Light sensors for objective light measurement in ambulatory polysomnography

Ambulatory polysomnography (PSG) does not commonly include an objective measure of light to determine the time of lights off (Loff), and thus cannot be used to calculate important indices such as sleep onset latency and sleep efficiency. This study examined the technical specifications and appropriateness of a prototype light sensor (LS) for use in ambulatory Compumedics Somte PSG.Two studies were conducted. The first examined the light measurement characteristics of the LS when used with a portable PSG device, specifically recording trace range, linearity, sensitivity, and stability. This involved the LS being exposed to varying incandescent and fluorescent light levels in a light controlled room. Secondly, the LS was trialled in 24 home and 12 hospital ambulatory PSGs to investigate whether light levels in home and hospital settings were within the recording range of the LS, and to quantify the typical light intensity reduction at the time of Loff. A preliminary exploration of clinical utility was also conducted. Linearity between LS voltage and lux was demonstrated, and the LS trace was stable over 14 hours of recording. The observed maximum voltage output of the LS/PSG device was 250 mV, corresponding to a maximum recording range of 350 lux and 523 lux for incandescent and fluorescent light respectively. At the time of Loff, light levels were within the recording range of the LS, and on average dropped by 72 lux (9–245) in the home and 76 lux (4–348) in the hospital setting. Results suggest that clinical utility was greatest in hospital settings where patients are less mobile. The LS was a simple and effective objective marker of light level in portable PSG, which can be used to identify Loff in ambulatory PSG. This allows measurement of additional sleep indices and support with clinical decisions.

The Effect of Serial Dependence on Visual Judgment of Single-Case Charts: An Addendum

This study reanalyzed data presented in a previous investigation (Ottenbacher, 1986a) that explored the relationship between graphic characteristics and visual judgments in single-case charts. Specifically, Ottenbacher computed autocorrelation coefficients for five graphs and examined the relationship between serial dependence and rater agreement or disagreement. The method used by Ottenbacher (1986a) was adopted from previous research and involved analyzing data points combined across baseline and treatment phases. The argument is made that this analysis is incorrect and that serial dependence should be computed using only the baseline data. Reanalysis of the data presented by the previous investigation reveals a strong association (.94) between degree of serial dependence and rater disagreement. The concept of serial dependence and its influence on the analysis of single-case graphs is discussed and the appropriate method of computing serial dependence is presented.

Exercise Improves Physical Function and Mental Health of Brain Cancer Survivors: Two Exploratory Case Studies

Background Malignant brain tumors are unpredictable and incurable, with 5-year survival rates less than 30%. The poor prognosis combined with intensive treatment necessitates the inclusion of complementary and supportive therapies that optimize quality of life and reduce treatment-related declines in health. Exercise therapy has been shown to be beneficial in other cancer populations, but no evidence is available for brain cancer survivors. Therefore, we report results from 2 preliminary cases. Methods Two female patients diagnosed with glioblastoma multiforme and oligodendroglioma participated in a structured and supervised 12-week exercise program. The program consisted of two 1-hour resistance and aerobic exercise sessions per week and additional self-managed aerobic sessions. Outcome measures of strength, cardiovascular fitness, and several psychological indicators (depression, anxiety, and quality of life) were recorded at baseline, after 6 weeks and at the conclusion of the intervention. Results Exercise was well tolerated; both participants completed all 24 sessions and the home-based component with no adverse effects. Objective outcome measures displayed positive responses relating to reduced morbidity. Similar positive responses were found for psychological outcomes. Scores on the Hospital Anxiety and Depression Scale showed clinically meaningful improvements in depression and total distress. Conclusion These findings provide initial evidence that, despite the difficulties associated with brain cancer treatment and survivorship, exercise may be safe and beneficial and should be considered in the overall management of patients with brain cancer.

Visual analysis of single-case time series: Effects of variability, serial dependence, and magnitude of intervention effects

Visual analysis is the dominant method of analysis for single-case time series. The literature assumes that visual analysts will be conservative judges. We show that previous research into visual analysis has not adequately examined false alarm and miss rates or the effect of serial dependence. In order to measure false alarm and miss rates while varying serial dependence, amount of random variability, and effect size, 37 students undertaking a postgraduate course in single-case design and analysis were required to assess the presence of an intervention effect in each of 27 AB charts constructed using a first-order autoregressive model. Three levels of effect size and three levels of variability, representative of values found in published charts, were combined with autocorrelation coefficients of 0, 0.3 and 0.6 in a factorial design. False alarm rates were surprisingly high (16% to 84%). Positive autocorrelation and increased random variation both significantly increased the false alarm rates and interacted in a nonlinear fashion. Miss rates were relatively low (0% to 22%) and were not significantly affected by the design parameters. Thus, visual analysts were not conservative, and serial dependence did influence judgment.

