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Background: Across a range of policy areas and geographies, governments and philanthropists are increasingly looking to adopt a social outcomes contracting (SOC) approach. Under this model, an agreement is made that a provider of services must achieve specific, measurable social and/or environmental outcomes and payments are only made when these outcomes have been achieved. Despite this growing interest, there is currently a paucity of evidence in relation to the tangible improvement in outcomes associated with the implementation of these approaches. Although promising, evidence suggests that there are risks (especially around managing perverse incentives).[1] The growing interest in SOC has been accompanied by research of specific programmes, policy domains or geographies, but there has not been a systematic attempt to synthetise this emerging evidence. To address this gap, this systematic review aims to surface the best evidence on when and where effects have been associated with SOC. Methods: This mixed-methods systematic review protocol has been prepared using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol (PRISMA-P) guidelines (Additional File 2) (Shamseer et al., 2010). The review aims to consult policymakers throughout the evidence synthesis process, by adopting a user-involved research process. This will include the establishment and involvement of a Policy Advisory Group (PAG). The PAG will consist of a large, diverse, international group of policy makers who are or have been actively involved in funding and shaping social outcomes contracts (Additional File 3). The following electronic databases will be searched: ABI/INFORM Global, Applied Social Sciences Index & Abstracts (ASSIA), Scopus, International Bibliography of the Social Sciences (IBSS), PAIS Index, PolicyFile Index, Proquest Dissertations and Theses, ProQuest Social Science, Social Services Abstracts, Web of Science, Worldwide Political Science Abstracts and PsycINFO. We will also conduct a comprehensive search of grey literature sources. Studies will be imported into Covidence and screened (after de-duplication) independently by two reviewers, using explicit inclusion/exclusion criteria. We will conduct risk of bias and quality assessment using recommended tools and we will extract data using a pre-piloted, standardised data extraction form. If meta-synthesis cannot be conducted for the effectiveness component, we will carry out a descriptive narrative synthesis of the quantitative evidence, categorised by type of intervention, type of outcome/s, population characteristics and/or policy sector. The qualitative studies will be synthesised using thematic content analysis (Thomas and Harden 2008). If possible, we will also analyse the available economic data to understand the costs and benefits associated with SOC. Finally, we will conduct a cross-study synthesis, which will involve bringing together the findings from the effectiveness review, economic review and qualitative review. We recognise that the proposed conventional effectiveness review method may lead to inconclusive or partial findings given the complexity of the intervention, the likely degree of heterogeneity and the under-developed evidence base. We see a traditional systematic review as an important foundation to describe the evidence landscape. We will use this formal review as a starting point and then explore more contextually rooted review work in future. Discussion: We will use the systematic review findings to produce accessible and reliable empirical insights on whether, when, and where (and if possible, how) SOC approaches deliver improved impact when compared to more conventional funding arrangements. The outputs will support policymakers to make informed decisions in relation to commissioning and funding approaches. Systematic review registration: This systematic review was registered with the International Prospective Register of Systematic Reviews (PROSPERO), on 20th November 2020 and was last updated on 21 January 2021: (registration number PROSPERO CRD42020215207). [1] A perverse incentive in an outcomes-based contract is an incentive that has unintended and undesirable results. For instance, a poorly designed welfare-to-work scheme could create incentives for service providers to prioritise clients who are easier to help and to ‘park’ those who are harder to assist (NAO 2015).

When the social impact bond (SIB) model was first introduced in 2010, there were many claims about how these projects could transform public service delivery. This article investigates how SIB projects have been designed in relation to two original intentions: (1) shifting the focus of public service delivery to achieving impact and (2) transferring risk from the government to external investors. Qualitative content analysis of SIB projects launched until 2020 in the US and UK (n = 114) is used to plot and analyze how the design of SIB projects vary across these intentions. We find that SIB design in practice has deviated from the model’s original intent in several important ways: In the UK, payable outcomes are generally not subject to rigorous validation methods. In both the US and the UK, upfront capital is generally independent and at-risk, but risk mitigation strategies may limit the intended transfer of risk to investors.

