Effect of experience of severe stroke on subjective valuations of quality of life after stroke

Previous work suggests that the quality of life associated with severe disability after stroke is rated very poorly by members of the public, often as being worse than death. Other evidence suggests that experience of illness alters perceptions of its severity. This was tested for severe stroke. Eleven patients with severely disabling stroke, but able to complete a standard gamble interview, 22 age and sex matched controls, and 20 health professionals participated. A standard gamble interview was carried out to determine the quality of life (utility) associated with three hypothetical scenarios representing mild, moderate, and severe stroke, and current health. A sample was retested for reliability, and comparisons were made with other measures of health status. All three subject groups showed wide variation in the utilities they attached to each of the scenarios. The control subjects' valuations were lower than those of either patients or staff members, especially for moderate stroke (median 0.30, 0.73, and 0.68 respectively). There were weak to moderate correlations between utilities and other measures of health status including the Barthel index (r=0.51) and Rivermead mobility score (r=0.24). Test retest-reliability was modest (reliability coefficient 0.75), but indicators of the internal validity of the results were good. In conclusion, it cannot be assumed that general population valuations are valid for patient groups. In clinical practice it is unsafe to make any assumption about subjective quality of life after stroke, due to the wide range of valuations given, although many people rate severe and moderate stroke at least as bad as death.

Evidence for higher-order structure formation by the c-myb 18-mer phosphorothioate antisense (codons 2-7) oligodeoxynucleotide: potential relationship to antisense c-myb inhibition

We have demonstrated the formation of higher-order structures (presumably tetraplexes) by an 18-mer phosphorothioate antisense c-myb oligodeoxyribonucleotide that has been shown to have activity in the treatment of leukemia xenograft models. Although not observable by conventionally employed techniques, such as PAGE and dimethyl sulfate (DMS) protection, the formation of such higher-order structures by this oligonucleotide was revealed by several techniques. These included capillary gel electrophoresis (CGE), which demonstrated the presence of molecules with greatly increased retention time compared with the monomer; magnetic circular dichroism spectroscopy, which demonstrated a band at 290 nm, a characteristic of antiparallel tetraplexes; and fluorescence energy transfer measurements. For the last, the 18-mer phosphorothioate oligonucleotide was synthesized with a 5'-fluorescein group. Similar to the molecular beacon model, its fluorescence was quenched when combined in solution with tetraplex-forming oligomers that contained a 3'-Dabcyl moiety. 7-Deazaguanosine inhibits the formation of tetraplexes by eliminated Hoogsteen base pair interactions. The wild-type and 7-deazaguanosine-substituted antisense c-myb oligomers differentially downregulated the expression of the c-myb proto-oncogene in K562 and HL60 cells, with the wild-type oligomer being the least active. The 18-mer c-myb molecule can, therefore, form highly complex structures, whose analysis in solution cannot be limited to examination of slab gel electrophoresis results alone.

A principal component analysis of facial expressions

Pictures of facial expressions from the Ekman and Friesen set (Ekman, P., Friesen, W. V., (1976). Pictures of facial affect. Palo Alto, California: Consulting Psychologists Press) were submitted to a principal component analysis (PCA) of their pixel intensities. The output of the PCA was submitted to a series of linear discriminant analyses which revealed three principal findings: (1) a PCA-based system can support facial expression recognition, (2) continuous two-dimensional models of emotion (e.g. Russell, J. A. (1980). A circumplex model of affect. Journal of Personality and Social Psychology, 39, 1161-1178) are reflected in the statistical structure of the Ekman and Friesen facial expressions, and (3) components for coding facial expression information are largely different to components for facial identity information. The implications for models of face processing are discussed.

Stage Ia endometrial carcinoma diagnosed on removal of an IUD

This is a case report of a 49-year-old woman who presented with offensive vaginal discharge. Her Lippes loop IUD was removed and discovered to have suspicious material attached. Histology report was of endometrial carcinoma. This is the first report of an endometrial carcinoma being completely removed along with an IUD.

Antidepressant drugs and generic counselling for treatment of major depression in primary care: randomised trial with patient preference arms

OBJECTIVES

To compare the efficacy of antidepressant drugs and generic counselling for treating mild to moderate depression in general practice. To determine whether the outcomes were similar for patients with randomly allocated treatment and those expressing a treatment preference.