Traditional chinese medicine: an update on clinical evidence

BACKGROUND

As an alternative medical system, Traditional Chinese Medicine (TCM) has been increasingly used over the last several decades. Such a consumer-driven development has resulted in introduction of education programs for practitioner training, development of product and practitioner regulation systems, and generation of an increasing interest in research. Significant efforts have been made in validating the quality, effectiveness, and safety of TCM interventions evidenced by a growing number of published trials and systematic reviews. Commonly, the results of these studies were inconclusive due to the lack of quality and quantity of the trials to answer specific and answerable clinical questions.

OBJECTIVES

The methodology of a randomized clinical trial (RCT) is not free from bias, and the unique features of TCM (such as individualization and holism) further complicate effective execution of RCTs in TCM therapies. Thus, data from limited RCTs and systematic reviews need to be interpreted with great caution. Nevertheless, until new and specific methodology is developed that can adequately address these methodology challenges for RCTs in TCM, evidence from quality RCTs and systematic reviews still holds the credibility of TCM in the scientific community.

CONCLUSIONS

This article summarizes studies on TCM utilization, and regulatory and educational development with a focus on updating the TCM clinical evidence from RCTs and systematic reviews over the last decade. The key issues and challenges associated with evidence-based TCM developments are also explored.

The high-level mobility assessment tool (HiMAT) for traumatic brain injury. Part 2: Content validity and discriminability

PRIMARY OBJECTIVES

(i) To assess the measurement properties of the high-level mobility assessment tool (HiMAT) for people with traumatic brain injury (TBI), (ii) to measure the extent to which the HiMAT is a uni-dimensional, discriminative hierarchical outcome scale.

RESEARCH DESIGN

The content validity was assessed using a three-stage process of investigating internal consistency, factor analysis and Rasch analysis. The uni-dimensionality of the HiMAT items was also tested. Discriminability was investigated by correlating raw and logit scores obtained from Rasch analysis. The study was conducted at a major rehabilitation facility using a convenience sample of 103 adults with TBI.

MAIN OUTCOMES AND RESULTS

The internal consistency for the high-level items was very high (Cronbach's alpha = 0.99). Principal axis factoring identified several balance items as belonging to a second factor not related to high-level mobility, hence these items were excluded. Rasch analysis identified several misfitting items, such as walking around a figure of eight and stopping from a run, which were also excluded. Logit scores were used to exclude clustered and, therefore, redundant items. Raw scores correlated very highly (r = 0.98) with logit scores, indicating that raw scores provided good discriminability and were suitable for use by clinicians.

CONCLUSION

The HiMAT, which assesses higher-level mobility requirements of people with TBI for return to pre-accident social, leisure and sporting activities, is a uni-dimensional and discriminative scale for quantifying therapy outcomes.

Can transtheoretical model measures predict relapse from the action stage of change among ex-smokers who quit after calling a quitline?

This study explored whether transtheoretical model (TTM) measures could predict relapse from the action stage, i.e., during the first 6 months of smoking cessation. Predictors of relapse were examined between time 2 (3-month) and time 3 (6-month) assessments (n = 247), and also between time 3 (6-month) and time 4 (12-month) assessments (n = 204). Consistent predictors of relapse included lower self-efficacy and determination to quit and higher temptations to smoke. Some predictors of relapse changed according to how long a person had already been quit for. Contrary to the TTM, greater behavioral change process use predicted relapse among people who had already quit for less than a month, and did not prevent relapse among those who had already quit for a month or more between time 2 and time 3. Cross-sectional analyses showed significant decreases in temptations to smoke and in the use of some of the change processes, which stabilised at about 1 month post-cessation. The findings suggest that there may be a stage boundary at around 1 month post-cessation, and question the homogeneity, and hence validity, of the TTM-defined action stage of change.

High-Level Mobility Assessment Tool (HiMAT): interrater reliability, retest reliability, and internal consistency

BACKGROUND AND PURPOSE

The High-Level Mobility Assessment Tool (HiMAT) assesses high-level mobility in people who have sustained a traumatic brain injury (TBI). The purpose of this study was to investigate the interrater reliability, retest reliability, and internal consistency of data obtained with the HiMAT.

