Reduced penetrance alleles for Huntington's disease: a multi-centre direct observational study

OBJECTIVE

To obtain penetrance data for Huntington's disease when DNA results are in the range of 36-39 CAG repeats and assess the consistency of reporting the upper allele from two reference centres.

METHOD

Data were collected anonymously on age of onset or age last known to be unaffected from a cohort of individuals with results in this range. DNA samples were re-analysed in two reference centres. Kaplan-Meier analysis was used to construct an age of onset curve and penetrance figures.

RESULTS

Clinical data and concordant DNA results from both reference centres were available for 176 samples; penetrance figures (and 95% confidence intervals) for this cohort, at age 65 and 75 years, were 63.9% (55.5% to 73.2%) and 74.2% (64.2% to 84.2%), respectively. Inclusion of 28 additional subjects for whom repeat DNA results were unavailable, obtained from only one reference centre, or discrepant by one repeat within this range, gave penetrance data (including 95% confidence intervals) at ages 65 and 75 years of 62.4% (54.4% to 70.4%) and 72.7.% (63.3% to 82.1%), respectively. 238 duplicate results were available from the reference centres; 10 (4.2%) differed by one CAG repeat in the reporting of the upper allele and in two (0.84%) of these cases the discrepancy was between 39 and 40 repeats.

CONCLUSION

When DNA results are in this range, a conservative approach is to say that there is at least a 40% chance the person will be asymptomatic at age 65 years and at least a 30% chance the person will be asymptomatic at age 75 years.

Oral or topical nasal steroids for hearing loss associated with otitis media with effusion in children

BACKGROUND

Otitis media with effusion (OME) is common and may cause hearing loss with associated developmental delay. Treatment remains controversial.

OBJECTIVES

To examine evidence for or against treating children with hearing loss associated with OME with systemic or topical intranasal steroids.

SEARCH STRATEGY

We searched the Cochrane Ear, Nose and Throat Disorders Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library Issue 4 2005, MEDLINE (1966 to 2006), EMBASE (1974 to 2006), and the CINAHL, LILACS, Zetoc, IndMED, SAMED, KoreaMed, MEDCARIB and Cambridge Scientific Abstracts databases in January 2006.

SELECTION CRITERIA

Randomised controlled trials of oral and topical intranasal steroids, either alone or in combination with another agent such as an antibiotic, were included.

EXCLUSIONS

publications in abstract form only; uncontrolled, non-randomised or retrospective studies; studies reporting outcomes with ears (rather than children).

DATA COLLECTION AND ANALYSIS

Data were extracted from the published reports by the authors independently using standardised data extraction forms and methods. The methodological quality of the included studies was independently assessed by the authors as described in the Cochrane Handbook. Dichotomous results were expressed as an odds ratio using a fixed-effect model together with the 95% confidence intervals. Continuous data were analysed using the weighted mean difference in a fixed-effect model. Tests for heterogeneity between studies were performed using a Mantel-Haenszel approach. In trials with a cross-over design, post cross-over treatment data were not used.

MAIN RESULTS

No study prospectively documented hearing loss associated with OME prior to randomisation. Follow up was mainly short term. The odds ratio for OME persisting after short-term follow up in children treated with oral steroids compared to control was 0.22 (95% CI 0.08 to 0.63). The odds ratio for OME persisting after short-term follow up for children treated with oral steroids plus antibiotic compared to control plus antibiotic was 0.37 (95% CI 0.25 to 0.56). However, there was significant heterogeneity between studies included in the latter comparison (P < 0.01). Trends favoured steroids for most other comparisons, but confidence intervals included unity. There was no evidence of benefit for steroid treatment for OME or hearing loss associated with OME in the longer term.

AUTHORS' CONCLUSIONS

Both oral and topical intranasal steroids alone or in combination with an antibiotic lead to a quicker resolution of OME in the short term, however, there is no evidence of longer term benefit.

