Evaluation of individual and group changes in social outcome after aneurysmal subarachnoid haemorrhage: a long-term follow-up study

The development and evaluation of an online hearing loss prevention program

Recent studies underline the need for research on approaches to encouraging healthy listening habits. This study aims to develop and evaluate an online hearing loss prevention program; and examine its influence on the participants' use of hearing protection, hearing loss prevention knowledge, attitude towards noise, and program useability and adherence. The study was conducted in the county of Västra Götaland, Sweden, from March through October 2021. The program included four modules focused on hearing and hearing loss prevention and was accessible to the participants for four weeks. In total, 75 participants completed the program which was evaluated using the Youth Attitude to Noise Scale and four additional self-designed questionnaires. The questionnaires were deployed before and immediately after program completion. The findings indicate that the program may influence the participants' attitudes toward noise and the use of hearing protection. The participants who completed the program perceived high useability and increased hearing loss prevention knowledge. This program is most needed to promote healthy hearing. Future studies should target specific groups with this program and evaluate its long-term effects.

Prospective study: Long-term outcome at 12-15 years after aneurysmal subarachnoid hemorrhage

BACKGROUND

Patients with aneurysmal subarachnoid hemorrhage (aSAH) have poor outcome. Studies on outcome beyond 1 year post-aSAH are few, and late recovery is poorly investigated, initiating this prospective outcome study on patients 12-15 years after an aSAH. We hypothesized to find; functional improvement > 1 year post-ictus; increased long-term mortality in aSAH patients vs matched controls, and finally to present; predictors of long-term favorable outcome (GOS 4-5).

METHODS

We prospectively investigated patients, admitted 2000-2003 to the Sahlgrenska University Hospital, 1 year post-ictus using Glasgow Outcome Scale (GOS). The patients were revalidated 12-15 years post-aSAH by structured-telephone interviews (GOS), followed by statistical analysis.

RESULTS

A total of 158 patients were included, (women n = 114, men n = 44), with a mean age of 55 years at aSAH. Patients treated with surgical clipping had lower mortality. At the follow-up 12-15 years post-aSAH, all 103 survivors (65.2%) were categorized as having; good recovery (39.9%), moderate disability (15.2%), or severe disability (10.1%). Within the patient cohort, 23.6% improved GOS over time. Fifty-five patients died, median at 4 years post-ictus. aSAH patients had 3.5 times increased mortality 12-15 years post-ictus vs matched controls (P < .0001). Patients with favorable outcome at 1 year (67.3%, n = 101) had similar survival probability as control patients. Prognostic indicators of long-term favorable outcome were low age and high GOS at 1-year follow-up, (AUCROC, 0.79).

CONCLUSIONS

Individual functional improvement was found >1 year post-ictus. Patients with favorable outcome at 1 year had similar long-term life expectancy as the general population. Indicators of long-term favorable prognosis were low age at ictus and high GOS at 1-year follow-up.

A prospective outcome study observing patients with severe traumatic brain injury over 10-15 years

BACKGROUND

Severe traumatic brain injury (sTBI) can be divided into primary and secondary injuries. Intensive care protocols focus on preventing secondary injuries. This prospective cohort study was initiated to investigate outcome, including mortality, in patients treated according to the Lund Concept after a sTBI covering 10-15 years post-trauma.

METHODS

Patients were included during 2000-2004 when admitted to the neurointensive care unit, Sahlgrenska University Hospital. Inclusion criteria were: Glasgow coma scale score of ≤8, need for artificial ventilation and intracranial monitoring. Glasgow Outcome Scale (GOS) was used to evaluate outcome both at 1-year and 10-15 years post-trauma.