SUBJECTS

Three physical therapists and 103 people with TBI were recruited from a rehabilitation hospital.

METHODS

Three physical therapists concurrently assessed a subset of 17 subjects with TBI to investigate interrater reliability. One physical therapist assessed a different subset of 20 subjects with TBI on 2 occasions, 2 days apart, to investigate retest reliability. Data from the entire sample of 103 subjects were used to investigate the internal consistency of this new scale.

RESULTS

Both the interrater reliability (intraclass correlation coefficient [ICC]=.99) and the retest reliability (ICC=.99) of the HiMAT data were very high. For retest reliability, a small systematic change was detected (t=3.82, df=19), indicating a marginal improvement of 1 point at retest. Internal consistency also was very high (Cronbach alpha=.97).

DISCUSSION AND CONCLUSION

The HiMAT is a new tool specifically designed to measure high-level mobility, which currently is not a component of existing scales used in TBI. This study demonstrated that the HiMAT is a reliable tool for measuring high-level mobility.

Association between intellectual functioning and age in children and young adults with Duchenne muscular dystrophy: further results from a meta-analysis

This study used meta-analytical techniques to explore the association between intelligence and age in children with Duchenne muscular dystrophy (DMD). The sample comprised 1224 children and young adults with DMD (mean age 12 y 3 mo, SD 4 y; range 2 y to 27 y). Standardized measures including the Wechsler Intelligence Scales (WIS) and the Stanford-Binet Intelligence Scales were used to estimate intelligence. No age-related difference was noted for Full-scale and Performance intelligence quotients (IQ). However, Verbal IQ increased significantly with age. Age-related increases were noted for the WIS Information, Similarities, Arithmetic, Comprehension, Digit Span, Picture Arrangement, Block Design, and Coding subscales. These results support the notion that younger children with DMD have deficits in verbal reasoning and verbal processing. Older children with DMD, particularly those of 14 years and older, were less likely to present with these problems. Implications of these findings and possible future research directions are discussed.

Self-reported sleep during the third trimester of pregnancy

Retrospective (questionnaire) and prospective (5-day diary) self-reports of sleep were obtained from 209 women during the 3rd trimester of pregnancy. On average, the women slept for 465 min, took around 20 min to get to sleep, and were awake for just over 30 min after initial sleep onset having woke 2.6 times on average. Sleep efficiency was around 89%. Significant differences were found between retrospective and prospective reports only on the number of minutes awake after sleep onset and on sleep efficiency. However, these differences were small. Retrospective and prospective reports were only moderately correlated. These results were not markedly different from values reported in much smaller, previous studies of pregnant women using polysomnography, suggesting that the self-reports were valid. The findings suggest that sleep parameters are not as adversely affected during the 3rd trimester of pregnancy as is generally believed.

Persistence of cognitive effects after withdrawal from long-term benzodiazepine use: a meta-analysis

Despite the widespread prescribing of benzodiazepines, uncertainty still surrounds the potential for cognitive impairment following their long-term use. Furthermore, the degree of recovery that may take place after withdrawal or the level of residual impairment, if any, that is maintained in long-term benzodiazepine users is also unclear. The current paper employed meta-analytic techniques to address two questions: (1) Does the cognitive function of long-term benzodiazepine users improve following withdrawal? (2) Are previous long-term benzodiazepine users still impaired at follow-up compared to controls or normative data? Results of the meta-analyses indicated that long-term benzodiazepine users do show recovery of function in many areas after withdrawal. However, there remains a significant impairment in most areas of cognition in comparison to controls or normative data. The findings of this study highlight the problems associated with long-term benzodiazepine therapy and suggest that previous benzodiazepine users would be likely to experience the benefit of improved cognitive functioning after withdrawal. However, the reviewed data did not support full restitution of function, at least in the first 6 months following cessation and suggest that there may be some permanent deficits or deficits that take longer than 6 months to completely recover.

Cognitive effects of long-term benzodiazepine use: a meta-analysis

INTRODUCTION

While benzodiazepines are the most widely used psychotropic drugs, there are relatively few studies that have examined deficits in cognitive functioning after long-term use. The literature that is available is difficult to interpret due to conflicting results as well as a variety of methodological flaws.

