REMCARE: reminiscence groups for people with dementia and their family caregivers - effectiveness and cost-effectiveness pragmatic multicentre randomised trial

OBJECTIVES

The aim of the REMiniscence groups for people with dementia and their family CAREgivers (REMCARE) study was to assess the effectiveness and cost-effectiveness of joint reminiscence groups for people with dementia and their family caregivers as compared with usual care.

DESIGN

A multicentre, pragmatic randomised controlled trial with two parallel arms - an intervention group and a usual-care control group - was carried out. A restricted dynamic method of randomisation was used with an overall allocation ratio of 1 : 1, restricted to ensure intervention groups of a viable size. Assessments, blind to treatment allocation, were carried out at baseline, 3 months and 10 months (primary end point).

SETTING

Most participants were recruited through NHS Memory Clinics and Community Mental Health Teams for older people. Assessments were usually carried out in the person's home, and treatment groups were held in a variety of community settings.

PARTICIPANTS

A total of 488 individuals (mean age 77.5 years) with mild to moderate dementia (meeting Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition criteria), who were initially living in the community, and who had a relative or other caregiver maintaining regular contact, who could act as an informant and was willing and able to participate in the intervention, were recruited to the study. Most carers were spouses (71%). A total of 350 dyads completed the study.

INTERVENTIONS

The intervention consisted of joint reminiscence groups held weekly for 12 consecutive weeks, followed by monthly maintenance sessions for a further 7 months. The sessions followed a treatment manual, and were led by two trained facilitators in each centre, supported by a number of volunteers. Up to 12 dyads were invited to attend each group.

MAIN OUTCOME MEASURES

The primary outcome measures were self-reported quality of life for the person with dementia and psychological distress for the carer [General Health Questionnaire-28 item version (GHQ-28)]. Secondary outcome measures included autobiographical memory and activities of daily living for the person with dementia, carer stress for the carer and mood, relationship quality and service use and costs for both parties.

RESULTS

The intention-to-treat analysis identified no differences in outcome between the intervention and control conditions on primary or secondary outcomes [self-reported quality of life in Alzheimer's disease: mean difference 0.07, standard error (SE) 0.65; F = 0.48; p = 0.53]. Carers of people with dementia allocated to the reminiscence intervention reported a significant increase in anxiety on a subscale of the GHQ-28 at the 10-month end point (mean difference 1.25, SE 0.5; F = 8.28; p = 0.04). Compliance analyses suggested some benefits for people with dementia who attended more reminiscence sessions; however, carers attending more groups showed increased caregiving stress. Use of health- and social-care services was modest, with no significant difference in service use between conditions. Owing to negligible difference in quality-adjusted life-year gains (derived from European Quality of Life-5 Dimensions) between the conditions the planned full economic analysis was curtailed.

CONCLUSIONS

This trial does not provide support for the effectiveness or cost-effectiveness of joint reminiscence groups for people with dementia and their carers. Although there may be some beneficial effects for people with dementia who attend sessions as planned, this must be viewed in the context of raised anxiety and stress in their carers. The reasons for these discrepant outcomes need to be explored further, and may necessitate reappraisal of the movement towards joint interventions.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN42430123.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 16, No. 48. See the HTA programme website for further project information.

Strategies for the prevention of erosive tooth surface loss

This article explores the available strategies for protection against erosive toothwear. As part of a preventive regime, the importance of dietary counselling is discussed. Risk factors that render patients susceptible to erosive toothwear need to be identified in early life, if possible, as it may improve their treatment outcome through the instigation of preventive measures. Practical advice and the importance of education regarding timing of toothbrushing following an acid challenge should be given to patients. Availability of fewer erosive beverages may prove acceptable alternatives for some patients, especially where poor compliance is an issue. Some patients may benefit from intra-oral appliances to improve and maintain delivery of fluoride. The importance of fluoride use and of products such as Pronamel/Tooth Mousse aimed at preventing erosive tooth surface loss are discussed.

Can CO2 hydrate assist in the underground storage of carbon dioxide?

The sequestration of CO2 in the deep geosphere is one potential method for reducing anthropogenic emissions to the atmosphere without necessarily incurring a significant change in our energy-producing technologies. Containment of CO2 as a liquid and an associated hydrate phase, under cool conditions, offers an alternative underground storage approach compared with conventional supercritical CO2 storage at higher temperatures. We briefly describe conventional approaches to underground storage, review possible approaches for using CO2 hydrate in CO2 storage generally, and comment on the important role CO2 hydrate could play in underground storage. Cool underground storage appears to offer certain advantages in terms of physical, chemical and mineralogical processes, which may usefully enhance trapping of the stored CO2. This approach also appears to be potentially applicable to large areas of sub-seabed sediments offshore Western Europe.