RESULTS

Ninety-five patients, (27 female and 68 male), were initially included. Both improvement and deterioration were noted between 1- and 10-15 years post-injury. Mortality rate (34/95) was higher in the studied population vs. a matched Swedish population, (Standard mortality rate (SMR) 9.5; P < 0.0001). When dividing the cohort into Good (GOS 4-5) and Poor (GOS 2-3) outcome at 1-year, only patients with Poor outcome had a higher mortality rate than the matched population (SMR 7.3; P < 0.0001). Further, good outcome (high GOS) at 1-year was associated with high GOS 10-15 years post-trauma (P < 0.0001). Finally, a majority of patients demonstrated symptoms of mental fatigue.

CONCLUSION

This indicates that patients with severe traumatic brain injury with Good outcome at 1-year have similar survival probability as a matched Swedish population and that high Glasgow outcome scale at 1-year is related to good long-term outcome. Our results further emphasise the advantage of the Lund concept.

The functional barometer -a self-report questionnaire in accordance with the International Classification of Functioning, Disability and Health for pain related problems; validity and patient-observer comparisons

Background

The International Classification of Functioning, Disability and Health, (ICF) provides a unified, international standardized framework for describing and classifying health and health-related functioning and disability. Based on an ICF core sets the Functional Barometer, (FB), was developed for assessments of perceived pain-related problems with functions, activity and quality-of-life by patients suffering from long-term pain. The aim was to evaluate the construct validity, and to compare the assessments of a patient’s problems from the perspectives of the patient and of the examining professional when using the validated FB and corresponding ICF-classification form, respectively.

Methods

Patients with long-term pain for more than 3 months that visited one of four pain clinics during specified time periods of data collections were eligible. The self-report Balanced Inventory for Spinal disorders was used for validation of the FB. Correspondingly to the validated FB an ICF-classification form for professional’s assessment was developed. The data sets for these inter-scale and the patient-professional comparisons were collected adjacent to the clinical examination. By the statistical method used for evaluation of the pairs of ordinal data presence of systematic disagreement was identified and measured separately from additional individual variations.

Results

The validation process resulted in a revised FB(2.0) that meets the requirements of good construct and content validity. The professionals’ ICF-classifications of the patients’ problems disagreed with the patients’ assessments on the FB(2.0); the percentage agreements ranged from 18% to 51%. The main reason was that the practitioners systematically underestimated the patients’ levels of problems but the different professionals contributed also to a large individual variability (noise) in assessment.

Conclusions

This study presents an ICF-based validated self-report questionnaire, The FB, to be used for identifying and describing pain-related problems with current functioning, activities and quality-of-life as perceived by patients suffering from long-term pain. The strong evidences of underestimation of the patients’ problems and the variability in the professionals’ ICF-classifications demonstrated the importance of describing the patient’s problems both from the patient’s and the professional’s perspective beneficial for the patient’s rehabilitation.

Effects of impairment-based exercise on performance of specific self-reported functional tasks in individuals with knee osteoarthritis

BACKGROUND

Little is known regarding how impairment-based exercises may improve performance of specific functional tasks in people with knee osteoarthritis (OA).

OBJECTIVE

The purpose of this study was to compare the probability that participation in an impairment-based exercise program or the same impairment-based program supplemented with agility and perturbation training will improve patient-reported function on specific functional tasks.

DESIGN

This study was a secondary analysis of data from a randomized clinical trial.

SETTING

The study was conducted in the outpatient physical therapy clinic of a large, university-based health center.

PARTICIPANTS

One hundred eighty-three people with knee OA (122 women, 61 men) participated.

INTERVENTIONS

Participants were randomly assigned to either a group that received agility and perturbation training with standard exercise therapy or a group that received only the standard exercise.

MEASUREMENTS

Specific functional items were taken from the physical function subscale of the Western Ontario and McMasters Universities Osteoarthritis Index, the Lower Extremity Function Scale, and the Activities of Daily Living Scale of the Knee Outcome Survey.

RESULTS

The probability of self-reported improvement in a variety of specific functional tasks was low following participation in either of the exercise programs. When only participants with moderate to severe difficulty performing specific functional tasks were considered in the analysis, the probability of success improved but was still limited.

