An in-depth characterisation of neonatal seizures by early continuous video-EEG analysis

Introduction Seizures are harmful to the neonatal brain; this compels many clinicians and researchers to persevere further in optimizing every aspects of managing neonatal seizures. Aims To delineate the seizure profile between non-cooled versus cooled neonates with hypoxic-ischaemic encephalopathy (HIE), in neonates with stroke, the response of seizure burden to phenobarbitone and to quantify the degree of electroclinical dissociation (ECD) of seizures. Methods The multichannel video-EEG was used in this research study as the gold standard to detect seizures, allowing accurate quantification of seizure burden to be ascertained in term neonates. The entire EEG recording for each neonate was independently reviewed by at least 1 experienced neurophysiologist. Data were expressed in medians and interquartile ranges. Linear mixed models results were presented as mean (95% confidence interval); p values <0.05 were deemed as significant. Results Seizure burden in cooled neonates was lower than in non-cooled neonates [60(39-224) vs 203(141-406) minutes; p=0.027]. Seizure burden was reduced in cooled neonates with moderate HIE [49(26-89) vs 162(97-262) minutes; p=0.020] when compared with severe HIE. In neonates with stroke, the background pattern showed suppression over the infarcted side and seizures demonstrated a characteristic pattern. Compared with 10 mg/kg, phenobarbitone doses at 20 mg/kg reduced seizure burden (p=0.004). Seizure burden was reduced within 1 hour of phenobarbitone administration [mean (95% confidence interval): -14(-20 to -8) minutes/hour; p<0.001], but seizures returned to pre-treatment levels within 4 hours (p=0.064). The ECD index in cooled, non-cooled neonates with HIE, stroke and in neonates with other diagnoses were 88%, 94%, 64% and 75% respectively. Conclusions Further research exploring the treatment effects on seizure burden in the neonatal brain is required. A change to our current treatment strategy is warranted as we continue to strive for more effective seizure control, anchored with use of the multichannel EEG as the surveillance tool.

Leadership in the community sector: promoting collaboration and social change in Belfast

Community development is centrally concerned with people in communities working together to achieve a common goal, that is, to collaborate, whether within local geographical communities, in communities of shared interests or among groups sharing a common identity. Its overarching goal is one of progressive transformational social change. As Belfast transitions from a conflict to a post-conflict society, there is a need for greater, more effective work at local community level in order to address a range of ongoing social and economic issues facing communities, including high levels of disadvantage and division. Given the significance of leadership in building effective collaboration and the centrality of collaboration for community development, it is important to understand how leadership is currently enacted and what kinds of leadership are required to support communities to collaborate effectively to bring about social change. This thesis thus centers on the kind of leadership practised and required to support collaboration for social change within the community sector in Belfast, a city that contains an estimated 28% of the total number of community and voluntary sector (CVS) organisations in Northern Ireland (Northern Ireland Council for Voluntary Action, 2012). Through a series of qualitative, in-depth interviews with people playing leadership roles in local communities, the study critically explores and analyses their experiences and perceptions in relation to leadership and collaboration. Community development in Belfast today is practised within a wider context of neoliberal policies, characterised by austerity and public spending cuts. Whilst not the only influencing factor, this context has had a particular and profound impact on the nature and role of community development practised, and on the kind of leadership enacted within it. The space for reflection and transformative action appears to be shrinking as the contraction of resources to support community development in local communities continues unabated. Those playing leadership roles increasingly find themselves compelled to spend time seeking resources and managing complex funding arrangements rather than focusing on the social change dimensions of their work. Collaboration as promoted by the state seems to have become an instrumental tactic used to implement its austerity measures and curtail the potential of the community sector. Despite this, local leaders are driving initiatives that attempt to push back, helping the sector refocus on its transformational goals of social change. To do this requires support. Those playing leadership roles require resources, including time, to encourage and enable communities to reconnect with the purpose and underpinning values of community development. Leaders also need support to develop and promote new, progressive narratives and visions and pursue these through building collaboration and solidarity.

The spiritual and professional impact of stillbirth

Stillbirth is without question one of the most devastating experiences of grief for parents and families. The death of a baby is also a distressing experience for healthcare professionals who share hopes of a live healthy baby at the end of pregnancy. It is a sad reality however, that in Ireland one in 238 babies will die before birth. The creation and nurture of new life in pregnancy is a spiritual experience as a new baby is at the same time experienced and anticipated. There is little in the published literature concerning the spiritual impact of stillbirth on healthcare chaplains who are the main providers of spiritual care for parents and staff colleagues in Irish maternity units. In addition there are few qualitative studies that explore the impact of stillbirth on consultant obstetricians and no published studies on the spiritual impact of stillbirth on bereaved parents. This study explored the spiritual and professional impact of stillbirth on Irish maternity healthcare chaplains, consultant obstetricians and bereaved parents. Following an overall review of spiritual care provision following stillbirth in the Irish maternity services, thematic analysis was used in the first phase of the study following in-depth interviews with maternity healthcare chaplains. Interpretative Phenomenological Analysis was used in the second and third phases with consultant obstetricians and bereaved parents respectively. The data from both maternity healthcare chaplains and consultant obstetricians revealed that stillbirth posed immense personal, spiritual and professional challenges. Chaplains expressed the spiritual and professional impact of stillbirth in terms of perception of their role, suffering, doubt and presence as they provided care for bereaved parents. A review of spiritual care provision in the Irish maternity services revealed a diversity of practice. The data from consultant obstetricians identified considerable personal, professional and spiritual impact following stillbirth that was identified in superordinate themes of human response to stillbirth, weight of professional responsibility, conflict of personal faith and incongruence between personal faith and professional practice. Data from bereaved parents revealed that stillbirth was spiritually challenging and all parents expressed that stillbirth posed considerable challenge to their faith/ belief structure. The parents of only three babies felt that their spiritual needs were adequately addressed while in hospital. The data had six superordinate themes of searching for meaning, maintaining hope, importance of personhood, protective care, questioning core beliefs and relationships. Other findings from the data from bereaved parents outlined the importance of environment of care and communication. This study has revealed the immense impact of stillbirth on healthcare chaplains, consultant obstetricians and most especially the spiritual impact for bereaved parents. Recommendations are made for improvements in clinical and spiritual care for bereaved parents following stillbirth and for staff wellbeing and support initiatives. Further research areas are recommended in the areas of spiritual care, theological reflection, bereavement care, post-mortem consent procedures and staff wellbeing.