This report is part of the GO Lab-supported International Network for Data on Impact and Government Outcomes (INDIGO). This report reflects on the general landscape of impact bond projects across the world. The first section analyses the countries leading the way with impact bonds in a number of categories and it also examines the distribution of projects across different policy sectors. The second section provides an overview of international impact bonds - projects where at least one of the outcome payers is located in a different country to the location of service delivery. It presents key statistics on international impact bonds, and analyses their distribution across policy areas and geographies. The last section features the projects of the Life Chances Fund. This report uses data as of 01 July 2021.

The much-vaunted Social Impact Bond (SIB) approach is typically understood as a form of public service arrangement where social investment backs the voluntary sector’s delivery of outcomes contract...

Since the early 1990s, the “activation turn” has become a standard welfare orthodoxy at the heart of international welfare systems. Although policymakers talk confidently about the well‐being gains of activation interventions and their employment outcomes, a growing body of research has focused instead on questions around “activation process well‐being”—the potential well‐being effects of participation in activation programmes themselves. The present article makes three main contributions to the theory, knowledge, and policy practice of this activation well‐being literature. First, the paper develops an original conceptual framework that newly connects well‐being theory, qualitative variation in programmatic form, and empirically testable well‐being expectations for participating service users. Second, the paper uses multivariate statistical analyses to examine six conceptually derived hypotheses around variation in programme forms and implications for participating service users' well‐being, drawing on the case study of U.K. activation policy. Noteworthy is the paper's unique distributional insights into well‐being effects across different types of service users. Third, the paper offers new policy contributions around the relevance of policy form to service user well‐being as well as important pointers to key programme features in this regard.

Social Impact Bonds (SIBs) are an innovation wherein, in theory, private investment, instead of government funding, is levered to fund social interventions (Warner, 2013; Edmiston & Nicholls 2018)....

Transaction cost economics is applied in this paper to social impact bonds to explore how public service commissioners could improve outcomes-based contracts. The authors supply a framework for assessing the quality of outcomes specifications and clarify the trade-off between a robust value case for government and the transaction costs associated with specifying such a deal. Illustrated by two examples, the authors suggest that commissioners aim for a ‘requisite’ contract: one that minimizes opportunism while balancing the costs of developing a more robust outcomes specification. Policy-makers and managers are increasingly looking to outcomes-based contracts, including social impact bonds, as a way to improve social outcomes. The success of these contracts is predicated on how well-specified the outcomes are within them. This paper provides practitioners with an easy-to-use framework for assessing outcomes specifications. They need to consider the definition of the eligible cohort; the alignment of payable outcomes to the policy intent; and the accuracy of prices for attributable outcomes. Practitioners should aim for a ‘requisite’ contract—a contract that minimizes service provider and investor opportunism while balancing the costs associated with developing a more robust outcomes specification.

Social Impact Bonds are considered a highly marketised form of public service delivery and are understood to “work” through the introduction of new capital into payment-by-results contracts. This paper, for the first time, connects findings from UK SIBs to the evaluation of conventional payment-by-results contracts and the theoretical literature on governance and accountabilities. Markets and capital emerge as a potential red herring with hybridity of governance and the “social” positioned as important dimensions facilitating qualitatively different services. This raises questions as to whether it is possible to extend SIBs, or whether increased scale and mainstream investors will dilute the “SIB effect”.

Welfare-to-work services have been a key area of experimentation in quasi-marketised public service delivery. This chapter develops and extends a conceptual framework for unpacking variation in the formulation of quasi-markets and finds that there are important differences in the type of market adopted by two British employment support schemes: Work Programme and Work Choice. A novel quasi-experimental analysis is then used to investigate the implications of the alternate market formulations for those with health conditions and disabilities, by comparing the employment and earning outcomes for a matched group of participants on the two schemes. The findings suggest that the promises of innovation and performance improvement allied to the provider-directed Work Programme are not met. Employment and earnings outcomes are significantly and sizeably lower for the Work Programme than for Work Choice. The hybrid market position of Work Choice – which leans towards a provider-directed arrangement but retains important levers for both the state- and user- preferences – emerges as an important mediator of programme participant experiences.