LIMITATIONS

The results are generalizable only to self-reported assessment of performance of specific functional tasks.

CONCLUSIONS

Impairment-based exercise may not be enough to make substantial improvement in performance of specific functional tasks. Task-specific exercise approaches need to be explored for people with knee OA.

On the threshold - evaluation of variability in effects of acupuncture in a gender perspective

Variable results of pain alleviation in response to acupuncture have been reported, complicating its interpretation. Sources of variability are probably multi-factorial, including the contribution of gender related effects. Gender related variation in perceived pain has been discussed frequently, but documented effects of acupuncture referring to gender are sparse. Furthermore, factors such as operationalisation of the outcome variable and the statistical method for evaluation could also be sources of variability. When pain is regarded as subjective, the produced data should be treated as ordinal. The rank-based method by Svensson, taking the non-metric qualities of the ordinal data into account as well as the variability at the group and the individual level, is therefore an alternative. The present commentary aims to (1) evaluate changes in electrical sensory thresholds and electrical pain thresholds after low frequency electro-acupuncture separately in healthy women and men; (2) introduce and exemplify the method by Svensson in a user-friendly approach. To analyze the systematic patterns of change in thresholds, indicating evidence of treatment on a group level, the relative position (RP) and relative concentration (RC), were measured. The variation related to the individual, the relative rank variation (RV) was also measured. The results were divergent between women (n = 23) and men (n = 22), i.e. unchanged sensory threshold after acupuncture at the group level in women while changed in men. The assessed pain threshold after acupuncture on the other hand was changed towards higher levels in women and unchanged in men. The individual variation was apparent in both women and men but larger in women. For statistical analysis of the variability for both group and individual related effects, the rank-based method by Svensson could be used. The present study indicates that evaluation of sensory and pain threshold response should be analysed separately in women and men.

The prognostic value of NSE and S100B from serum and cerebrospinal fluid in patients with spontaneous subarachnoid hemorrhage

Neuron-specific enolase (NSE) and S100B protein have been shown to be increased in cerebrospinal fluid (CSF) and serum of patients suffering from subarachnoid hemorrhage. This study was designed to evaluate the accuracy of NSE and S100B from CSF and serum for the prognosis of outcome and the detection of cerebral infarction, vasospasm and intracranial hypertension. In 55 patients with spontaneous subarachnoid hemorrhage and requiring external ventricular drainage the concentrations of NSE and S100B were determined daily from the serum and the CSF from admission until day 8. At ICU discharge patients' outcome was assessed by the Glasgow outcome scale and occurrence of cerebral infarction, vasospasm and intracranial hypertension were registered. Mean and peak values of each parameter for each patient were calculated. For accuracy assessment receiver operating characteristics were used. Bad outcome (Glasgow outcome scale 1 to 3) was found in 33 patients. Cerebral infarction, vasospasm, and intracranial hypertension were found in 31 (56%), 34 (62%), and 36 (65%) patients. Mean and peak values of NSE CSF (P<0.001), S100B CSF (P<0.001), and S100B serum (P<0.001) but not of NSE serum provided the ability to distinguish between patients with good and bad outcome. The accuracy of NSE CSF and S100B CSF did not differ significantly from that of S100B serum. NSE CSF (P<0.001), S100B CSF (P<0.001), and S100B serum (P<0.001) allowed the detection of cerebral infarction and intracranial hypertension. Cerebral vasospasm was detected by none of the parameters. In conclusion, NSE CSF, S100B CSF, and S100B serum provide similar prognostic values for outcome, intracranial hypertension and cerebral infarction. Significantly lower accuracy was found for NSE serum.