Are we missing diagnostic opportunities in cases of carcinoid tumours of the appendix?

OBJECTIVE

Carcinoid tumour of appendix is an uncommon condition that can potentially give rise to a variation in management. We aimed to assess the occurrence and mode of presentation of carcinoid tumour of appendix, and any variation of its management.

METHODS

All appendicectomies that took place at North Middlesex University Hospital, London between 1995 and 2005 were considered for study.

RESULTS

A total of 1941 appendicectomies took place. Sixteen (0.82%) patients had carcinoid tumours. The mean age of patients with carcinoid tumour (41.8 years) was significantly higher than those with non-carcinoid pathology (27.7 years) (p = 0.001). The incidence of female patients was higher than the male amongst the carcinoid tumour group (female/male ratio 2.2). None of the carcinoid tumours were identified at operation. Eight patients as well as their general practitioners (53.3%) were unaware of the diagnosis. Multidisciplinary team involvement or specialty referral took place in three cases (20%). One patient (6.6%) required right hemicolectomy. Three patients (20%) were followed-up in inconsistent manner.

CONCLUSIONS

Carcinoid tumour of the appendix remains an incidental diagnosis. Patients with carcinoids were significantly older than non-carcinoid conditions. There was a trend of increased occurrence of carcinoids amongst the females. Re-operation rate was low. There was a wide variation in involving the multidisciplinary team, conveying the diagnosis to patients as well as their general practitioners, and follow-ups. This can be perceived as a missed opportunity of selective screening of synchronous and metachronous lesions, raises clinical governance issues and has medicolegal implications.

Unusual presentation of idiopathic retroperitoneal fibrosis: case report

Idiopathic retroperitoneal fibrosis (IRF) is an uncommon entity described as progressive proliferation of connective tissues leading to a fibrous plaque-like lesions that encases the aorta and inferior vena cava inferior to the level of the renal arteries. Mass forming retroperitoneal fibrosis is rare. We present a rare case of a unilateral focal retroperitoneal mass simulating a tumour encasing the middle third of the left ureter, with involvement of the ipsilateral scrotum.

The development and validation of a patient-reported questionnaire to assess outcomes of elbow surgery

We developed a questionnaire to assess patient-reported outcome after surgery of the elbow from interviews with patients. Initially, 17 possible items with five response options were included. A prospective study of 104 patients (107 elbow operations) was carried out to analyse the underlying factor structure, dimensionality, internal and test-retest reliability, construct validity and responsiveness of the questionnaire items. This was compared with the Mayo Elbow performance score clinical scale, the Disabilities of the Arm, Shoulder and Hand questionnaire, and the Short-Form (SF-36) General Health Survey. In total, five questions were considered inappropriate, which resulted in the final 12-item questionnaire, which has been referred to as the Oxford elbow score. This comprises three unidimensional domains, 'elbow function', 'pain' and 'social-psychological'; with each domain comprising four items with good measurement properties. This new 12-item Oxford elbow score is a valid measure of the outcome of surgery of the elbow.

Inclusion or exclusion of intratumoral vessels in relative cerebral blood volume characterization in low-grade gliomas: does it make a difference?

We assessed the influence of inclusion (method 1) and exclusion (method 2) of intratumoral vessels when determining maximum relative cerebral blood volume (rCBVmax) in 3 types of low-grade gliomas (LGGs): astrocytomas, oligoastrocytomas, and oligodendrogliomas. Method 1 yielded significantly higher mean rCBVmax than method 2. However, only method 2 demonstrated a significant (P = .026) association between rCBVmax and membership of a differently ranked histologic category. Exclusion of intratumoral vessels appears, therefore, preferable when determining rCBVmax in LGGs.