Access the CPD MCQs for this issue online here ### Key points Epilepsy is a disorder of the brain characterized by a predisposition to generate abnormal synchronous neuronal activity. This results in recurrent and unpredictable interruptions of normal brain function, observed clinically as epileptic seizures.1 Epilepsy is common; 50 million people worldwide are affected and the estimated prevalence of active epilepsy [continuing seizures or the need for antiepileptic drug (AED) treatment] is 4–10 per 1000 people.2 Within the UK, ∼600 000 people have a diagnosis of epilepsy and take antiepileptic medication.3 All anaesthetists will regularly encounter patients with epilepsy in their practice and should be aware of the special considerations when managing patients with this disorder. Planned and thoughtful care of these patients can minimize the risk of seizure occurrence in the perioperative period. ### Diagnosis of epilepsy Epilepsy is conventionally diagnosed after two unprovoked seizures occurring at least 24 h apart. This reflects the fact that after two non-febrile seizures, more than 70% of people will have another seizure within 4 yr,4 whereas only 40–50% of people will go on to develop epilepsy after a single unprovoked seizure.5 The diagnosis of epilepsy depends on a convincing history, witnessed seizures, or both in combination with investigations including …

A wide range of user groups from policy makers to media commentators demand ever more spatially detailed information yet the desired data are often not available at fine spatial scales. Increasingly, small area estimation (SAE) techniques are called upon to fill in these informational gaps by downscaling survey outcome variables of interest based on the relationships seen with key covariate data. In the process SAE techniques both rely extensively on small area Census data to enable their estimation and offer potential future substitute data sources in the event of Census data becoming unavailable. Whilst statistical approaches to SAE routinely incorporate intervals of uncertainty around central point estimates in order to indicate their likely accuracy, the continued absence of such intervals from spatial microsimulation SAE approaches severely limits their utility and arguably represents their key methodological weakness. The present article presents an innovative approach to resolving this key methodological gap based on the estimation of variance of the between-area error term from a multilevel regression specification of the constraint selection for iterative proportional fitting (IPF). The performance of the estimated credible intervals are validated against known Census data at the target small area and show an extremely high level of performance. As well as offering an innovative solution to this long-standing methodological problem, it is hoped more broadly that the research will stimulate the spatial microsimulation community to adopt and build on these foundations so that we can collectively move to a position where intervals of uncertainty are delivered routinely around spatial microsimulation small area point estimates.

Waves of successive Devolution Deals are transforming England’s landscape of spatial governance and transferring new powers to city-regions, facilitating fundamental qualitative policy reconfigurations and opening up new opportunities as well as new risks for citizens and local areas. Focused on city-region’s recently emerging roles around employment support policies the article advances in four ways what are currently conceptually and geographically underdeveloped literatures on employment support accountability levers. Firstly, the paper dissects weaknesses in the accountability framework of Great Britain’s key national contracted-out employment support programme and identifies the potential for city-regions to respond to these weaknesses. Secondly, the article highlights the centrality of the nationally neglected network accountability lever in supporting these unemployed individuals and advances this discussion further by introducing to the literature for the first time a conceptual distinction between what we term ‘positive’ and ‘negative’ forms of these accountably levers that currently remain homogenised within the literature. Crucially, the argument sets out for the first time in the literature why analytically it is the positive version of network accountability that is the key – and currently missing at national-level – ingredient to the design of effective employment support for the priority group of ‘harder-to-help’ unemployed people who have more complex and/or severe barriers to employment. Thirdly, the paper argues from a geographical perspective that it is city-regions that are uniquely positioned in the English context to create the type of positively networked integrated employment support ‘ecosystem’ that ‘harder-to-help’ individuals in particular require. Finally, the discussion situates these city-region schemes within their broader socio-economic and political context and connects with broader debates around the lurching development of neoliberalism. In doing so it argues that whilst these emerging city-region ecosystem models offer much progressive potential their relationship to the problematic neoliberal employment support paradigm remains uncertain given that they refine, embed and indeed buttress that same neoliberal employment policy paradigm rather than fundamentally challenging or stepping beyond it.