A method to analyse observer disagreement in visual grading studies: example of assessed image quality in paediatric cerebral multidetector CT images

The purpose was to demonstrate a non-parametric statistical method that can identify and explain the components of observer disagreement in terms of systematic disagreement as well as additional individual variability, in visual grading studies. As an example, the method was applied to a study where the effect of reduced tube current on diagnostic image quality in paediatric cerebral multidetector CT (MDCT) images was investigated. Quantum noise, representing dose reductions equivalent to steps of 20 mA, was artificially added to the raw data of 25 retrospectively selected paediatric cerebral MDCT examinations. Three radiologists, blindly and randomly, assessed the resulting images from two different levels of the brain with regard to the reproduction of high- and low-contrast structures and overall image quality. Images from three patients were assessed twice for the analysis of intra-observer disagreement. The intra-observer disagreement in test-retest assessments could mainly be explained by a systematic change towards lower image quality the second time the image was reviewed. The inter-observer comparisons showed that the paediatric radiologist was more critical of the overall image quality, while the neuroradiologists were more critical of the reproduction of the basal ganglia. Differences between the radiologists regarding the extent to which they used the whole classification scale were also found. The statistical method used was able to identify and separately measure a presence of bias apart from additional individual variability within and between the radiologists which is, at the time of writing, not attainable by any other statistical approach suitable for paired, ordinal data.

A structured questionnaire to assess patient compliance and beliefs about medicines taking into account the ordered categorical structure of data

RATIONALE, AIMS AND OBJECTIVE

The objectives were to describe and evaluate the structured medication questionnaire and to improve data handling of results from the Morisky four-item scale for patient compliance and Beliefs about Medicines Questionnaire-specific (BMQ-specific).

METHODS

A questionnaire was developed with the purpose of being used when identifying medication errors and assessing patient compliance to and beliefs about medicines.

RESULTS

A majority of the respondents (62%; CI 45-77%) had at least one medication error. Assuming that all items are equally important in the Morisky four-item scale we presented four alternative ways to create a unidimensional global scale. A two-dimensional global scale was also constructed. The results from the BMQ-specific were presented in different ways, all taking into account that the scale has ordered verbal categories: at the level addressing each specific question, at the sub-scales 'concern' and 'necessity' level and at the global level.

CONCLUSIONS

The structured medication questionnaire can be used in daily practice as a tool to identify drug-related problems. The choice of how to use and present data from those scales in research depends on patient characteristics and how discriminating one would like the scales to be.

Development of a questionnaire to measure patient-reported postoperative recovery: content validity and intra-patient reliability

AIMS AND OBJECTIVES

In this study we describe the development of a short, easy-to-use questionnaire to measure postoperative recovery and evaluate its content validity and intra-patient reliability. The questionnaire is designed to evaluate the progress of postoperative recovery and the long-term follow-up of possible effects of interventions during recovery.

METHODS

The study involved four steps. (1) A conceptualization and item definitions were based on a theoretical framework and a description of patients' postoperative recovery from the perspective of patients, registered nurses and surgeons; (2) Content validity of items was tested through expert judgements; (3) A test run of the questionnaire was performed to confirm its feasibility and workload requirement; and (4) The stability of the questionnaire was evaluated through intra-patient reliability assessment.

RESULTS

As a result of the operationalization process of the concept postoperative recovery, five dimensions (physical symptoms, physical functions, psychological, social, activity) and 19 items were identified. Each item was formulated as a statement in the questionnaire. Content validity was judged to be high. After the pre-test of the questionnaire a revision with refinements in the layout was made. The vast majority of items showed a high level of intra-patient reliability.

CONCLUSION

Based on a theoretical framework and empirical data, we developed a short and easy-to-use tentative questionnaire to measure patient-reported postoperative recovery. Initial support for content validity was established. The vast majority of items showed a high level of test-retest reliability.

Decreased pulsatile blood flow in the patella in patellofemoral pain syndrome

BACKGROUND

Anterior knee pain without clinical and radiologic abnormalities has primarily been explained from a purely structural view. A recently proposed biologic and homeostatic explanation questions the malalignment theory. No objective measurement of the pathophysiology responsible for changes in local homeostasis has been presented.

