 22 institutions, the prevalence of new arrivals to residential care since Hurricane Matthew varied significantly across the four tools, ranging from 0.69% according to the aggregated child interviews to 20.96% according to the aggregated staff interviews. Record availability and quality was very poor and child participation was difficult to arrange due to travel and scheduling constraints. Interpretation Robust measurement of new arrivals to residential care institutions was not feasible in Haiti following Hurricane Matthew. Moreover, many of the challenges encountered are likely to be encountered in humanitarian emergencies in other settings. Therefore, the research team does not recommend scale-up of these methods in most humanitarian settings. Alternative approaches that incorporate household survey methods to ascertain movement into residential care based on reports from caregivers may be more realistic in places with poor pre-existing governance systems and weak registries and records for residential care institutions.