Long-term and well-managed marine protected areas (MPAs) can, under the right circumstances, contribute to biodiversity conservation and fisheries management, thus contributing to food security and sustainable livelihoods. This article emphasizes (1) the potential utility of MPAs as a fisheries management tool, (2) the costs and benefits of MPAs for fishing communities, and (3) the foundations of good governance and management processes for creating effective MPAs with a dual fisheries and conservation mandate. This article highlights case studies from numerous regions of the world that demonstrate practical and often successful solutions in bridging the divide between MPA management and fisheries sustainability, with a focus on small-scale coastal fisheries in order to emphasize lessons learned. To be an effective fisheries management tool, MPAs should be embedded in broader fisheries management and conservation plans. MPAs are unlikely to generate benefits if implemented in isolation. The spatial and temporal distribution of benefits and costs needs to be taken into account since proximal fishery-dependent communities may experience higher fishing costs over the short and long-term while the fisheries benefits from MPAs may only accrue over the long-term. Key lessons for effectively bridging the divide between biodiversity conservation and fisheries sustainability goals in the context of MPAs include: creating spaces and processes for engagement, incorporating fisheries in MPA design and MPAs into fisheries management, engaging fishers in management, recognizing rights and tenure, coordinating between agencies and clarifying roles, combining no-take-areas with other fisheries management actions, addressing the balance of costs and benefits to fishers, making a long-term commitment, creating a collaborative network of stakeholders, taking multiple pressures into account, managing adaptively, recognizing and addressing trade-offs, and matching good governance with effective management and enforcement. © 2014 The Authors. Aquatic Conservation: Marine and Freshwater Ecosystems published by John Wiley & Sons, Ltd.

The past 15 years have seen considerable change in how welfare-to-work provision (WTW) is organised and delivered across the advanced economies with a consistent trend towards new public management (NPM) principles of contractualism, managerialism and marketisation. The financial crisis of 2008, and ensuing economic downturn, has done nothing to move European policies leftwards and the drift towards these neoliberal inspired WTW arrangements is as strong as ever. The aim of this article is to focus on the governmentalities of these new WTW regimes and to raise provocations for WTW analysts around underlying discourses, framings and power relations within these reforms. Taking the UK Coalition government's WTW programme as its empirical focus, the article emphasises the analytical relevance and leverage of the recent US-focused literature on neoliberal paternalism as well as Foucault's governmentalities framework. In doing so the discussion highlights the need to recognise the discursive and symbolic proje...

Ventilation-associated pneumonia (VAP) is the commonest nosocomial infection in intensive care. Implementation of a VAP prevention care bundle is a proven method to reduce its incidence. The UK care bundle recommends maintenance of the tracheal tube cuff pressure at 20 to 30 cmH₂O with 4-hourly pressure checks and use of tracheal tubes with subglottic aspiration ports in patients admitted for more than 72 h.To evaluate the effects of tracheal tube type and cuff pressure monitoring technique on leakage of subglottic secretions past the tracheal tube cuff.Bench-top study.Laboratory.A model adult trachea with simulated subglottic secretions was intubated with a tracheal tube with the cuff inflated to 25 cmH₂O. Experiments were conducted using a Portex Profile Soft Seal tracheal tube with three cuff pressure monitoring strategies and using a Portex SACETT tracheal tube with intermittent cuff pressure checks.Rate of simulated secretion leakage past the tracheal tube cuff.Mean ± SD leakage of fluid past the Profile Soft Seal tracheal tube cuff was 2.25 ± 1.49 ml min⁻¹ with no monitoring of cuff pressure, 2.98 ± 1.63 ml min⁻¹ with intermittent cuff pressure monitoring and 3.83 ± 2.17 ml min⁻¹ with continuous cuff pressure monitoring (P 0.001). Using a SACETT tracheal tube with a subglottic aspiration port and aspirating the simulated secretions prior to intermittent cuff pressure checks reduced the leakage rate to 0.50 ± 0.48 ml min⁻¹ (P 0.001).Subglottic secretions leaked past the tracheal tube cuff with all tube types and cuff pressure monitoring strategies in this model. Significantly higher rates were observed with continuous cuff pressure monitoring and significantly lower rates were observed when using a tracheal tube with a subglottic aspiration port. Further evaluation of medical device performance is needed in order to design more effective VAP prevention strategies.