HYPOTHESIS

Flexing the knee joint interferes with the perfusion of the patellar bone in patellofemoral pain syndrome.

STUDY DESIGN

Case control study; Level of evidence, 4.

METHODS

Pulsatile blood flow in the patella was measured continuously and noninvasively using photoplethysmography. Measurements were made with the patient in a resting position with knee flexion of 20 degrees and after passive knee flexion to 90 degrees. In total, 22 patients with patellofemoral pain syndrome were examined bilaterally, and 33 subjects with healthy knees served as controls.

RESULTS

The pulsatile blood flow in the patient group decreased after passive knee flexion from 20 degrees to 90 degrees (systematic change in position, or relative position [RP] = -0.32; 95% confidence interval for RP, -0.48 to -0.17), while the response in the control group showed no distinct pattern (RP = 0.17; 95% confidence interval for RP, -0.05 to 0.31). The difference between the groups was significant (P = .0002). The median change in patients was -26% (interquartile range, 37).

CONCLUSIONS

Pulsatile patellar blood flow in patellofemoral pain syndrome patients is markedly reduced when the knee is being flexed, which supports the previous notion of an ischemic mechanism involved in the pathogenesis of this pain syndrome.

Corticotropin releasing factor in urine—A possible biochemical marker of fibromyalgia

The purpose of this preliminary study was to evaluate the relationship between a possible biochemical marker of stress, 24-h urinary concentrations of Corticotropin Releasing Factor-Like Immunoreactivity (CRF-LI), and ratings of stress-related symptoms like depression and anxiety, as well as to evaluate pain and emotional reactions in patients with fibromyalgia (FM). Another purpose was to study the effects of massage and guided relaxation, with respect to change in the same variables. Urine sampling and ratings were performed before treatments, after and 1 month after completed treatments. Concentrations of CRF-LI was analysed with radioimmnoassay technique. For the assessment of depression, anxiety and pain the CPRS-A questionnaire was used and for rated pain and emotional reactions the NHP questionnaire was used. The 24-h urinary concentration of the CRF-LI was found to be related to depression, mood and inability to take initiative. After treatment the urinary CRF-LI concentrations and the rated levels of pain and emotional reactions were found to have decreased. In conclusion, the 24-h urinary CRF-LI concentration may be used as a biochemical marker of stress-related symptoms such as depression in patients with FM and possibly also other conditions characterized by chronic pain. Therapies such as massage and guided relaxation may be tried for the amelioration of pain and stress but further studies are required.

A prospective, population-based, follow-up study of mild traumatic brain injury in children

OBJECTIVE

Outline the annual incidence of mild traumatic brain injury in children, aged 0-17 years, using the American Congress of Rehabilitation Medicine classification and record the presence of new symptoms up to six months after injury.

SETTINGS AND METHODS

The study population comprised all the children in the age group of 0-17 years (a total of 40,984) in an administrative district in south-western Sweden. All the individuals registered in the Brain Injury Register, during the periods 1 January to 30 June 1999 and 1 April to 30 September 2000, fulfilling the inclusion criteria defined by American Congress of Rehabilitation Medicine, were included. New symptoms occurring three to six months after the injury were recorded using a mailed 21-item questionnaire.

RESULTS

192 children fulfilled the criteria, yielding an annual incidence of 468/100,000 (95% CI 402-535/100,000). Boys accounted for 57 per cent and fall injuries accounted for 61 per cent of the external causes. New symptoms were reported by 24 per cent of those who answered the questionnaire.

CONCLUSION

This study revealed that the annual incidence of mild traumatic brain injury in children was almost as high as that among adults in the same area and population.

