BackgroundAcute lacunar ischaemic stroke, white matter hyperintensities, and lacunes are all features of cerebral small vessel disease. It is unclear why some small vessel disease lesions present with acute stroke symptoms, whereas others typically do not.AimTo test if lesion location could be one reason why some small vessel disease lesions present with acute stroke, whereas others accumulate covertly.MethodsWe identified prospectively patients who presented with acute lacunar stroke symptoms with a recent small subcortical infarct confirmed on magnetic resonance diffusion imaging. We compared the distribution of the acute infarcts with that of white matter hyperintensity and lacunes using computational image mapping methods.ResultsIn 188 patients, mean age 67 ± standard deviation 12 years, the lesions that presented with acute lacunar ischaemic stroke were located in or near the main motor and sensory tracts in (descending order): posterior limb of the internal capsule (probability density 0·2/mm3), centrum semiovale (probability density = 0·15/mm3), medial lentiform nucleus/lateral thalamus (probability density = 0·09/mm3), and pons (probability density = 0·02/mm3). Most lacunes were in the lentiform nucleus (probability density = 0·01–0·04/mm3) or external capsule (probability density = 0·05/mm3). Most white matter hyperintensities were in centrum semiovale (except for the area affected by the acute symptomatic infarcts), external capsules, basal ganglia, and brainstem, with little overlap with the acute symptomatic infarcts (analysis of variance, P < 0·01).ConclusionsLesions that present with acute lacunar ischaemic stroke symptoms may be more likely noticed by the patient through affecting the main motor and sensory tracts, whereas white matter hyperintensity and asymptomatic lacunes mainly affect other areas. Brain location could at least partly explain the symptomatic vs. covert development of small vessel disease.

There is inconsistency in reporting the appearance of minerals on radiological images. • Only 46 studies confirmed mineral appearance using a non-imaging method. • Iron is the mineral more widely studied, consistently hypointense on T2*-weighted MRI. • T1-weighted MRI consistently reported copper, calcium and manganese hyperintense. • Calcium is consistently reported hypointense on T2-weighted MRI and hyperattenuating on CT.

BackgroundIntegrating mental health into primary care is a global priority. It is proposed to ‘task-share’ the screening, diagnosis and treatment of common mental disorders from specialists to primary care workers. Key to facilitating this is training primary care workers to deliver mental health care. Mental health training in Africa shows a predominance of short-term, externally driven training programmes. Locally, a more sustainable delivery system was needed.AimThe aim of the study was to develop and evaluate a locally delivered, long-term, in-service training programme to facilitate mental health care in primary care.MethodsThis was a quasi-experimental study using mixed methods. The in-service training programme was delivered in weekly 1-h sessions by local psychiatry staff to 20 primary care nurses at the clinic over 5 months. The training was evaluated using quantitative data from participant questionnaires and analysis of the referrals from primary to specialist care. Qualitative data were collected via semi-structured interviews and 14 observed training sessions.ResultsThe training was feasible and well received. Referrals to the mental health nurse increased in quality and participants’ self-rated competence improved. Additional benefits included the development of supervision skills of mental health nurses and providing a forum for staff to discuss service improvement. The programme acted as a vehicle to pilot integration in one clinic and identify unanticipated barriers prior to rollout.ConclusionsLong-term, in-service training, using existing local staff had benefits to the integration of mental health into primary care. This approach could be relevant to similar contexts elsewhere.

Background A number of community based surveys have identified an increase in psychological symptoms and distress but there has been no examination of symptoms at the more severe end of the mental health spectrum. Aims We aimed to analyse numbers and types of psychiatric presentations to inform planning for future demand on mental health services in light of the COVID-19 pandemic. Method We analysed electronic data between January and April 2020 for 2534 patients referred to acute psychiatric services, and tested for differences in patient demographics, symptom severity and use of the Mental Health Act 1983 (MHA), before and after lockdown. We used interrupted time-series analyses to compare trends in emergency department and psychiatric presentations until December 2020. Results There were 22% fewer psychiatric presentations the first week and 48% fewer emergency department presentations in the first month after lockdown initiated. A higher proportion of patients were detained under the MHA (22.2 v. 16.1%) and Mental Capacity Act 2005 (2.2 v. 1.1%) (χ2(2) = 16.3, P < 0.0001), and they experienced a longer duration of symptoms before seeking help from mental health services (χ2(3) = 18.6, P < 0.0001). A higher proportion of patients presented with psychotic symptoms (23.3 v. 17.0%) or delirium (7.0 v. 3.6%), and fewer had self-harm behaviour (43.8 v. 52.0%, χ2(7) = 28.7, P < 0.0001). A higher proportion were admitted to psychiatric in-patient units (22.2 v. 18.3%) (χ2(6) = 42.8, P < 0.0001) after lockdown. Conclusions UK lockdown resulted in fewer psychiatric presentations, but those who presented were more likely to have severe symptoms, be detained under the MHA and be admitted to hospital. Psychiatric services should ensure provision of care for these patients as well as planning for those affected by future COVID-19 waves.