Minor injuries telemedicine

A minor injuries telemedicine network in Grampian connects 14 accident and emergency departments in community hospitals to a teaching hospital department. In a six-month study, 407 new telemedicine consultations met the inclusion criteria. Rates of transfer for treatment to the base hospital were used as an outcome measure. Fourteen out of a total of 19 members of medical staff gave telemedical advice. They were mainly middle-grade accident and emergency doctors. Transfer rates were 16-48% (median 29%) across staff. The rates did not seem to be affected by the base doctor's seniority, but were a reflection of that doctor's experience of and confidence in using videoconferencing equipment for clinical purposes. Transfer rates decreased as experience increased. Training for doctors undertaking the provision of specialist advice should include the clinical practicalities of making remote diagnoses.

A randomized controlled trial to evaluate the effectiveness and cost-effectiveness of psychodynamic counselling for general practice patients with chronic depression

BACKGROUND

Counsellors have been employed in general practice with little evidence of effectiveness. This study examined the effectiveness and cost-effectiveness of short-term counselling in general practice for patients with chronic depression either alone or combined with anxiety.

METHOD

A randomized controlled trial with an economic evaluation was carried out in Derbyshire. One hundred and forty-five patients were recruited at seven GP practices by screening using the Beck Depression Inventory. Both the experimental and control group received routine GP treatment but the experimental group were also referred to the practice counsellor. Depression, anxiety and other mental health symptoms, social and interpersonal functioning and social support were measured at baseline, 6 months and 12 months. Comprehensive costs were also estimated.

RESULTS

There was an overall significant improvement in the actual scores over time, but there were no significant differences between the two groups on any of the measures at either 6 or 12 months. However fewer experimental group patients were still 'cases' on the BDI than controls at 12 months. There were no significant differences in the mean total costs, aggregate costs of services, or any service-group costs except for primary care, between the experimental and control groups over time.

CONCLUSIONS

This trial demonstrates only very limited evidence of improved outcomes in those referred to counselling and increased primary care treatment costs in the short-term. Stricter referral criteria to exclude the more severely depressed in the group (BDI > or = 24) might have yielded more conclusive results.

Microbial diversity and resistance to copper in metal-contaminated lake sediment

Contamination of habitats with heavy metals has become a worldwide problem. We describe herein the analysis of lake sediment contaminated with high concentrations of copper as a consequence of mine milling disposal over a 100-year period. Copper concentrations in the sediment were found to vary with depth and ranged from 200 to 5500 ppm. Analysis of the microbial community with T-RFLP identified a minimum of 20 operational taxonomic units (OTU). T-RFLP analysis along a depth profile detected as many as nine shared OTUs across 15 centimeters, suggesting a conservation of community structure over this range. Only two genera, Arthrobacter and Ralstonia, were detected among 50 aerobic copper-resistant isolates cultivated on R2A, one of which (Ralstonia sp.) was characterized by the sequestration of copper, identified by electron diffraction scanning, in growing colonies. Scanning electron microscopy showed changes to the outer envelope of the cells when grown in the presence of copper. The copper-resistant Ralstonia isolates were also resistant to Ni, Cd, and Zn, showing two patterns of phenotypic resistant to these three metals in which either resistance to Zn or Ni was expressed in an isolate but never both.

A literature review of dementia care mapping: methodological considerations and efficacy

Dementia care mapping (DCM) is a popular method for evaluating the quality of care and well-being of people with dementia in formal care settings. Keywords and thesaurus searches were conducted between 1992 and June 2001 using a range of bibliographic databases. Studies that had specifically examined the efficacy of DCM or, had used DCM as the main outcome measure, were included in the review. Nine studies met the inclusion criteria and were evaluated in this review. The review highlights some methodological limitations in the DCM studies to date, including sampling bias, inadequate sample size, short evaluation periods and a lack of consideration of the confounding variables commonly associated with dementia. The evidence presented for DCM suggests that it has good face validity and reliability. However, other aspects of validity remain less convincing and it can only be regarded as a moderately valid instrument. Whilst its theoretical background makes DCM particularly appealing to nurses wishing to improve the quality of their care, it is a very time-consuming method and requires considerable investment in terms of nursing resources. Consequently, it is essential that more scientifically based studies are conducted to enable other aspects of validity to be developed, thus enhancing the value of DCM as an outcome measure of nursing care.