OBJECTIVE

To systematically evaluate and integrate the available research findings to determine the effect of long-term benzodiazepine use on cognitive functioning using meta-analytical techniques.

METHODS

Thirteen research studies that employed neuropsychological tests to evaluate cognitive performance after long-term use of benzodiazepine medication met inclusion criteria. The neuropsychological tests employed in these 13 studies were each categorised as measuring one of 12 cognitive domains. Separate effect sizes were calculated for each of the 12 cognitive categories. Each study was only allowed to contribute one effect size to each cognitive category by averaging together the effect sizes from the same study if more than one type of test was used to measure a particular category. This strategy resulted in equal weight being given to each study per category, regardless of the number of tests in that category.

RESULTS

The overall mean number of patients who were benzodiazepine users was 33.5 (SD +/- 28.9) and the mean number of controls was 27.9 (SD +/- 19.6). The duration of benzodiazepine use ranged from 1 to 34 (mean 9.9) years. Long-term benzodiazepine users were consistently more impaired than controls across all cognitive categories examined, with effect sizes ranging in magnitude from -1.30 to -0.42. The mean weighted effect size was -0.74 (SD +/- 0.25). None of the effect sizes had 95% CIs that spanned zero and, therefore, all of these effects were significant and different to zero.

CONCLUSION

Moderate-to-large weighted effect sizes were found for all cognitive domains suggesting that long-term benzodiazepine users were significantly impaired, compared with controls, in all of the areas that were assessed. However, this study has several limitations, one being that it includes a relatively small number of studies. Further studies need to be conducted; ideally, well designed, controlled studies that thoroughly investigate certain areas of cognitive functioning and present data in such a way so as to be amenable to inclusion in a meta-analysis. Incorporating the information from these studies into a larger meta-analysis would allow for a more thorough and statistically sound investigation of the effects of moderator variables. The observation that long-term benzodiazepine use leads to a generalised effect on cognition has numerous implications for the informed and responsible prescription of these drugs.

What Is the Right Thing at the Right Time? Interactions Between Stages and Processes of Change Among Smokers Who Make a Quit Attempt

C. A. Perz, C. C. DiClemente, and J. P. Carbonari (1996) claim support for the transtheoretical model notion that success in smoking cessation involves doing the right thing at the right time: emphasising experiential change processes during the contemplation and preparation stages and shifting to behavioral process activities during action. A key methodological limitation of Perz et al. was their failure to control for stage of change, a measure that has been shown to be predictive of cessation. This study replicates the prospective findings of Perz et al. in a different data set, then controls for stage of change when it is predictive of cessation, and finds that the measures of "appropriate" change process use developed by Perz et al. no longer predict cessation. The authors conclude that stage of change, in particular the distinction between smoking and not smoking, is more important than change process use in predicting cessation outcomes.

The Mobility Scale for Acute Stroke Patients: concurrent validity

OBJECTIVE

A new scale, the Mobility Scale for Acute Stroke Patients (MSAS), was developed to specifically discriminate between the lower levels of mobility found in acute stroke patients in the first two weeks post onset. The aim of this study was to investigate the concurrent validity of this new scale with other established scales.

MAIN OUTCOME MEASURES

Concurrent validity was assessed with respect to four other well-validated measures: Motor Assessment Scale (MAS), Functional Ambulation Classification system (FAC), Functional Independence Measure (FIM), and Barthel Index (BI). The measures selected for comparison contained items similar to those in the MSAS.

SUBJECTS

From a total of 539 patients who were admitted over a two-year period with a primary diagnosis of stroke, 106 satisfied the criteria for inclusion in this study.

RESULTS

The MSAS was found to have a high level of concurrent validity (r > 0.80) when the total score was correlated with the total scores of the MAS, FAC, FIM (mobility and ADL) and BI. A high level of association was found between the nonbed mobility items (sit to stand, stand and walk) of the MSAS and the mobility items (toileting, transfers, walk and stairs) of the FIM and BI. There was a weaker association between the MSAS items and the ADL items (activities of daily living) of the BI and FIM.

CONCLUSION

A new scale designed specifically for acute stroke patients was found to have a high degree of concurrent validity when compared with four other scales containing similar items.

Accuracy and reliability of observational gait analysis data: judgments of push-off in gait after stroke

BACKGROUND AND PURPOSE

Physical therapists routinely observe gait in clinical practice. The purpose of this study was to determine the accuracy and reliability of observational assessments of push-off in gait after stroke.