DESIGN

Randomised controlled trial, with patient preference arms. Follow up at 8 weeks and 12 months and abstraction of GP case notes.

SETTING

31 general practices in Trent region.

PARTICIPANTS

Patients aged 18-70 who met research diagnostic criteria for major depression; 103 patients were randomised and 220 patients were recruited to the preference arms.

MAIN OUTCOME MEASURES

Difference in mean Beck depression inventory score; time to remission; global outcome assessed by a psychiatrist using all data sources; and research diagnostic criteria.

RESULTS

At 12 months there was no difference between the mean Beck scores in the randomised arms. Combining the randomised and patient preference groups, the difference in Beck scores was 0.4 (95% confidence interval -2.7 to 3.5). Patients choosing counselling did better than those randomised to it (mean difference in Beck score 4.6, 0.0 to 9.2). There was no difference in the psychiatrist's overall assessment of outcome between any of the groups. 221/265 (83%) of participants with a known outcome had a remission. Median time to remission was shorter in the group randomised to antidepressants than the other three groups (2 months v 3 months). 33/221 (15%) patients had a relapse.

CONCLUSIONS

Generic counselling seems to be as effective as antidepressant treatment for mild to moderate depressive illness, although patients receiving antidepressants may recover more quickly. General practitioners should allow patients to have their preferred treatment.

Facilitating factors for, barriers to, and outcomes of interdisciplinary education projects in the health sciences

Appropriate collaboration and communication among health professionals is viewed as increasingly important in meeting the challenges of today's health care system. Student socialization to interdisciplinary practice is thought to be facilitated through interdisciplinary academic and clinical learning experiences during the educational program. The purpose of this article is to identify factors commonly cited as facilitating and inhibiting interdisciplinary education, to provide insight for the development of successful interdisciplinary education projects.

Evaluating telemedicine in an accident and emergency setting

This paper outlines the methodology of an evaluation of telemedicine in an Accident and Emergency (A&E) setting. Telemedicine technology consisting of ISDN 2 based videoconferencing and 'store & forward' software has been installed and is currently being evaluated in two minor injury units (MIUs) and a District General Hospital (DGH) A&E department in Lincolnshire. A cost-benefit analysis will be conducted using a pragmatic prospective case-control study with both a concurrent and retrospective control group. Any differences in resource use (including direct and indirect costs) between the intervention (Telemedicine) and the control (No Telemedicine) groups will be identified from both a patient and NHS perspective. A variety of health and non-health outcome measures will be recorded including staff and patient acceptability of the new technology.

Radiography of the lumbar spine in primary care patients with low back pain: randomised controlled trial

OBJECTIVE

To test the hypothesis that radiography of the lumbar spine in patients with low back pain is not associated with improved clinical outcomes or satisfaction with care.

DESIGN

Randomised unblinded controlled trial.

SETTING

73 general practices in Nottingham, north Nottinghamshire, southern Derbyshire, north Lincolnshire, and north Leicestershire. 52 practices recruited participants to the trial.

SUBJECTS

421 patients with low back pain of a median duration of 10 weeks.

INTERVENTION

Radiography of the lumbar spine.

MAIN OUTCOME MEASURES

Roland adaptation of the sickness impact profile, visual analogue scale for pain, health status, EuroQol, satisfaction with care, use of primary and secondary care services, and reporting of low back pain at three and nine months after randomisation.

RESULTS

The intervention group were more likely to report low back pain at three months (relative risk 1.26, 95% confidence interval 1.00 to 1.60) and had a lower overall health status score and borderline higher Roland and pain scores. A higher proportion of participants consulted their doctor in the three months after radiography (1.62, 1.33 to 1.97). Satisfaction with care was greater in the group receiving radiography at nine but not three months after randomisation. Overall, 80% of participants in both groups at three and nine months would have radiography if the choice was available. An abnormal finding on radiography made no difference to the outcome, as measured by the Roland score.

CONCLUSIONS

Radiography of the lumbar spine in primary care patients with low back pain of at least six weeks' duration is not associated with improved patient functioning, severity of pain, or overall health status but is associated with an increase in doctor workload. Guidelines on the management of low back pain in primary care should be consistent about not recommending radiography of the lumbar spine in patients with low back pain in the absence of indicators for serious spinal disease, even if it has persisted for at least six weeks. Patients receiving radiography are more satisfied with the care they received. The challenge for primary care is to increase satisfaction without recourse to radiography.

