Effectiveness and cost-effectiveness of a brief school-based group programme for parents of children at risk of ADHD: a cluster randomised controlled trial

BACKGROUND

National Institute for Health and Care Excellence guidelines recommend a stepped care approach for the identification and management of children with, or at risk of, attention-deficit/hyperactivity disorder (ADHD). We investigated the effectiveness, cost-effectiveness and acceptability of a group parenting intervention programme (+/- a teacher session) for children at risk of ADHD.

METHODS

In a three-arm cluster randomised controlled trial, 12 primary schools were randomly assigned to control, parent-only and combined (parent + teacher) intervention arms. Eligible children had high levels of parent-rated hyperactivity/inattention (n = 199). At 6 month follow-up, the primary outcome measure was the parent-completed Conners' Rating Scale - Revised (ADHD index). Secondary outcomes included the Conners' sub-scales (hyperactivity, cognitive problems/inattention and oppositional behaviour), the teacher-completed Conners' Rating Scale - Revised, child health-related quality of life, parental burden and parental mental health. The cost-effectiveness analyses reflected a health and personal social services perspective.

TRIAL REGISTRATION

ISRCTN87634685.

RESULTS

Follow-up data were obtained from 76 parents and 169 teachers. There was no effect of the parent-only (mean difference = -1.1, 95% CI -5.1,2.9; p = 0.57) or combined interventions (mean difference = -2.1, 95% CI -6.4,2.1; p = 0.31) on the ADHD index. The combined intervention was associated with reduced parent-reported hyperactivity symptoms (mean difference = -5.3; 95% CI -10.5,-0.01; p = 0.05) and the parent-only intervention with improved parental mental health (mean difference = -1.9; 95% CI -3.2,-0.5; p = 0.009). The incremental costs of the parent-only and the combined interventions were £73 and £123, respectively. Above a willingness-to-pay of £31 per one-point improvement in the ADHD index, the parent-only programme had the highest probability of cost-effectiveness. Participants found the interventions acceptable.

CONCLUSIONS

For children at risk of ADHD, this school-based parenting programme was not associated with improvement in core ADHD symptoms. Secondary analyses suggested a possible reduction in parent-reported hyperactivity and parental mental health problems. Future research should compare targeted interventions against watchful waiting and specialist referral.

Current Evidence for the Use of Laminar Flow in Reducing Infection Rates in Total Joint Arthroplasty

Since the introduction of laminar air flow in orthopaedic theatres by Sir John Charnley, it has widely become accepted as the standard during orthopaedic procedures such as joint arthroplasty. We present a review of available current literature for the use of laminar flow operating theatre ventilation during total joint arthroplasty and examines the effectiveness of laminar flow ventilated operating theatres in preventing post-operative wound infection. Results of our findings suggest that while bacterial and air particulate is reduced by laminar air flow systems, there is no conclusive effect on the reduction of post-operative wound infections following total joint arthroplasty. We conclude that a combination of strict aseptic technique, prophylactic antibiotics and good anaesthetic control during surgery remains crucial to reduce post-operative surgical infections.

Report on the creation of a diabetes register and retinopathy screening outcomes in the Mid-West of Ireland

BACKGROUND

With concerns that blind registration in Ireland due to diabetic retinopathy is continuing to rise, a structured retinopathy screening service is in the process of being rolled out nationally.

AIMS

To report on the validation process for creating a register of diabetics in the Mid-West of Ireland, and findings following retinopathy screening of a representative sample.

METHODS

National primary care databases were employed in generating provisional lists of diabetic patients in the Health Service Executive (HSE) Mid-West area. Subsequent engagement with the corresponding general practices over a three year period between 2010 and 2013 facilitated the validation of these lists. A summary of the retinopathy screening outcomes of 1,434 patients and pre-existing screening patterns is reported.

RESULTS

The number of patients on the Mid-West diabetes register to date is 11,126. Of the 1,434 patients screened, 288 (20.1 %) had background retinopathy, while 117 (8.2 %) had sight-threatening retinopathy. Seventeen (19.8 %) of the 86 patients identified with maculopathy required treatment with intravitreal injections. Of the 610 patients questioned about previous screening events, 389 (63.8 %) said they had undergone an ocular examination within the previous 12 months.

CONCLUSIONS

The HSE Mid-West has over 11,000 patients on its database ready to be screened by the national programme, with the treatment of maculopathy expected to have the largest impact on resources. Although the majority of patients are already undergoing screening in the community in an ad hoc fashion, the rates of sight-threatening retinopathy encountered highlight the timeliness of the full implementation of the national programme.

A quantitative analysis of diabetic retinopathy screening in a regional treatment centre

The aim of the study was to assess the current diabetic retinopathy screening infrastructure and implications on workload for a designated treatment centre following roll-out of a national screening programme. A combination of chart analysis and patient questionnaire was undertaken over a 4-week period in 2011 at Cork University Hospital (CUH). Data were collected on 97 patients and categorized. as demographic, medical, and screening-related. The majority of patients (80; 82.5%} had either no retinopathy or background retinopathy only. One (1.0%) patient was deemed to be ungradable due to dense cataract, while 6 (6.2%) patients had non-diabetic ocular pathology requiring follow-up. Only 11% were screened through retinal photography. In all, 74 (76.3%) patients were deemed suitable for community rather than hospital screening. Digital retinal photography is an underused screening resource Significant numbers of patients could be discharged from hospital-based to community screening to offset the increased workload expected from the national screening programme.

Neurobehavioural changes in a patient with bilateral lesions of the globus pallidus

This study has characterized the long-term neurobehavioural changes in a woman who, following the intake of an unidentified substance, sustained subtotal bilateral lesions of the globus pallidus and small lesions at selective sites adjacent to it. Associated with these lesions was a significantly reduced blood flow in multiple frontal cortical regions, most prominently in area 10, the anterior cingulate and the supplementary motor cortex. Her cognitive deficits were generally consistent with those found in patients with frontal lobe dysfunction but some deficits, i.e. in visual memory and learning, were more compatible with temporal lobe dysfunction. Incapacitating personality or obsessive compulsive changes as reported by others with similar lesions were absent and she could live independently. The cognitive changes are consistent with the view that the globus pallidus has important functions in mediating how internal representations of stimulus input are converted into various forms of action, for example, in planning solutions to problems and in working memory.