SUBJECTS

Eighteen physical therapists and 11 subjects with hemiplegia following a stroke participated in the study.

METHODS

Measurements of ankle power generation were obtained from subjects following stroke using a gait analysis system. Concurrent videotaped gait performances were observed by the physical therapists on 2 occasions. Ankle power generation at push-off was scored as either normal or abnormal using two 11-point rating scales. These observational ratings were correlated with the measurements of peak ankle power generation.

RESULTS

A high correlation was obtained between the observational ratings and the measurements of ankle power generation (mean Pearson r=.84). Interobserver reliability was moderately high (mean intraclass correlation coefficient [ICC (2,1)]=.76). Intraobserver reliability also was high, with a mean ICC (2,1) of.89 obtained.

DISCUSSION AND CONCLUSION

Physical therapists were able to make accurate and reliable judgments of push-off in videotaped gait of subjects following stroke using observational assessment. Further research is indicated to explore the accuracy and reliability of data obtained with observational gait analysis as it occurs in clinical practice.

Evaluating the effectiveness of stroke rehabilitation: choosing a discriminative measure

OBJECTIVE

To evaluate the discriminative ability of several measures of physical disability used to determine quality of outcome for poststroke rehabilitation.

DESIGN

A comparative study, using Rasch analysis, of the discriminative ability of functional status and mobility measures in rehabilitation patients with stroke.

SETTING

A 26-bed rehabilitation unit, on site of a tertiary teaching hospital in Melbourne, Australia.

PARTICIPANTS

A consecutive sample of 106 patients with acute stroke admitted for rehabilitation.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Rasch analysis of the motor subscale of the FIM instrument, Motor Assessment Scale, Functional Ambulation Classification, gait velocity, and gait endurance.

RESULTS

The more difficult items of the FIM motor scale adequately discriminated among higher functioning patients. The gait velocity measure further distinguished 9% of the sample, who functioned at a higher level than could be indicated by FIM motor subscale. The other measures did not add levels of discrimination to that provided by the FIM motor. Ability estimates provided by Rasch analysis of the FIM motor scale were a more accurate indication of ability than raw scores. Raw scores underestimated change in ability observed at higher levels of ability.

CONCLUSION

Rasch estimates of the FIM motor subscale provide a discriminative measure for evaluating outcomes and change in ability achieved in stroke rehabilitation.

Accident cognitions and subsequent psychological trauma

This study used a sample of 72 consecutive attendees to hospital following motor vehicle accidents. It aimed to assess the relationship between demographic variables, details of the accident and cognitions about the accident recorded soon afterward, and degree of psychological trauma 3 and 6 months later. Psychological trauma was assessed using the General Health Questionnaire, Impact of Event Scale, and Posttraumatic Stress Disorder Interview. A structured interview was used to gain information about demographic, accident, and accident cognition variables. Results showed that initial cognitions such as perceived threat to life, rather than demographic or accident variables, had the strongest relationships to subsequent trauma.

Self-reported voice problems among three groups of professional singers

A vocal health questionnaire was administered to three groups of professional singers and a "friendship-matched" group of nonsingers in Melbourne, Australia. The responses of 79 opera, 57 musical theatre and 31 contemporary (excluding rock) singers and 86 nonsingers were analysed. The questionnaire solicited information regarding biographical data speaking and singing voice-use behaviours, and vocal health over the previous 12 months in terms of experiences of vocal impairment, vocal disability, and handicap. Significant differences between singers and nonsingers in the prevalence and nature of voice problems were reported. Of the singers, 44% reported one or more occurrences of a diagnosed vocal condition compared to 21% of nonsingers and 69% of singers experienced vocal disability compared to only 41% of nonsingers, over the previous 12 months. In contrast, no significant differences were found between the three different styles of singers in their experience of vocal impairment, disability or handicap.

Prevalence of voice problems in teachers

Teachers are frequently cited as experiencing a high rate of vocal dysfunction (1-7). Despite considerable research in the area of voice problems in teachers, the prevalence of voice disorders in this group is unknown. This study investigated the prevalence of self-reported voice problems in teachers using a mail survey of a simple random sample of 1168 state school teachers (preschool-Grade 12) in South Australia. As part of the survey, teachers were asked to report voice problems for the day of the survey, during the current teaching year, and during their careers. The response rate was 75%, with 16% of teachers reporting voice problems on the day of the survey, 20% reporting problems during the current teaching year, and 19% reporting problems at some time during their career. Females were twice as likely as males to report voice problems. These findings clearly indicate a need for further investigation of the causes of vocal dysfunction in teachers and for the development of educational programs aimed at preventing voice problems in this group of professional voice users.