Excretion of Sweat and Urine Pyridinoline Crosslinks in Healthy Controls and Subjects with Established Metabolic Bone Disease

Convenient techniques for measuring rates of bone turnover have been developed in recent years with the advent of biochemical markers of bone metabolism. One recent of these techniques is a collection method and quantitative enzyme immunoassay for free pyridinoline crosslinks in human sweat. The concentrations of pyridinoline crosslinks in 5-day sweat collections and first morning void and 24-hour urine collections from healthy subjects and subjects with established metabolic bone disorders were determined. T-scores were higher in the sweat system than in the urine system by up to 10-fold in postmenopausal subjects, women with hyperparathyroidism, and subjects with postmenopausal osteoporosis. For subjects with postmenopausal osteoporosis, receiver-operating characteristic curve analysis yielded areas under the curve of 0.699, 0.629, and 0.520 for sweat pyridinoline, first morning void urine pyridinoline, and 24 hour urine pyridinoline respectively. The areas under the curve of the sweat and first morning void urine measurements were significantly greater (p<0.05) than the 24-hour pyridinoline measurements. Healthy postmenopausal subjects and subjects with postmenopausal osteoporosis were monitored before and during estrogen replacement therapy or alendronate therapy. Sweat pyridinoline values declined by 49.0 +/- 12.4% and 19.4 +/- 19.9% for estrogen and alendronate subjects respectively. We conclude that this non-invasive technique is a sensitive and specific measure of bone resorption and is appropriate as an adjunct to techniques such as bone density and may also be useful in monitoring of response to anti-resorptive therapies.

A metadata framework for interoperating heterogeneous genome data using XML

The rapid advances in the Human Genome Project and genomic technologies have produced massive amounts of data populated in a large number of network-accessible databases. These technological advances and the associated data can have a great impact on biomedicine and healthcare. To answer many of the biologically or medically important questions, researchers often need to integrate data from a number of independent but related genome databases. One common practice is to download data sets (text files) from various genome Web sites and process them by some local programs. One main problem with this approach is that these programs are written on a case-by-case basis because the data sets involved are heterogeneous in structure. To address this problem, we define metadata that maps these heterogeneously structured files into a common eXtensible Markup Language (XML) structure to facilitate data interoperation. We illustrate this approach by interoperating two sets of essential yeast genes that are stored in two yeast genome databases (MIPS and YPD).

Redefining leadership responsibilities following organizational redesign

A redefinition of leadership roles was necessitated by the adoption of program management, which accompanied the merger of two large academic hospitals, each of which consisted of two sites. Directors of professional departments were removed when staff were deployed to programs. Program directors were selected to manage the new programs, and profession leaders were identified to monitor standards of practice. The roles and accountabilities of the new program and profession leaders needed to be clarified for incumbents and other hospital staff. This article describes the process undertaken to clarify those responsibilities. The resulting Guide outlines 14 specific and collaborative responsibilities of program and profession leaders. Plans for review and future development of the Guide are discussed.

Importance of precision in bone density measurements

Bone densitometry, regardless of the specific technique, is not perfectly reproducible even when consistently performed in exact accordance with the manufacturer's recommendations. Precision must be quantified at each densitometry facility in precision studies of the various skeletal sites used for monitoring. The precision, as the root-mean-square standard deviation or root-mean-square coefficient of variation, is then used to determine the change in bone density that constitutes the least significant change and the minimum interval between follow-up measurements. Until precision studies are performed, the least significant change cannot be determined for any level of statistical confidence, making the interpretation of serial studies impossible.

Interdisciplinary health professional education: a historical review

A historical review was conducted to examine the advances made, nationally and internationally, in interdisciplinary health professional education since the mid-1960s. One hundred and nineteen articles were reviewed and divided by decade into the following subheadings: models, courses, communication/group process issues, and international perspectives. Twenty-seven articles, categorized as models, defined the conceptual field, described curriculum and program development, or provided a framework for evaluation. Thirty-two articles dealt with interdisciplinary courses, focusing on objectives, content areas, or innovative methods. Nine articles contributed content on interdisciplinary communication and group process issues, from which guidelines were abstracted. Fifty-one articles contributed an international perspective, leading to the recognition that interdisciplinary health professional education, practice, and research is a global movement.

