Examination of the psychometric properties of the FORensic oUtcome Measure (FORUM): a new outcome measure for forensic mental health services

Introduction

Forensic mental health services provide care to people in secure psychiatric hospitals and specialised community teams. Measuring outcomes is important to ensure such services perform optimally, however existing measures are not sufficiently comprehensive and are rarely patient reported.

Objectives

To examine a novel instrument for measuring outcomes in forensic mental health services, the FORensic oUtsome Measure (FORUM), which consists of a complementary patient reported questionnaire (FORUM-P) and clinician reported questionnaire (FORUM-C).

Methods

Inpatients at a forensic psychiatric service based in a regional healthcare organization in the UK completed the FORUM-P, while members of their clinical teams completed the FORUM-C. Patients and clinicians also provided feedback on the questionnaires.

Results

Sixty-two patients participated with a mean age of 41.0 years (standard deviation 11.3). For internal consistency, Cronbach’s alpha for the FORUM-P was 0.87 (95% confidence interval (CI) 0.80-0.93) and for the FORUM-C was 0.93 (95% CI 0.91-0.96). For test-retest reliability the weighted kappa for the FORUM-P was 0.44 (95% CI 0.24-0.63) and for the FORUM-C was 0.78 (95% CI 0.73-0.85). For interrater reliability of the FORUM-C the Spearman correlation coefficient was 0.47 (95% CI 0.18-0.69). The FORUM-P received an average rating of 4.0 out of 5 for comprehensiveness, 4.6 for ease of use and 3.9 for relevance, while the FORUM-C received 4.1 for comprehensiveness, 4.5 for ease of use and 4.3 for relevance.

Conclusions

Outcome measures in forensic mental health can be developed with good measures of reliability and validity, and can be introduced into services to monitor patient progress.

Disclosure

No significant relationships.

Suicidal ideation in the perinatal period: findings from the Thailand-Myanmar border

BACKGROUND

Suicide is a leading cause of maternal death globally. Migrant and refugee populations may experience higher risk of suicide. We report data on suicidal ideation from migrant and refugee women living on the Thailand-Myanmar border.

METHODS

Women were recruited in their first trimester of pregnancy. Depression status was assessed by diagnostic interview in the first, second and third trimesters and at 1 month post-partum. We calculated prevalence of suicidal ideation and used logistic regression to identify associated socio-demographic factors.

RESULTS

During the perinatal period, 5.3% (30/568) women experienced suicidal ideation. Refugee women were more likely to experience suicidal ideation than migrant women (8.0 versus 3.1%; P = 0.01). Most women with suicidal ideation did not have severe depression. Previous trauma (OR 2.32; 95% CI: 1.70-3.15) and unplanned pregnancy (OR 2.74; 95% CI: 1.10-6.86) were significantly associated with suicidal ideation after controlling for all other variables.

CONCLUSIONS

Suicidal ideation represents an important symptom among migrant and refugee women on the Thailand-Myanmar border. Screening only those with severe depression may be insufficient to identify women at risk of suicide. Community-level interventions addressing social and gender inequalities and prioritization of family planning programmes are needed alongside targeted suicide prevention initiatives to help lower the rates of people dying by suicide.

Technology-supported home monitoring in heart failure patients

Background

Digital health promises to enhance the prevailing episodic models of chronic heart failure (HF) care.

Purpose

We aimed to test the hypothesis that digital home monitoring with centralised specialist support for remote management of HF and major vascular comorbidities is more effective in optimising medical therapy and improving patients' quality of life than digital home monitoring alone.

Methods and results

In a two-armed partially blinded parallel randomised controlled trial, seven sites in the United Kingdom recruited a total of 202 adults with HF (71.3 years SD 11.1; mean left ventricular ejection fraction 32.9% SD 15.4). Participants were selected for being at high risk of adverse outcomes or high potential to benefit from remote management. Participants in both study arms were given an internet-enabled tablet computer, Bluetooth-enabled blood pressure monitor and weighing scales for health monitoring. After a run-in period, participants randomized to intervention received additional regular feedback to support self-management and their primary care doctors received instructions on blood investigations and pharmacological treatment. The primary outcome was the use of recommended medical therapy, for chronic HF and major comorbidities, measured as a composite opportunity score. Co-primary outcome was change in physical score of Minnesota Living with Heart failure questionnaire.

