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  1. I Bone,
  2. G N Fuller
  1. Dr GN Fuller, Department of Neurology, Gloucester Royal Hospital, Great Western Road, Gloucester GL1 3NN, UK geraint{at}

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Patients with sleepiness may be referred to neurology outpatients for assessment, yet most neurologists have limited training in this area. There are an increasing number of interventions to help these patients. Neil Douglas, professor of respiratory medicine with a particular interest in sleep, outlines the approach to the sleepy patient in the first article of this issue.

In in-patient practice, few problems are more difficult to assess and manage than the patient with an altered mental state. Such patients are often seen in the intensive care unit with great expectation placed upon the neurologist to “sort out what is going on” or what to expect. Many of these patients have general medical problems so neurologists must consider the possibility of metabolic, infective, or drug induced disorders and not focus solely on the nervous system. A team approach to such patients is imperative in maximising chances of good outcome. We have aimed here in the next three articles, respectively from David Batemen, Niall Cartlidge, and David Bates, to introduce the trainee to the logical approaches of assessment, evaluating coma-like states, and defining prognosis. In addition a reanalysis of a classical paper may help in defining prognosis using some newer statistical methods.

The patient referred with confusion is difficult to assess. Michael Johnson explores how to recognise the syndrome of delirium, its differential diagnosis and management.

Coma and the vegetative state raise ethical and legal issues, the latter being of practical concern to neurologists. Professor Sheila McLean provides a legal perspective of the current thinking about persistent vegetative state as well as providing insights into how the legal system approaches the issue.


There is a relatively small practically applicable literature relating to coma, its management and prognosis and this is referred to in the articles that follow. Here we include a few other references of particular value.

Vegetative state


  • The diving bell and the butterfly. Bauby J-D. London: Fourth Estate, 1998.

This short and moving book describes the experience of someone in the locked-in state.

  • The permanent vegetative state: practical guidance on diagnosis and management. Wade DT, Johnston C. BMJ 1999;319:841–4.

A concise practical guide to diagnosis and management.

Legal and ethical

  • Ethical issues in diagnosis and management of permanent vegetative state. Wade DT. BMJ 2001;322:352–4.

Discusses diagnosis and ethical issues from a medical perspective.

  • Legal and ethical aspects of the vegetative state. McLean SAM. J Clin Path 1999;52:490–3.

A plea to review all end of life decisions so doctors, patients, and relatives can make honest decisions without fear of legal reprisal.

  • Neuropathology in vegetative and severely disabled patients after head injury. Jennett B, Adams JH, Murray LS, et al. Neurology 2001;56:486–90.

The clinician who originally described the vegetative state compares the neuropathology of patients with severe disability with that of permanent vegetative state (PVS).

  • Practice parameters: assessment and management of patients in the persistent vegetative state. American Academy of Neurology. Neurology 1995;45:1015–8.

The official AAN practice statements on PVS can be obtained from

Brain stem death


  • A code of practice for the diagnosis of brain stem death, including guidelines for the identification and management of potential organ and tissue donors. Department of Health. Available free from: PO Box 410, Wetherby, West Yorks, LS23 7LN.

Current official advice on the diagnosis of brain stem death.


  • Discontinuation of ventilation after brain stem death. Swinburn JMA, Ali SM, Banerjee DJ, et al. BMJ 1999; 318:1753–6.

  • Brain death—well settled yet still unresolved. Capron AM. N Engl J Med 2001;344:1244–6.

Two recent articles that discuss some of the ethical issues surrounding brain stem death.


This is a useful source of guidelines on all subjects. American Sleep Association practice guidelines are available from this site

Useful web resource on many aspects of sleep, for patients and professionals, provided by NIH.

Confusion and delirium

  • Delirium: acute confusional states. Lipowski ZJ. New York: Oxford University Press, 1990.

An excellent and readable monograph that is now a little out of date.

Guidelines prepared by psychiatrists for the management of delirium as defined in DSM-IV. In addition this provides an overview of the condition from a psychiatric viewpoint with suggestions for the management of most aspects of delirium.

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