Background Mental health crises are common in people with complex emotional needs (our preferred working term for people diagnosed with a 'personality disorder'), yet this population is often dissatisfied with the crisis care they receive. Exploring their experiences and views on what could be improved, and those of carers and healthcare staff, is key to developing better services. Aims We aimed to synthesise the relevant qualitative literature. Method Five databases were searched. Eligible studies included service users with a diagnosis of personality disorder and their carers or relevant staff, focused on crisis responses and used a qualitative design. Data were analysed with thematic synthesis. Results Eleven studies were included, most focusing on emergency departments. Four meta-themes emerged: (a) acceptance and rejection when presenting to crisis care: limited options and lack of involvement of carers; (b) interpersonal processes: importance of the therapeutic relationship and establishing a framework for treatment; (c) managing recovery from a crisis: clear recovery plan and negotiating collaboration; and (d) equipping and supporting staff: training and emotional support. Conclusions Our findings suggest that emergency departments have major limitations as settings to provide crisis care for people with complex emotional needs, but there is a lack of research exploring alternatives. The quality of the therapeutic relationship was central to how care was experienced, with collaborative and optimistic staff highly valued. Staff reported feeling poorly supported in responding to the needs of this population. Research looking at experiences of a range of care options and how to improve these is needed.

Highlights Antidepressant gender disparity less in type 2 diabetes than general population No evidence of ethnic disparity in antidepressant prescribing in type 2 diabetes No evidence of disparity in antidepressant prescribing for insulin users Considerable evidence gaps for antidepressant prescribing in type 2 diabetes

Background: The conflict in Syria has required humanitarian agencies to implement primary-level services for noncommunicable diseases (NCDs) in Jordan, given the high NCD burden amongst Syrian refugees; and to integrate mental health and psychosocial support into NCD services given their comorbidity and treatment interactions. However, no studies have explored the mental health needs of Syrian NCD patients. This paper aims to examine the interaction between physical and mental health of patients with NCDs at a Médecins Sans Frontières (MSF) clinic in Irbid, Jordan, in the context of social suffering. Methods: This qualitative study involved sixteen semi-structured interviews with Syrian refugee and Jordanian patients and two focus groups with Syrian refugees attending MSF's NCD services in Irbid, and eighteen semistructured interviews with MSF clinical, managerial and administrative staff. These were conducted by research staff in August 2017 in Irbid, Amman and via Skype. Thematic analysis was used. Results: Respondents describe immense suffering and clearly perceived the interconnectedness of their physical wellbeing, mental health and social circumstances, in keeping with Kleinman's theory of social suffering. There was a 'disconnect' between staff and patients' perceptions of the potential role of the NCD and mental health service in alleviating this suffering. Possible explanations identified included respondent's low expectations of the ability of the service to impact on the root causes of their suffering, normalisation of distress, the prevailing biomedical view of mental ill-health among national clinicians and patients, and humanitarian actors' own cultural standpoints. Conclusion: Syrian and Jordanian NCD patients recognise the psychological dimensions of their illness but may not utilize clinic-based humanitarian mental health and psychosocial support services. Humanitarian agencies must engage with NCD patients to elicit their needs and design culturally relevant services.

BackgroundIn structural Magnetic Resonance Imaging (MRI) of patients with a recent small subcortical infarct (RSSI) and small vessel disease (SVD) imaging markers coexist. However, their spatial distribution and prevalence with respect to the hemisphere of the RSSI remain unknown.Materials and MethodsFrom brain MRI in 187 patients with an acute lacunar ischemic stroke clinical syndrome and a relevant diffusion weighted imaging (DWI)‐positive lesion, we semiautomatically extracted the RSSI, microbleeds, lacunes, old cortical infarcts, and white matter hyperintensities (WMH) using optimized thresholding in the relevant sequences, and rated the load of perivascular spaces. We registered all images to an age‐relevant brain template and calculated the probability distribution of all SVD markers mentioned for patients who had the RSSI in each hemisphere separately. We used the Wilcoxon and chi‐squared tests to compare the volumes and frequencies of occurrence, respectively, of the SVD markers between hemispheres throughout the sample.ResultsFifty‐two percent patients (n = 97) had the RSSI in the left hemisphere, 42% (n = 78) in the right, 2.7% (n = 5) in both, and 3.7% (n = 7) in the cerebellum or brainstem. There was no significant difference in RSSI frequency between left and right hemispheres (p = .10) in the sample. The median volume of the RSSI (expressed as a percentage of the total intracranial volume) was 0.05% (IQR = 0.06). There was no difference in median percent volume of the right RSSIs versus left (p = .16). Neither was there a significant interhemispheric difference in the volume of any of the SVD markers regardless of the location of the RSSI and they were equally distributed in both hemispheres.ConclusionAssessment of SVD imaging markers in the contralateral hemisphere could be used as a proxy for the SVD load in the whole brain to avoid contamination by the RSSI of the measurements, especially of WMH.