Reassessment of vegetative compatibility of Sclerotinia homoeocarpa using nitrate-nonutilizing mutants

Nitrate-nonutilizing (nit) mutants were recovered for the first time from 21 isolates of Sclerotinia homoeocarpa collected in the United States. Mutants were selected from shredded mycelium of each isolate when cultured on water agar medium amended with 4% (wt/vol) potassium chlorate. The mutants could be classified into three phenotypes: nit1, nit3, and NitM, based on their growth on minimal medium (Czapek solution agar) supplemented with NaNO(2) or hypoxanthine. Complementary heterokaryons were observed in pairings between different phenotypes of nit mutants derived from compatible isolates, but not in self-fusions or pairings between incompatible isolates. The vigor of prototrophic growth varied with isolates and mutant phenotypes. Strong and continuous heterokaryons, as well as weak and spontaneous ones, formed depending on pairings of nit mutants. Stable heterokaryons between compatible isolates, but apoptotic reactions between incompatible isolates, were observed immediately after hyphal fusion under the epifluorescence microscope. The 21 isolates used in this study, which were previously assigned into 11 different vegetative compatibility groups (VCGs) based on the formation of a barrage zone at the contact site of paired isolates on complete medium (potato dextrose agar), were regrouped into five VCGs based on heterokaryon formation between nit mutants on minimal medium.

Sour sweets: a new type of erosive challenge?

OBJECTIVE

To assess the erosive potential of a number of commercially available sour sweets in the laboratory.

METHODS

The erosive potential was assessed by measuring the pH, neutralisable acidity and ability to erode permanent and deciduous enamel. These parameters were compared to those of an orange juice positive control.

RESULTS

The pH of the sour sweets ranged from 2.30-3.14 with their neutralisable acidity ranging from 9.78-66.9 ml of 0.1M NaOH. The amount of permanent enamel removed following one hour immersion in the drinks ranged from 2.16-10.88 microm and from 1.02-18.34 microm for deciduous enamel. In comparison, the orange juice (Tropicana smooth) control had a pH of 3.86, a neutralisable acidity of 37.1 ml of 0.1M NaOH and removed 5.23 microm of permanent enamel and 6.27 microm of deciduous enamel.

CONCLUSION

All the sour sweets tested were found to be erosive, some more so than orange juice. This information will be of use to clinicians when counseling younger patients with tooth surface loss.

Lamotrigine for acute and chronic pain

BACKGROUND

Anticonvulsant medicines have a place in the treatment of neuropathic pain (pain due to nerve damage). This review looks at the evidence for the pain relieving properties of lamotrigine.

OBJECTIVES

To assess the analgesic efficacy and adverse effects of the anticonvulsant lamotrigine for acute and chronic pain.

SEARCH STRATEGY

Randomised Controlled Trials (RCTs) of lamotrigine (and key brand names Lamictal, Lamictin, Neurium) in acute, chronic or cancer pain were identified from MEDLINE (1966 to August 2006), EMBASE 1994 to August 2006 and the CENTRAL register on The Cochrane Library (Issue 3, 2006). Additional reports were sought from the reference list of the retrieved papers.

SELECTION CRITERIA

RCTs investigating the use of lamotrigine (any dose and by any route) for treatment of acute or chronic pain. Assessment of pain intensity or pain relief, or both, using validated scales. Participants were adults aged 18 and over. Only full journal publication articles were included.

DATA COLLECTION AND ANALYSIS

Dichotomous data were used to calculate relative risk with 95% confidence intervals using a fixed effects model unless significant statistical heterogeneity was found. Continuous data was also reported where available. Meta-analysis was undertaken using a fixed effect model unless significant heterogeneity was present (I(2) >50%) in which case a random effects model was used. Numbers-needed-to-treat (NNTs) were calculated as the reciprocal of the absolute risk reduction. For unwanted effects, the NNT becomes the number-needed-to-harm (NNH) and was calculated.

MAIN RESULTS

Sixteen studies were identified. Nine studies were excluded. No studies for acute pain were identified. The seven included studies involved 502 participants, all for neuropathic pain. The studies covered the following conditions: central post stroke pain (1), diabetic neuropathy (1), HIV related neuropathy (2), intractable neuropathic pain (1), spinal cord injury related pain (1) and trigeminal neuralgia (1). The studies included participants in the age range of 26 to 77 years. Only one study for HIV related neuropathy had a statistically significant result for a sub group of patients on anti-retroviral therapy; this result is unlikely to be clinically significant NNT 4.3 (95% CI 2.3 to 37). Approximately 7% of participants taking lamotrigine reported a skin rash.

AUTHORS' CONCLUSIONS

Given the availability of more effective treatments including anticonvulsants and antidepressant medicines, lamotrigine does not have a significant place in therapy at present. The limited evidence currently available suggests that lamotrigine is unlikely to be of benefit for the treatment of neuropathic pain.