Evaluation of variations in sensory and pain threshold assessments by electrocutaneous stimulation

Assessed sensory and pain thresholds can change consequently to disturbances associated with ongoing pain. Such assessments could be an additional method in the daily clinical evaluation of perceived pain. To study the test-retest variability within-day and between-day of such procedures a newly developed instrument producing electrocutaneous stimulation, PainMatcher (PM), was used to assess the electrical sensory thresholds (EST) and pain thresholds (EPT) in healthy volunteers and in patients with pain. The produced data were considered ordinal and analyzed with rank-invariant statistics with properties of analyzing systematic disagreement, bias, and individual variations. The percentage agreements within +/- 1PM value for EST were in the two groups of healthy volunteers and patients in pain 94% and 92%, and for EPT assessments 49% and 78%, respectively. The variability in the EST assessments is possibly explained by a slight bias while the individual variations were negligible between the two occasions. The assessed EPT were unbiased in both groups while individual variations were significant among the healthy volunteers but negligible among the patients in pain. The EST was found to be increased in pain patients compared to healthy volunteers, p < 0.03, and the EPT decreased in pain patients compared to healthy volunteers, p < 0.001. The results in this study indicate stable and reliable assessments of EST and EPT except for a possible bias. The threshold assessment procedure followed in this study may be a valuable tool in the clinical evaluation of sensory and pain assessments in pain patients.

A new method for predicting functional recovery of stroke patients with hemiplegia: logarithmic modelling

OBJECTIVE

To examine the validity and applicability of logarithmic modelling for predicting functional recovery of stroke patients with hemiplegia.

DESIGN

Longitudinal postal survey.

SUBJECTS

Stroke patients with hemiplegia staying in a long-term rehabilitation facility, who had been referred from acute medical service 30-60 days after onset.

METHODS

Functional Independence Measure (FIM) scores were periodically assessed during hospitalization. For each individual, a logarithmic formula that was scaled by an interval increase in FIM scores during the initial 2-6 weeks was used for predicting functional recovery.

RESULTS

For the study, we recruited 18 patients who showed a wide variety of disability levels on admission (FIM scores 25-107). For each patient, the predicted FIM scores derived from the logarithmic formula matched the actual change in FIM scores. The changes predicted the recovery of motor rather than cognitive functions. Regression analysis showed a close fit between logarithmic modelling and actual FIM scores (across-subject R2 = 0.945).

CONCLUSIONS

Provided with two initial time-point samplings, logarithmic modelling allows accurate prediction of functional recovery for individuals. Because the modelling is mathematically simple, it can be widely applied in daily clinical practice.

THE NEW SWEDISH POST-CONCUSSION SYMPTOMS QUESTIONNAIRE: A MEASURE OF SYMPTOMS AFTER MILD TRAUMATIC BRAIN INJURY AND ITS CONCURRENT VALIDITY AND INTER-RATER RELIABILITY

OBJECTIVE

To study the concurrent validity and the inter-rater reliability of the Post-Concussion Symptoms Questionnaire.

DESIGN

The approach was to study the concurrent validity of the Post-Concussion Symptoms Questionnaire when used as an interview questionnaire compared with a self-report questionnaire administered by the patients. The inter-rater reliability was also studied when 2 different raters administered the Post-Concussion Symptoms Questionnaire interview.

PATIENTS

Thirty-five patients with mild traumatic brain injury were consecutively contacted by telephone and asked whether they would be willing to participate in a follow-up intervention.

METHODS

The Post-Concussion Symptoms Questionnaire was completed by the patients, who answered "Yes" or "No" to the standardized questions. The patients were then interviewed to check the certain "Yes" or "No" answers, 0-10 days after having completed the first Post-Concussion Symptoms Questionnaire. The raters filled in their ratings independently.

RESULTS

The concurrent validity of answers in the questionnaire compared with those in the interview ranged from 82% to 100% agreement. The inter-rater reliability results ranged from 93% to 100% agreement between the raters.

CONCLUSION

The Post-Concussion Symptoms Questionnaire with answers of "Yes" or "No" is a valid instrument. High reliability was found between the raters.

Patients' and nurses' perceptions of nursing problems in an acute care setting

AIM

This paper reports a study to determine the degree of agreement or disagreement between nurses and patients in their perceptions of the presence, severity, and importance of nursing problems.