At the end of the trial, the weighted opportunity score was 0.54 (CI 95% 0.46, 0.62) in the control group and 0.61 (CI 95% 0.52, 0.70) in the intervention arm (p for mean difference=0.25). Physical well-being of participants did not differ significantly between the groups either (p=0.55).

Conclusions

Central provision of tailored specialist management in a multimorbid HF population was feasible. However, there was no strong evidence for improvement in use of evidence-based therapies nor health-related quality of life.

Figure 1

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): National Institute for Health Research (NIHR) Health Services Research and Delivery; NIHR Career Development Fellowship

A core outcome set for pre-eclampsia research: an international consensus development study

OBJECTIVE

To develop a core outcome set for pre-eclampsia.

DESIGN

Consensus development study.

SETTING

International.

POPULATION

Two hundred and eight-one healthcare professionals, 41 researchers and 110 patients, representing 56 countries, participated.

METHODS

Modified Delphi method and Modified Nominal Group Technique.

RESULTS

A long-list of 116 potential core outcomes was developed by combining the outcomes reported in 79 pre-eclampsia trials with those derived from thematic analysis of 30 in-depth interviews of women with lived experience of pre-eclampsia. Forty-seven consensus outcomes were identified from the Delphi process following which 14 maternal and eight offspring core outcomes were agreed at the consensus development meeting. Maternal core outcomes: death, eclampsia, stroke, cortical blindness, retinal detachment, pulmonary oedema, acute kidney injury, liver haematoma or rupture, abruption, postpartum haemorrhage, raised liver enzymes, low platelets, admission to intensive care required, and intubation and ventilation. Offspring core outcomes: stillbirth, gestational age at delivery, birthweight, small-for-gestational-age, neonatal mortality, seizures, admission to neonatal unit required and respiratory support.

CONCLUSIONS

The core outcome set for pre-eclampsia should underpin future randomised trials and systematic reviews. Such implementation should ensure that future research holds the necessary reach and relevance to inform clinical practice, enhance women's care and improve the outcomes of pregnant women and their babies.

TWEETABLE ABSTRACT

281 healthcare professionals, 41 researchers and 110 women have developed #preeclampsia core outcomes @HOPEoutcomes @jamesmnduffy. [Correction added on 29 June 2020, after first online publication: the order has been corrected.].

Impact of a national enhanced recovery after surgery programme on patient outcomes of primary total knee replacement: an interrupted time series analysis from "The National Joint Registry of England, Wales, Northern Ireland and the Isle of Man"

OBJECTIVE

We aimed to test whether a national Enhanced Recovery After Surgery (ERAS) Programme in total knee replacement (TKR) had an impact on patient outcomes.

DESIGN

Natural-experiment (April 2008-December 2016). Interrupted time-series regression assessed impact on trends before-during-after ERAS implementation.

SETTING

Primary operations from the UK National Joint Registry (NJR) were linked with Hospital Episode Statistics (HES) data which contains inpatient episodes undertaken in National Health Service (NHS) trusts in England, and Patient Reported Outcome Measures (PROMs).

PARTICIPANTS

Patients undergoing primary planned TKR aged ≥18 years.

INTERVENTION

ERAS implementation (April 2009-March 2011).

OUTCOMES

Regression coefficients of monthly means of Length of stay (LOS), bed day costs, change in Oxford knee scores (OKS) 6-months after surgery, complications (at 6 months), and rates of revision surgeries (at 5 years).

RESULTS

486,579 primary TKRs were identified. Overall LOS and bed-day costs decreased from 5.8 days to 3.7 and from £7607 to £5276, from April 2008 to December 2016. Oxford knee score (OKS) change improved from 15.1 points in April 2008 to 17.1 points in December 2016. Complications decreased from 4.1 % in April 2008 to 1.7 % in March 2016. 5-year revision rates remained stable at 4.8 per 1000 implants years in April 2008 and December 2011. After ERAS, declining trends in LOS and bed costs slowed down; OKS improved, complications remained stable, and revisions slightly increased.

