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.