Assessing effectiveness of treatment of depression in primary care. Partially randomised preference trial

BACKGROUND

There is a mismatch between the wish of a patient with depression to have counselling and the prescription of antidepressants by the doctor.

AIMS

To determine whether counselling is as effective as antidepressants for depression in primary care and whether allowing patients to choose their treatment affects their response.

METHOD

A partially randomised preference trial, with patients randomised to either antidepressants or counselling or given their choice of either treatment. The treatment and follow-up were identical in the randomised and patient preference arms.

RESULTS

There were 103 randomised and 220 preference patients in the trial. We found: no differences in the baseline characteristics of the randomised and preference groups; that the two treatments were equally effective at 8 weeks, both for the randomised group and when the randomised and patient preference groups for a particular treatment were combined; and that expressing a preference for either treatment conferred no additional benefit on outcome.

CONCLUSIONS

These data challenge several assumptions about the most appropriate treatment for depression in a primary care setting.

A randomized trial of nasal spray salmon calcitonin in postmenopausal women with established osteoporosis: the prevent recurrence of osteoporotic fractures study. PROOF Study Group

PURPOSE

We conducted a 5-year, double-blind, randomized, placebo-controlled study to determine whether salmon calcitonin nasal spray reduced the risk of new vertebral fractures in postmenopausal women with osteoporosis.

SUBJECTS AND METHODS

A total of 1,255 postmenopausal women with established osteoporosis were randomly assigned to receive salmon calcitonin nasal spray (100, 200, or 400 IU) or placebo daily. All participants received elemental calcium (1,000 mg) and vitamin D (400 IU) daily. Vertebral fractures were assessed with lateral radiographs of the spine. The primary efficacy endpoint was the risk of new vertebral fractures in the salmon calcitonin nasal spray 200-IU group compared with the placebo group.

RESULTS

During 5 years, 1,108 participants had at least one follow-up radiograph. A total of 783 women completed 3 years of treatment, and 511 completed 5 years. The 200-IU dose of salmon calcitonin nasal spray significantly reduced the risk of new vertebral fractures by 33% compared with placebo [200 IU: 51 of 287, placebo: 70 of 270, relative risk (RR) = 0.67, 95% confidence interval (CI): 0.47- to 0.97, P = 0.03]. In the 817 women with one to five prevalent vertebral fractures at enrollment, the risk was reduced by 36% (RR = 0.64, 95% CI: 0.43- to 0.96, P = 0.03). The reductions in vertebral fractures in the 100-IU (RR = 0.85, 95% CI: 0.60- to 1.21) and the 400-IU (RR = 0.84, 95% CI: 0.59- to 1.18) groups were not significantly different from placebo. Lumbar spine bone mineral density increased significantly from baseline (1% to 1. 5%, P<0.01) in all active treatment groups. Bone turnover was inhibited, as shown by suppression of serum type-I collagen cross-linked telopeptide (C-telopeptide) by 12% in the 200-IU group (P <0.01) and by 14% in the 400-IU group (P<0.01) as compared with placebo.

CONCLUSION

Salmon calcitonin nasal spray at a dose of 200 IU daily significantly reduces the risk of new vertebral fractures in postmenopausal women with osteoporosis.

1997 UK Total Diet Study--dietary exposures to aluminium, arsenic, cadmium, chromium, copper, lead, mercury, nickel, selenium, tin and zinc

Concentrations of aluminium, arsenic, cadmium, chromium, copper, lead, mercury, nickel, selenium, tin and zinc were determined in samples from the 1997 UK Total Diet Study and used to estimate dietary exposures of the general UK population. Population average dietary exposures to aluminium (3.4 mg/day), arsenic (0.065 mg/day), cadmium (0.012 mg/day), chromium (0.10 mg/day), copper (1.2 mg/day), mercury (0.003 mg/day), nickel (0.13 mg/day), tin (1.8 mg/day) and zinc (8.4 mg/day) are similar to those from previous UK Total Diet Studies and are below the appropriate PTWIs, PMTDIs and TDIs. Dietary exposure of the UK population (0.026 mg/day) to lead is falling as a result of measures taken to reduce lead contamination of the environment and food and is well below the PTWI. There has been little change in UK estimates of selenium exposure since the 1994 Total Diet Study but current-estimates (0.039 mg/day) are lower than those derived from earlier Total Diet Studies.