Chumbe Island Coral Park Ltd (CHICOP), established in 1991 as the first managed marine park in Tanzania, has become an international test case for sustainable private marine conservation funded by ecotourism. The experiences, problems and achievements of CHICOP are described, in particular drivers and incentives for committed on-site MPA management in the legal and institutional environment of Zanzibar. The employment of local fishers as park rangers proved cost-effective and facilitated partnership with local fishing communities, as did Environmental Education (EE) programs for local schools and communities. Risks for private investors remain high though due to limited long-term security of tenure of leases and contracts.

Traumatic brain injuries result in significant morbidity and mortality. Accurate prediction of prognosis is desirable to inform treatment decisions and counsel family members. Objective To review the currently available prognostic tools for use in traumatic brain injury (TBI), to analyse their value in individual patient management and to appraise ongoing research on prognostic modelling.We present two patients who sustained a TBI in 2011-2012 and evaluate whether prognostic models could accurately predict their outcome. The methodology and validity of current prognostic models are analysed and current research that might contribute to improved individual patient prognostication is evaluated.Predicting prognosis in the acute phase after TBI is complex and existing prognostic models are not suitable for use at the individual patient level. Data derived from these models should only be used as an adjunct to clinical judgement and should not be used to set limits for acute care interventions. Information from neuroimaging, physiological monitoring and analysis of biomarkers or genetic polymorphisms may be used in the future to improve accuracy of individual patient prognostication. Clinicians should consider offering full supportive treatment to patients in the early phase after injury whilst the outcome is unclear.

INTRODUCTION: Traumatic brain injury (TBI) is a major cause of death and disability worldwide. Improved understanding of the impact of head injury and the extent and development of neuronal loss and cognitive dysfunction could lead to improved therapy and outcome for patients. AREAS COVERED: This paper reviews the currently available imaging techniques and defines their role in the diagnosis, management and prediction of outcome following traumatic brain injury. These imaging techniques provide delineation of the structural, physiological and functional derangements that result following acute injury, and map their development and association with late functional deficits. Imaging tools also have a role in defining the pathophysiological mechanisms responsible for further neuronal loss following the primary injury. Finally, this paper provides an overview of the role of functional imaging in classifying unresponsive coma and defining functional reorganisation of the brain following injury. EXPERT OPINION: Brain imaging is of key importance in TBI management, enabling efficient and accurate diagnoses to be made, informing management decisions and contributing to prognostication. Developments in imaging techniques promise to improve understanding of the structural and functional derangements, improve management and guide the development and implementation of novel neuroprotective strategies following head injury.

In response to the ‘hollowing out’ of government in the US and UK, there has been a prolonged but inconclusive period of attention paid by public administration researchers on ‘what works’ when gov...