Vocal problems among teachers: a review of prevalence, causes, prevention, and treatment

Voice disorders are thought to be one of the major occupational hazards of school teaching. The resulting symptoms can affect teachers' ability to function in the classroom and prevent them from developing effective working relationships with other staff and students. Sick leave, speech pathology management, and surgical intervention can be costly. Severe voice problems can also result in a teacher permanently leaving the classroom. Despite the significant implications of voice disorders for teachers, this review of published research demonstrates that findings concerning the prevalence of voice problems in teachers and the causes and contributing factors of those voice problems are inconclusive. Similarly, previous research on the efficacy of prevention programs and treatment of voice problems in teachers provide few firm conclusions. Further research based on sound empirical data is needed, as many past studies have relied on anecdotal or self-report data. More operational definitions of what constitutes a voice disorder and the associated contributing factors should be adopted, along with the use of more instrumental measures and careful attention to methodology and appropriate statistical analyses. Only then will we have a sound basis for the development of effective prevention and education programs for teachers.

Psychological symptoms in rural road trauma victims

There is limited research into the psychological aftermath for people who have experienced road accidents, especially outside major cities. This study by postal survey used the General Health Questionnaire-28, the Impact of Events Scale, the Post-Traumatic Stress Disorder Interview, and the Late Effects of Accidental Injury Questionnaire to assess the psychological effects on a sample of 80 people who had attended a hospital in a regional Australian centre following road accidents. Results showed that there were marked effects on many people and that these had not always been diagnosed or treated.

Decision polarization among rehabilitation team recommendations concerning discharge housing for stroke patients

This study sought to identify if decision polarization effects were operating in rehabilitation teams when making discharge housing recommendations for stroke patients. Using a Social Judgment Theory approach, individual clinicians were asked to nominate discharge housing for stroke patients. Teams were then assembled and clinicians repeated the task. The research was conducted at a sample of seven in-patient rehabilitation hospitals. The subjects were 74 clinicians who formed 13 teams. All subjects were volunteers, and represented the following professions: medicine, nursing, occupational therapy, physical therapy, speech therapy, and social work. A casebook which described 50 hypothetical stroke patients in terms of eight attributes was devised for the study. Subjects made housing recommendations to these patients using a 7-point scale. When compared to individual clinicians' recommendations, it was found that team housing recommendations made by all 13 teams polarized towards both more supported and, in the other extreme, more independent types of housing. However, teams placed a stronger emphasis on supported housing when compared with individual clinician decisions. This decision polarization suggests that housing recommendations made to patients may reflect team processes as well as patient needs. Rehabilitation teams should be aware of this negative team dynamic so that steps to minimize decision polarization can be taken.

Effect of progesterone and its 5 alpha and 5 beta metabolites on symptoms of premenstrual syndrome according to route of administration

Orally administered progesterone may have advantages over other routes of administration in the treatment of premenstrual syndrome (PMS) because of substantially higher levels of the anxiolytic metabolites 5 alpha and 5 beta pregnanolone. The only previous placebo-controlled trial which used oral progesterone reported beneficial effects in the treatment of PMS. The present study, a double-blind crossover trial, compared the administration of 300 mg daily oral progesterone with 200 mg daily vaginal progesterone and matched placebos for 10 days premenstrually. Although there was a significant treatment effect on symptoms, no difference between active treatments and placebo was found. The trial was terminated with 25 women completing treatment as it was evident that no clinically significant effect of either form of progesterone was likely to be detected even with twice the sample size. Serum levels of progesterone and metabolites showed that oral administration resulted in supraphysiological levels of 5 alpha and 5 beta metabolites and there was a negative correlation between 5 alpha pregnanolone levels and anxiety. However, this did not translate to overall reduction in premenstrual distress or anxiety beyond that achieved by placebo, as measured by validated questionnaires.

Identifying effective psychological treatments for insomnia: a meta-analysis

Insomnia is a debilitating and widespread complaint. Concern over the iatrogenic effects of pharmacological therapies has led to the development of several psychological treatments for insomnia. To clarify the effects of these treatments, 66 outcome studies representing 139 treatment groups were included in a meta-analysis. The results indicated that psychological treatments produce considerable enhancement of both sleep patterns and the subjective experience of sleep. In terms of enhancing sleep onset, active treatments were all superior to placebo therapies but did not differ greatly in efficacy. Greater therapeutic gains were available for participants who were clinically referred and who were not regular users of sedative hypnotics. Future research directions are suggested.