CONCLUSIONS

Different secular trends in outcomes for patients having TKR have been observed over the last decade. Although patient outcomes are better than a decade ago ERAS did not improve them at national level.

Effectiveness of open and arthroscopic rotator cuff repair (UKUFF): a randomised controlled trial

AIMS

The appropriate management for patients with a degenerative tear of the rotator cuff remains controversial, but operative treatment, particularly arthroscopic surgery, is increasingly being used. Our aim in this paper was to compare the effectiveness of arthroscopic with open repair of the rotator cuff.

PATIENTS AND METHODS

A total of 273 patients were recruited to a randomised comparison trial (136 to arthroscopic surgery and 137 to open surgery) from 19 teaching and general hospitals in the United Kingdom. The surgeons used their usual preferred method of repair. The Oxford Shoulder Score (OSS), two years post-operatively, was the primary outcome measure. Imaging of the shoulder was performed at one year after surgery. The trial is registered with Current Controlled Trials, ISRCTN97804283.

RESULTS

The mean OSS improved from 26.3 (standard deviation (sd) 8.2) at baseline, to 41.7 (sd 7.9) two years post-operatively for arthroscopic surgery and from 25.0 (sd 8.0) to 41.5 (sd 7.9) for open surgery. Intention-to-treat (ITT) analysis showed no statistical difference between the groups at two years (difference in OSS score -0.76; 95% confidence interval (CI) -2.75 to 1.22; p = 0.452). The confidence interval excluded the pre-determined clinically important difference in the OSS of three points. The rate of re-tear was not significantly different between the two groups (46.4% for arthroscopic and 38.6% for open surgery; 95% CI -6.9 to 25.8; p = 0.256). Healed repairs had the most improved OSS. These findings were the same when analysed per-protocol.

CONCLUSION

There is no evidence of difference in effectiveness between open and arthroscopic repair of rotator cuff tears. The rate of re-tear is high in both groups, for all sizes of tear and ages and this adversely affects the outcome. Cite this article: Bone Joint J 2017;99-B:107-15.

Can pain and function be distinguished in the Oxford Hip Score in a meaningful way? : an exploratory and confirmatory factor analysis

Objective

The objective of this study was to explore dimensionality of the Oxford Hip Score (OHS) and examine whether self-reported pain and functioning can be distinguished in the form of subscales.

Methods

This was a secondary data analysis of the UK NHS hospital episode statistics/patient-reported outcome measures dataset containing pre-operative OHS scores on 97 487 patients who were undergoing hip replacement surgery.

Results

The proposed number of factors to extract depended on the method of extraction employed. Velicer’s Minimum Average Partial test and the Parallel Analysis suggested one factor, the Cattell’s scree test and Kaiser-over-1 rule suggested two factors. Exploratory factor analysis demonstrated that the two-factor OHS had most of the items saliently loading either of the two factors. These factors were named ‘Pain’ and ‘Function’ and their respective subscales were created. There was some cross-loading of items: 8 (pain on standing up from a chair) and 11 (pain during work). These items were assigned to the ‘Pain’ subscale. The final ‘Pain’ subscale consisted of items 1, 8, 9, 10, 11 and 12. The ‘Function’ subscale consisted of items 2, 3, 4, 5, 6 and 7, with the recommended scoring of the subscales being from 0 (worst) to 100 (best). Cronbach’s alpha was 0.855 for the ‘Pain’ subscale and 0.861 for the ‘Function’ subscale. A confirmatory factor analysis demonstrated that the two-factor model of the OHS had a better fit. However, none of the one-factor or two-factor models was rejected.

Conclusion

Factor analyses demonstrated that, in addition to current usage as a single summary scale, separate information on pain and self-reported function can be extracted from the OHS in a meaningful way in the form of subscales.

Cite this article: Bone Joint Res 2014;3:305–9.