BACKGROUND

Patient experiences, values and preferences are increasingly acknowledged as important factors underpinning healthcare decision-making. The ability to identify patient problems accurately is an important prerequisite for planning and implementing individualized high quality care.

METHODS

A convenience sample of patients (n = 80) and Registered Nurses (n = 30) in an acute care setting responded to a 43-item questionnaire. Findings. Nurses identified patients' problems with a sensitivity of 0.53 and a positive predictive value of 0.50. Patients identified several severe problems that were not identified by nurses, particularly problems with nutrition, sleep, pain, and emotions/spirituality. Nurses underestimated the severity in 47% of mutually-identified problems. An overall level of agreement of 44% was found on the importance of patient problems. Low levels of agreement on severity and importance were related more to individual differences than to systematic differences.

CONCLUSIONS

Nurses need to be more aware that patients and nurses often hold disparate views of the priorities in nursing care. To plan individualized nursing care effectively, nurses need to elicit and use individual patients' preferences more systematically in care planning.

Non-parametric evaluation of memory changes at group and individual level following temporal lobe resection for pharmaco-resistant partial epilepsy

Group versus individual verbal and visuospatial memory outcome following epilepsy surgery was evaluated by a non-parametric method in 25 left and 29 right temporal lobectomy patients. Twenty-five controls were assessed twice. Analyses of change at an individual level evaluated by this statistical approach based on paired-ranks were compared to results with a method based on distances (Reliable Change). The left temporal lobectomy group deteriorated in the two verbal memory variables (p < 0.01 and 0.05). High levels of individual changes unexplained by group patterns were disclosed in the three memory variables analyzed in the patients. Significant individual change, although less pronounced, also occurred in the controls. Group versus individual outcome was adequately distinguished by the non-parametric method. To properly analyze memory change after epilepsy surgery, evaluation at group and individual level ought to combined.

Two-year prospective study of psychosocial outcomes and a cost-analysis of 'treatment-as-usual' versus an 'enhanced' (specialist liaison nurse) service for aneurysmal sub arachnoid haemorrhage (ASAH) patients and families

An 18-month retrospective study of 'treatment-as-usual' of aneurysmal subarachnoid haemorrhage (ASAH, n = 142) used as control to compare prospective study (n = 184) of an 'enhanced' ('Specialist Liaison Nurse'-SLN) service to reduce psychosocial trauma. Consultant notes, Glasgow Coma Scores and 'High Risk' bleeds scores provided clinical data. A standardized patient/carer designed questionnaire provided psychosocial data, plus a cost-analysis. The cohorts were good clinical and social matches. Sixty-five per cent of patients had 'high risk' bleeds, and 81% were Grade 1 and 2 on the GCS, 54% aged less than 55 years, 83% belonged to social classes 1-3 and 32% had school-aged children. Satisfaction with SLN inpatient and discharge care increased significantly, with reduced psychosocial trauma. The SLN produced net 'savings' of pounds sterling 155,000 p.a., from reduced time-off work, medical time and re-admissions. Prospectively, pounds sterling 1.6 + million annual 'savings' were identified on 80% of employed patients returning to work. Long-term dysfunctional stress is not inevitable for most ASAH patients as a SLN is clinically and fiscally cost-effective.

Gender differences in electrical pain threshold responses to transcutaneous electrical nerve stimulation (TENS)