Rehabilitation teams decisions on discharge housing for stroke patients

For older people who have had a stroke, appropriate housing can promote independence and well being. However, suboptimal team accommodation recommendations may result in placement of an individual where their needs are not met, and their skills are not maximized. Although clinical judgments regarding patient discharge are routinely made by rehabilitation teams, this area has received limited research attention. This study examines how rehabilitation teams determine the most appropriate housing to recommend to stroke patients after their discharge from hospitals. A Social Judgment Theory approach was used to document and analyze the accommodation recommendations and policies of 13 rehabilitation teams (clinician n = 74). Teams were asked to consider 50 hypothetical stroke patients, and determine the most appropriate discharge housing to recommend to these patients. Each stroke patient was described in terms of 8 attributes: mobility status, ability to manage their own affairs, patient's choice of housing, personal activity of daily living (ADL) skills, domestic and community ADL skills, general health status, social situation, and premorbid living arrangements. Clinicians were provided with a response scale on which to record their recommendations. The results showed considerable yet reliable differences among teams concerning recommendations made, and judgment policies adopted. Although the highly structured and hypothetical nature of this research limits the external validity of findings, the results suggest that teams may also face difficulties with housing recommendations in the more complex clinical environment. Further studies to assess actual clinical team decision making are needed. Such studies could lead to the development of a standardized research-based protocol to help teams formalize and optimize their housing recommendations.

Identifying effective psychological treatments for insomnia: a meta-analysis

Insomnia is a debilitating and widespread complaint. Concern over the iatrogenic effects of pharmacological therapies has led to the development of several psychological treatments for insomnia. To clarify the effects of these treatments, 66 outcome studies representing 139 treatment groups were included in a meta-analysis. The results indicated that psychological treatments produce considerable enhancement of both sleep patterns and the subjective experience of sleep. In terms of enhancing sleep onset, active treatments were all superior to placebo therapies but did not differ greatly in efficacy. Greater therapeutic gains were available for participants who were clinically referred and who were not regular users of sedative hypnotics. Future research directions are suggested.

An evaluation of the Circadian Type Questionnaire

This study evaluates the psychometric properties and assesses the test-retest reliability and longer-term stability of scores on the Circadian Type Questionnaire (CTQ) of Folkard et al. (1979) in a sample of 445 students. The scales were found to lack internal consistency and the factor structure originally proposed was not replicated. Cultural variation in CTQ scores was suggested. Test-retest reliability, over three months in a subgroup of 36, was poor for the V and M scales. Longer-term stability, over nine months in a subgroup of 36 who were exposed to shiftwork, was better but significant decreases were found in rigidity of sleeping habits (R_s) and morningness (M) scores. A factor analysis suggested that the scales should be constructed differently; however, the properties of such scales were still not optimal. The CTQ has psychometric flaws and needs to be improved before it could be expected to reliably function as a predictive test of adaptation to shiftwork.

Rehabilitation of older injured workers

This paper provides a review of international findings in rehabilitation outcomes for older workers. Older workers are disadvantaged in terms of their rehabilitation following injury. They sustain more serious injuries, take longer to recover and are less likely to return to work than younger workers. This results in substantial economic costs to the community as well as a reduction in financial security and quality of life for the older person. A number of possible explanations for the relationship between age and rehabilitation outcomes are discussed. It is proposed that the application of a 'biopsychosocial' model to rehabilitation outcome may be a useful way of conceptualizing the complexity of the rehabilitation process in older workers and predicting rehabilitation outcomes.

Seasonality in panic disorder

Following a clinical observation of increased anxiety symptoms and mood changes during winter in panic disorder patients, the Seasonal Pattern Assessment Questionnaire (SPAQ) was completed by 133 patients. Global Seasonality Scores (GSS), and the prevalence of Seasonal Affective Disorder (SAD), were significantly higher than reported in general population studies. Seasonal changes were also found in anxiety and panic attacks. These findings suggest the possibility of a common aetiology for panic disorder and SAD, that seasonality may be a far more general phenomenon in psychopathology, and that light therapy may be a useful treatment for some panic disorder patients.