Protocol for the United Kingdom Rotator Cuff Study (UKUFF): a randomised controlled trial of open and arthroscopic rotator cuff repair

This protocol describes a pragmatic multicentre randomised controlled trial (RCT) to assess the clinical and cost effectiveness of arthroscopic and open surgery in the management of rotator cuff tears. This trial began in 2007 and was modified in 2010, with the removal of a non-operative arm due to high rates of early crossover to surgery. Cite this article: Bone Joint Res 2014;3:155-60.

A structured review of patient-reported outcome measures for patients with skin cancer, 2013

BACKGROUND

The collection of patient-reported outcome measures (PROMs) within the national PROMs programme for elective procedures is now established mandatory practice in the NHS with high response rates and completion.

OBJECTIVES

This review examines the evidence of PROMs for people with skin cancer.

METHODS

Comprehensive searches were conducted using several sources and databases, using a detailed search strategy developed by the University of Oxford's PROM Group. Articles were assessed for eligibility. Data were extracted per PROM for each measurement property and appraised using an appraisal framework.

RESULTS

A total of 3517 articles were identified in the searches, and 28 were included in the final review after assessment by two independent reviewers. Two generic instruments (SF-36 and Sickness Impact Profile) and nine condition-specific PROMs were identified.

CONCLUSIONS

Overall, there is a limited volume of published evidence for the application of generic PROMs for people with skin cancer. Evaluation of the EQ-5D may be particularly important given its widespread use in many other healthcare contexts in the U.K. The Skin Cancer Index could be considered for piloting in the NHS. For patients with nonmelanoma skin cancers, the Skindex measures may also be considered. The SCQOLIT has some evidence of applicability across both skin cancer types but more evaluations are needed. The FACT-M does have more promising characteristics for patients with malignant melanomas although no evidence of testing in the U.K. was found. The forthcoming EORTC-M may prove a useful measure given the expertise and track record of this European collaboration in cancer and quality of life.

Five-year results of a randomised controlled trial comparing mobile and fixed bearings in total knee replacement

There is conflicting evidence about the merits of mobile bearings in total knee replacement, partly because most randomised controlled trials (RCTs) have not been adequately powered. We report the results of a multicentre RCT of mobile versus fixed bearings. This was part of the knee arthroplasty trial (KAT), where 539 patients were randomly allocated to mobile or fixed bearings and analysed on an intention-to-treat basis. The primary outcome measure was the Oxford Knee Score (OKS) plus secondary measures including Short Form-12, EuroQol EQ-5D, costs, cost-effectiveness and need for further surgery. There was no significant difference between the groups pre-operatively: mean OKS was 17.18 (sd 7.60) in the mobile-bearing group and 16.49 (sd 7.40) in the fixed-bearing group. At five years mean OKS was 33.19 (sd 16.68) and 33.65 (sd 9.68), respectively. There was no significant difference between trial groups in OKS at five years (-1.12 (95% confidence interval -2.77 to 0.52) or any of the other outcome measures. Furthermore, there was no significant difference in the proportion of patients with knee-related re-operations or in total costs. In this appropriately powered RCT, over the first five years after total knee replacement functional outcomes, re-operation rates and healthcare costs appear to be the same irrespective of whether a mobile or fixed bearing is used.

Specificity and responsiveness of patient-reported and clinician-rated outcome measures in the context of elbow surgery, comparing patients with and without rheumatoid arthritis

OBJECTIVES

To examine and contrast the ability of patient-reported and clinician-rated measures, reflecting different levels of specificity, to detect differences in outcomes between patients with and without rheumatoid arthritis (RA), at 6 months following elbow surgery.

METHODS

One hundred and four consecutive patients/elbows self-completed the Oxford Elbow Score (OES), Disabilities of the Arm, Shoulder and Hand (DASH) and SF-36 general health questionnaires prior to elbow surgery. A surgeon assessed the standard Mayo Elbow Performance Score (MEPS) and recorded patients' diagnoses. Assessments were repeated 6 months following surgery in an outpatient clinic. Patients also completed pain "transition" and global satisfaction items. Patients who did not attend completed their assessment by post.