The provision of a telepsychology service to Shetland: client and therapist satisfaction and the ability to develop a therapeutic alliance

We conducted a pilot study to assess the feasibility and acceptability of videoconferencing as a means of providing a clinical psychology service in the Shetland Islands. A general practitioner was equipped with a desktop PC-based system connected to a mainland hospital videoconferencing system by ISDN at 128 kbit/s. Qualitative methods were used to assess user satisfaction, the ability to form a therapeutic relationship and client improvement. Over one year, 10 patients (eight female, two male) participated in the videoconferencing therapy sessions. The psychologist and all but one of the clients were highly satisfied with the videoconferencing therapy sessions. The clients were able to develop a positive therapeutic relationship with the psychologist and all reported some improvement from therapy. The results showed that videoconferencing is a feasible and acceptable means of providing therapy to patients in remote areas.

Regional nerve blocks. Part 8--Using a nerve stimulator to locate peripheral nerves

This is a relatively specialised technique aimed more at enhancing the skills of doctors regularly performing local anaesthetic blocks. It is a useful device for confirming the location of major nerves and plexuses proximally, but not necessary for most peripheral nerve blocks.

The clinical utility of the Beck Depression Inventory after traumatic brain injury

PRIMARY OBJECTIVE

To examine the psychometric properties of the Beck Depression Inventory (BDI) in traumatic brain injury (TBI) and to determine the relative endorsement of somatic-performance and cognitive-affective items in this group.

RESEARCH DESIGN

Prospective 2 year follow up assessment.

METHODS

117 patients discharged from an inpatient TBI rehabilitation service completed the BDI as part of a 24 month follow up assessment. Demographic and injury related data were obtained from patient files and significant others.

MAIN OUTCOMES

A principal components analysis revealed three factors describing affective and performance items, negative attitudes towards oneself and somatic disturbance. The reliability estimate was high (coefficient alpha = 0.92). A dependent sample t-test revealed higher endorsement of the cognitive-affective subscale with more clients classified as at least moderately depressed using the cognitive-affective rather than the total BDI score.

CONCLUSION

This study provides preliminary evidence suggesting that the BDI may be an effective screening tool for self reported depression in TBI.

Empowerment: a view of two low-income African-Americans communities

Field theory and empowerment were used as guiding conceptual frameworks to address empowerment issues in two low-income inner city African-Americans communities. Field theory and empowerment provided a conceptualization of these communities in terms of the possible impact of the physical environment of these communities on their residents and the health care professionals who worked with these residents. The most likely response is learned helplessness and depression that are antithetical to empowerment. These frameworks also were helpful in generating strategies to foster empowerment among these community residents. These strategies include helping residents to redefine their behavior as ways of coping with a hostile environment that confronts them with poverty and racism and to reconnect with natural supports in the community for the purpose of enhancing community coalitions and alliances.

Regional nerve blocks. Part 7--Intercostal nerve blocks

This is the seventh in our series of regional nerve blocks. This month we outline a useful block for a variety of in-hospital/clinical applications.

Regional nerve blocks. Part 6--Femoral nerve blocks

This is the sixth in our series of regional nerve blocks. Femoral nerve blocks by a lateral approach, have the potential to block the lumbar plexus if sufficient volume is used.

Health care needs assessment in prisons: a toolkit

BACKGROUND

Since 1999, prison health services and health authorities have been jointly responsible for assessing the health care needs of the prison population. To facilitate this process, the Department of Public Health and Epidemiology at the University of Birmingham developed a toolkit for carrying out a health care needs assessment of the prison population.

METHODS

This paper describes the principles of the epidemiological approach to needs assessment and presents a stepped approach to carrying out a health care needs assessment in prisons. Some examples of the kind of health care needs to be found in prisons are presented.

RESULTS

A systematic approach to the assessment of the health care needs of prisoners ensures that all the essential components of this important planning exercise are considered. The prison population is described, health problems are identified and quantified, and a review of current services is carried out. This allows the most effective solutions to addressing the health problems to be established. The process can be time consuming and is reliant on good data sources, but it does ensure that health problems and service elements are considered and addressed together rather than in a disjointed manner.

CONCLUSION

The stepped approach to epidemiological needs assessment allows health problems and current services to be identified. It also allows these to be matched to appropriate service requirements.