Neuropsychological change in young people at high risk for schizophrenia: results from the first two neuropsychological assessments of the Edinburgh High Risk Study

BACKGROUND

Studies of groups of individuals who have a genetically high risk of developing schizophrenia, have found neuropsychological impairments that highlight likely trait markers of the schizophrenic genotype. This paper describes the change in neuropsychological function and associations with psychiatric state of high risk participants during the first two assessments of the Edinburgh High Risk Study.

METHODS

Seventy-eight high risk participants and 22 normal controls, age and sex matched completed two neuropsychological assessments 18 months to 2 years apart. The areas of function assessed include intellectual function, executive function, learning and memory, and verbal ability and language.

RESULTS

The high risk participants performed significantly worse on particular tests of verbal memory and executive function over the two assessments than matched controls. Those high risk participants who experienced psychotic symptoms were found to exhibit a decline in IQ and perform worse on tests of verbal memory and executive function than those without symptoms. An increase in psychotic symptoms between the two assessments in the high risk group was found to be associated with an apparent decline in IQ and memory.

CONCLUSIONS

The results suggest that the development of psychotic symptoms is preceded by a decline in IQ and memory. This may reflect a general and a more specific disease process respectively.

Alendronate for the treatment of osteoporosis in men

BACKGROUND

Despite its association with disability, death, and increased medical costs, osteoporosis in men has been relatively neglected as a subject of study. There have been no large, controlled trials of treatment in men.

METHODS

In a two-year double-blind trial, we studied the effect of 10 mg of alendronate or placebo, given daily, on bone mineral density in 241 men (age, 31 to 87 years; mean, 63) with osteoporosis. Approximately one third had low serum free testosterone concentrations at base line; the rest had normal concentrations. Men with other secondary causes of osteoporosis were excluded. All the men received calcium and vitamin D supplements. The main outcome measures were the percent changes in lumbar-spine, hip, and total-body bone mineral density.

RESULTS

The men who received alendronate had a mean (+/-SE) increase in bone mineral density of 7.1+/-0.3 percent at the lumbar spine, 2.5+/-0.4 percent at the femoral neck, and 2.0+/-0.2 percent for the total body (P<0.001 for all comparisons with base line). In contrast, men who received placebo had an increase in lumbar-spine bone mineral density of 1.8+/-0.5 percent (P<0.001 for the comparison with base line) and no significant changes in femoral-neck or total-body bone mineral density. The increase in bone mineral density in the alendronate group was greater than that in the placebo group at all measurement sites (P<0.001). The incidence of vertebral fractures was lower in the alendronate group than in the placebo group (0.8 percent vs. 7.1 percent, P=0.02). Men in the placebo group had a 2.4-mm decrease in height, as compared with a decrease of 0.6 mm in the alendronate group (P=0.02). Alendronate was generally well tolerated.

CONCLUSIONS

In men with osteoporosis, alendronate significantly increases spine, hip, and total-body bone mineral density and helps prevent vertebral fractures and decreases in height.

Equipoise and the ethics of the Canadian Lung Volume Reduction Surgery Trial study: should there be a randomized, controlled trial to evaluate lung volume reduction surgery?

The physical improvement is so great following lung volume reduction surgery that there is growing opinion that a randomized, controlled trial is unnecessary. A randomized, controlled trial, it is argued, would deprive those patients randomly assigned to the nonsurgical treatment arm the 'benefit' of lung volume reduction surgery. Entering a trial in which one arm leads to a surgical intervention and the other to best medical management also poses a variety of ethical difficulties. If one is to be offered surgery, there must be perceived benefit because the physician has an obligation to offer the best possible treatment for his or her patient. If a patient agrees to have surgery, the expectation is that surgery would help. Thus, a patient randomly assigned to the medical arm of a trial may easily believe that he or she is being deprived of surgery that may help them. This paper illustrates this dilemma using the Canadian Lung Volume Reduction Surgery Trial. The authors discuss the concept of 'equipoise' in three dimensions, adding community equipoise to theoretical equipoise and clinical equipoise earlier described by Freedman. The paper concludes that the Canadian Lung Volume Reduction Surgery Trial needs to continue because of the clinical equipoise that drives it.