Gender differences in pain perception have been frequently discussed, but the documented gender-related pain-alleviating effects of non-pharmacological methods are sparse. In this study we aimed to investigate changes in electrical sensory thresholds and electrical pain thresholds, in response to high frequency transcutaneous electrical nerve stimulation, TENS, for 20 min in healthy women (n=29) and men (n=29). The thresholds were assessed pre-, during-, and post-TENS. The pattern of change in thresholds was evaluated with a rank-based statistical method regarding the level of systematic change, expressed as relative position (RP) and additional individual changes, expressed as relative rank variance (RV), with its 95% confidence intervals. Equal levels of systematic changes towards increased electrical sensory thresholds were seen in women and men post-TENS (RP, 0.35; 95% CI, 0.07, 0.63, and RP, 0.36; 95% CI, 0.17, 0.53, respectively). At the same point of time, systematic changes towards increased electrical pain thresholds were only seen in women (RP, 0.43; 95% CI, 0.27, 0.60), while they were unchanged in men (RP, -0.01; 95% CI, -0.13, 0.10). Significant additional individual variations were found in the women's responses of assessed electrical sensory and pain thresholds but not in the men's. It is concluded that both women and men responded with a significant increase of the electrical sensory threshold to high frequency TENS, but only women responded with increase of the electrical pain thresholds. The individual variation of the responses was greater in the women than in the men.

Cost-benefit analysis of an integrated approach to reduce psychosocial trauma following neurosurgery compared with standard care: two-year prospective comparative study of enhanced specialist liaison nurse service for aneurysmal subarachnoid hemorrhage (ASAH) patients and carers

BACKGROUND

Dysfunctional psychosocial stress often follows standard treatment for aneurysmal subarachnoid hemorrhage (ASAH). An enhanced Specialist Liaison Nurse (SLN) service sought to reduce this stress in a 2-year comparative prospective study, and was designed to determine if such a service would be cost-effective?

METHOD

Clinical data based on consultant notes, included Glasgow Coma Scale (GCS) and high-risk bleed score. Psychosocial outcomes used a standardized patient/carer designed questionnaire to compare outcomes of the SLN cohort (n = 184) with retrospective 18/12 control ASAH cohort (n = 142). Costs-benefits analysis identified savings in reduced need for subsequent medical care, time-off-work, and contributions to the economy.

RESULTS

The cohorts were socio-clinically well matched; 54% aged less than 55 years, 83% were middle-class and 32% had children still in school; 65% of SLN patients had high risk bleeds, and 81% were Grade 1 and 2 on the G.C.S. The SLN patients and carers had statistically significantly reduced psychosocial trauma compared to controls, with early and easy accessibility being the key to success of SLN. Net savings of $280,000 per annum at 2003 prices, from reduced time-off work, re-admissions and saved medical time. Prospectively, more than $3.03 million is added to the national economy by the 80% of employed patients returning to work.

CONCLUSIONS

We conclude that an integrated ASAH treatment yields major psychosocial and economic benefits. Dysfunctional stress after an ASAH is not inevitable in the majority of patients. High-technology neurosurgery is not just a public cost but also improves and saves lives and generates revenue.

Comparison of cohorts of elective and emergency neurosurgical patients: psychosocial outcomes of acoustic neuroma and aneurysmal sub arachnoid hemorrhage patients and carers

OBJECTIVES

To compare the psychosocial outcomes of cohorts of elective [Acoustic Neuroma (AN)] and emergency [Aneu-rysmal Sub Arachnoid Hemorrhage (ASAH)] Neurosurgical patients and carers.

METHODS

The standardized Wessex Patient Carer Questionnaire was designed with patients and carers and provided psychosocial and economic outcome data following elective or emergency surgery. Clinical data on size of tumor and size of bleed, respectively, were extracted from Consultant notes.

RESULTS

Both cohorts were generally satisfied with neurosurgical in-patient care but both suffered high-economic costs and were predominately very dissatisfied with community care. There were significant psychosocial differences between elective and emergency patients, and despite greater relative physical disability among elective patients, it was the emergency cohort who had worse psychosocial outcomes.

CONCLUSIONS

Despite many common psychosocial features, the differences between the cohorts were mainly psychological rather than physiological, because of greater 'post-traumatic-stress-reaction' in the emergency cohort, indicating the need for appropriate psychosocial care immediately after neurosurgery to reduce unnecessary distress and costs to patients, carers, and community.