N-acetylaspartate (NAA) is an amino acid derivative primarily located in the neurons of the adult brain. The function of NAA is incompletely understood. Decrease in brain tissue NAA is presently considered symptomatic and a potential biomarker of acute and chronic neuropathological conditions. The aim of this study was to use microdialysis to investigate the behavior of extracellular NAA (eNAA) levels after traumatic brain injury (TBI). Sampling for this study was performed using cerebral microdialysis catheters (M Dialysis 71) perfused at 0.3 μL/min. Extracellular NAA was measured in microdialysates by high-performance liquid chromatography in 30 patients with severe TBI and for comparison, in radiographically “normal” areas of brain in six non-TBI neurosurgical patients. We established a detailed temporal eNAA profile in eight of the severe TBI patients. Microdialysate concentrations of glucose, lactate, pyruvate, glutamate, and glycerol were measured on an ISCUS clinical microdialysis analyzer. Here, we show that the temporal profile of microdialysate eNAA was characterized by highest levels in the earliest time-points post-injury, followed by a steady decline; beyond 70 h post-injury, average levels were 40% lower than those measured in non-TBI patients. There was a significant inverse correlation between concentrations of eNAA and pyruvate; eNAA showed significant positive correlations with glycerol and the lactate/pyruvate (L/P) ratio measured in microdialysates. The results of this on-going study suggest that changes in eNAA after TBI relate to the release of intracellular components, possibly due to neuronal death or injury, as well as to adverse brain energy metabolism.

Developmental dyslexia is a disability of literacy skill that has also been associated with sensory processing deficits, primarily for the detection of dynamic auditory and visual stimuli. Here we examined whether analogous deficits extend into the domain of somatosensory perception. Detection thresholds for each of three frequencies of vibration were obtained for 11 readers with a prior history of dyslexia and 14 similarly aged adult controls. The poor readers were significantly less sensitive to vibration at 3 Hz (P

The circulation of fluid in a basin containing several topographic barriers is considered. Meridional barriers situated east of another barrier “shadow” the western barrier with respect to Rossby wave propagation. The steady circulation responds by reducing the flow through the gaps in the western barrier. As a consequence, the nature of the recirculation zone described in Pedlosky et al. is strongly affected by the shadowing topography. Generally, the effect of the shadowing topography is to enhance and enlarge the zone of recirculation. It is shown that the effectiveness of the shadow depends on whether the eastern barrier is a peninsula or internal “island.” In the latter case, the effect of the barrier depends strongly on the relative meridional extents of the two topographic features. In all cases, the peninsula is by far the most effective shadowing barrier in reducing the flow around the western barrier. Both analytical and laboratory models of the circulation are described. In the former ...

The aim of these studies was to provide reference data on intersubject variability and reproducibility of diffusion tensor imaging. Healthy volunteers underwent imaging on two occasions using the same 3T Siemens Verio magnetic resonance scanner. At each session two identical diffusion tensor sequences were obtained along with standard structural imaging. Fractional anisotropy, apparent diffusion coefficient, axial and radial diffusivity maps were created and regions of interest applied in normalised space. The baseline data from all 26 volunteers were used to calculate the intersubject variability, while within session and between session reproducibility were calculated from all the available data. The reproducibility of measurements were used to calculate the overall and within session 95% prediction interval for zero change. The within and between session reproducibility data were lower than the values for intersubject variability, and were different across the brain. The regional mean (range) coefficient of variation figures for within session reproducibility were 2.1 (0.9–5.5%), 1.2 (0.4–3.9%), 1.2 (0.4–3.8%) and 1.8 (0.4–4.3%) for fractional anisotropy, apparent diffusion coefficient, axial and radial diffusivity, and were lower than between session reproducibility measurements (2.4 (1.1–5.9%), 1.9 (0.7–5.7%), 1.7 (0.7–4.7%) and 2.4 (0.9–5.8%); p

What you need to know Routine preoperative investigations are expensive, labour intensive, and of questionable value, especially as they may contribute to morbidity or cause additional delays due to spurious results.1 2 3 4 5 Preoperative assessment clinics are usually based in the hospital where surgery will occur and are run according to local policies and procedures. The number of elective surgeries within the NHS has risen: 10.6 million operations took place in 2012-13 compared with 6.61 million in 2002-03. Even if only a small percentage of tests are unnecessary, large numbers of patients will be affected. Elective surgeries are those scheduled in advance and excludes medical emergencies. The guidance covers patients over 16 years old. It includes healthy people and those who have one or more of the following comorbidities—cardiovascular, respiratory, renal, diabetes, and obesity—who are having minor, intermediate, or major or complex elective surgery (box 1). Individuals are classified by the severity of disease using the American Society of Anesthesiologists (ASA) classification system (box 2), and extent of surgery to guide testing. #### Box 1: Surgery grades and examples ##### Minor ##### Intermediate ##### Major or complex