Retest reliability of the temporal and distance characteristics of hemiplegic gait using a footswitch system

Using a footswitch system, the retest reliability of the temporal and distance parameters of gait was investigated within a session for 22 stroke patients in the early phase of rehabilitation. High to very high reliability was found for the temporal and distance parameters of gait, and the temporal symmetry index based on the difference in single-limb support duration between each leg (r = 0.85 to 0.98; intraclass correlation coefficients (ICC)(2,1) = 0.82 to 0.98). Significant differences were found between the two trials for velocity, stride length, and total double support (p < .05). Despite the high reliability coefficients, 95% confidence intervals, which take into account the random and systematic error, were wide for all parameters. These wide confidence intervals indicate that the use of two consecutive measurements for interpreting an individual patient's change would not be a sensitive method for monitoring progress or deterioration during rehabilitation. Strategies that may improve the clinical usefulness of temporal and distance gait measures in stroke rehabilitation are discussed. These include further reducing error sources, increasing data collection per measurement, using serial measurements on each patient, or using less rigorous confidence intervals.

Sleeping patterns during pregnancy in Japanese women

Although sleep disturbance is commonly reported in pregnancy, there have been few studies on sleep characteristics in pregnancy. In this study, all women attending the antenatal clinic at Sapporo Medical College Hospital for 1 month during autumn and 3 months during winter were surveyed with a questionnaire and sleep log. Of the 192 patients, 169 (88.0%) stated that sleep was altered from their usual experience. A principal components analysis identified three sleep factors from the ten items in the measure of sleep used (Sleep Log). The three factors were: Sleep Duration and Quality, Insomnia and Daytime Alertness. Although no significant differences across trimesters were found on the three sleep factors, Sleep Duration and Quality, and Insomnia were worst during the first trimester. Sleep normalized in the second trimester, but the third trimester was characterized by increased Insomnia and decreased Daytime Alertness. The most frequent reasons cited by women for sleep alterations were urinary frequency, backache or ache in the hips and fetal movement. Contingency X2 analyses were used to investigate a relationship between the frequency of reporting the reasons and the trimester of pregnancy. Significant increases were found in reporting as the reasons for sleep difficulties, fetal movement in the third trimester, and heartburn, nausea and vomiting in the first trimester. The description of sleep patterns during pregnancy has clinical relevance as sleep alterations in pregnancy are common.

Long-term stability and psychometric properties of the Composite Scale of Morningness

Prompted by some discrepancies in the report detailing the development of the Composite Scale (CS) of Morningness (Smith et al. 1989) this study replicated the examination of the psychometric properties of the CS on a large sample (n = 424) of health science students. It was confirmed that the mean and range of CS scores previously reported were in error. The finding that the CS has good psychometric properties when used on samples of students was replicated and extended to a smaller (n = 35) sample of individuals working on rotating shifts. CS scores were found to be stable over time and did not change when subjects were exposed to night- and shiftwork.

Melatonin and hormonal changes in disturbed sleep during late pregnancy

Although sleep disturbance is commonly reported in pregnancy, there have been surprisingly few studies on the etiology of this condition. Since most hormones show circadian rhythmicity and maintain specific phase relationships with that of the sleep-wake cycle, it was of interest to establish whether sleep disturbances covaried with endocrine changes. This overnight study of pregnant women compared melatonin, cortisol, and prolactin secretion rhythms in six good sleepers and six poor sleepers. The groups were compared by ratios of the areas under the various hormonal curves. Significant differences in the cortisol/melatonin ratio were found between the poor sleeper group (lower values) and the good sleeper group (higher values). Nonsignificant trends, which might be expected to become significant with larger sample sizes, were found for decreased amplitude in the cortisol rhythm and increased amplitude in the melatonin rhythm in poor sleepers. The decreased amplitude of the cortisol rhythm in poor sleepers appeared to be due to a suppression of the early morning (0500-0800) rise. Prolactin levels were high and showed no rhythmicity in both groups. These differences may reflect changes in the circadian pacemaker system of poor sleepers, with increases in melatonin release being a response to counteract poor sleep.

Traumatic atlanto-occipital dislocation in two dogs

In 2 cases of traumatic atlanto-occipital dislocation in the dog, neurologic signs were associated with cranial cervical pain. Treatment consisted of manual reduction, with the dog under general anesthesia, followed by application of a plaster cast to hold the head and neck in flexion. Recovery was complete in both cases.