Importance Combined oxygen 15–labeled positron emission tomography ( 15 O PET) and brain tissue oximetry have demonstrated increased oxygen diffusion gradients in hypoxic regions after traumatic brain injury (TBI). These data are consistent with microvascular ischemia and are supported by pathologic studies showing widespread microvascular collapse, perivascular edema, and microthrombosis associated with selective neuronal loss. Fluorine 18–labeled fluoromisonidazole ([ 18 F]FMISO), a PET tracer that undergoes irreversible selective bioreduction within hypoxic cells, could confirm these findings. Objective To combine [ 18 F]FMISO and 15 O PET to demonstrate the relative burden, distribution, and physiologic signatures of conventional macrovascular and microvascular ischemia in early TBI. Design, Setting, and Participants This case-control study included 10 patients who underwent [ 18 F]FMISO and 15 O PET within 1 to 8 days of severe or moderate TBI. Two cohorts of 10 healthy volunteers underwent [ 18 F]FMISO or 15 O PET. The study was performed at the Wolfson Brain Imaging Centre of Addenbrooke’s Hospital. Cerebral blood flow, cerebral blood volume, cerebral oxygen metabolism (CMRO 2 ), oxygen extraction fraction, and brain tissue oximetry were measured in patients during [ 18 F]FMISO and 15 O PET imaging. Similar data were obtained from control cohorts. Data were collected from November 23, 2007, to May 22, 2012, and analyzed from December 3, 2012, to January 6, 2016. Main Outcomes and Measures Estimated ischemic brain volume (IBV) and hypoxic brain volume (HBV) and a comparison of their spatial distribution and physiologic signatures. Results The 10 patients with TBI (9 men and 1 woman) had a median age of 59 (range, 30-68) years; the 2 control cohorts (8 men and 2 women each) had median ages of 53 (range, 41-76) and 45 (range, 29-59) years. Compared with controls, patients with TBI had a higher median IBV (56 [range, 9-281] vs 1 [range, 0-11] mL; P P = .02). Although both pathophysiologic tissue classes were present within injured and normal appearing brains, their spatial distributions were poorly matched. When compared with tissue within the IBV compartment, the HBV compartment showed similar median cerebral blood flow (17 [range, 11-40] vs 14 [range, 6-22] mL/100 mL/min), cerebral blood volume (2.4 [range, 1.6- 4.2] vs 3.9 [range, 3.4-4.8] mL/100 mL), and CMRO 2 (44 [range, 27-67] vs 71 [range, 34-88] μmol/100 mL/min) but a lower oxygen extraction fraction (38% [range, 29%-50%] vs 89% [range, 75%-100%]; P 2 values consistent with irreversible injury. Comparison with brain tissue oximetry monitoring suggested that the threshold for increased [ 18 F]FMISO trapping is probably 15 mm Hg or lower. Conclusions and Relevance Tissue hypoxia after TBI is not confined to regions with structural abnormality and can occur in the absence of conventional macrovascular ischemia. This physiologic signature is consistent with microvascular ischemia and is a target for novel neuroprotective strategies.

In response to the 2013 ISH-CSF task force review on comorbidities in NPH we assessed 73 patients who were diagnosed with NPH and underwent shunt surgery at our tertiary neurosurgical unit between August 2008 and August 2012.

This study aimed to estimate the incidence of hospital transmission of influenza A subtype H1N1 [A(H1N1)], to identify high-risk areas for such transmission and to evaluate common characteristics of affected patients. In this single-centre retrospective cohort study, 10 patients met the criteria for hospital-acquired A(H1N1) infection over a three-month period. All affected patients required an escalation of their care and the mortality rate was 20%. Clinicians should be aware of the risk of nosocomial A(H1N1) infection that exists despite routine infection control measures and should consider additional control measures including vaccination of hospital inpatients and healthcare staff.