RESULTS

Twenty-three (22%) patients had RA. These patients were more likely than other patients to have bilateral elbow problems and to have total elbow replacement (85.7% versus 10.5% P<0.001). Patients with RA had more severe preoperative elbow-specific scores, and experienced a large and significantly greater amount of change in elbow function, as measured by the OES function (P=0.002) and pain scales (P=0.013). The surgeon-assessed elbow-specific MEPS score also detected a large and significant difference between the two groups (P<0.001). However, these differences were not detected by the upper limb specific DASH, by any SF-36 general health dimensions, or by transition or satisfaction items.

CONCLUSIONS

The OES performed well in assessing surgical outcomes in patients with RA. Neither the upper limb specific DASH nor the SF-36 is specific or responsive enough to warrant its exclusive use as an outcome measure for elbow surgery.

LEVEL OF EVIDENCE

Level II (prospective non-randomised study).

Transfers of women planning birth in midwifery units: data from the birthplace prospective cohort study

OBJECTIVE

To examine the percentage of women transferred, reasons for transfer and factors associated with the transfer of women planning birth in midwifery units (MUs).

DESIGN

Prospective cohort study.

SETTING

All freestanding midwifery units (FMUs) and alongside midwifery units (AMUs) in England.

PARTICIPANTS

Twenty-nine thousand, two hundred and forty-eight eligible women with a singleton, term and 'booked' pregnancy, planning birth in an MU between April 2008 and April 2010.

METHODS

Multivariable logistic regression was used to explore the sociodemographic and clinical characteristics associated with transfer.

MAIN OUTCOME MEASURES

Transfer during labour or within 24 hours of birth.

RESULTS

Over one in four women were transferred from AMUs and over one in five from FMUs. In both types of MU, compared with multiparous women aged 25-29 years, nulliparous women aged <20 years had higher odds of transfer (FMU-adjusted odds ratio [OR], 4.5; 95% confidence interval [CI], 3.10-6.57; AMU-adjusted OR, 2.6; 95% CI, 2.18-2.06), and the odds of transfer increased with increasing age. Nulliparous women aged ≥ 35 years in FMUs had 7.4 times the odds of transfer (95% CI, 5.43-10.10) and, in AMUs, 6.0 times the odds of transfer (95% CI, 4.81-7.41). Starting labour care after 40 weeks of gestation and the presence of complicating conditions at the start of labour care were also independently associated with a higher risk of transfer.

CONCLUSIONS

Transfer from MUs is common, especially for first-time mothers. This study provides evidence on the maternal characteristics associated with an increased risk of transfer, which can be used to inform women's choices about place of birth.

Assessing patients for joint replacement

We obtained pre-operative and six-month post-operative Oxford hip (OHS) and knee scores (OKS) for 1523 patients who underwent total hip replacement and 1784 patients who underwent total knee replacement. They all also completed a six-month satisfaction question.

Scatter plots showed no relationship between pre-operative Oxford scores and six-month satisfaction scores. Spearman’s rank correlation coefficients were -0.04 (95% confidence interval (CI) -0.09 to 0.01) between OHS and satisfaction and 0.04 (95% CI -0.01 to 0.08) between OKS and satisfaction. A receiver operating characteristic (ROC) curve analysis was used to identify a cut-off point for the pre-operative OHS/OKS that identifies whether or not a patient is satisfied with surgery. We obtained an area under the ROC curve of 0.51 (95% CI 0.45 to 0.56) for hip replacement and 0.56 (95% CI 0.51 to 0.60) for knee replacement, indicating that pre-operative Oxford scores have no predictive accuracy in distinguishing satisfied from dissatisfied patients.

In the NHS widespread attempts are being made to use patient-reported outcome measures (PROMs) data for the purpose of prioritising patients for surgery. Oxford hip and knee scores have no predictive accuracy in relation to post-operative patient satisfaction. This evidence does not support their current use in prioritising access to care.

Negative energy balance and hepatic gene expression patterns in high-yielding dairy cows during the early postpartum period: a global approach

In high-yielding dairy cows the liver undergoes extensive physiological and biochemical changes during the early postpartum period in an effort to re-establish metabolic homeostasis and to counteract the adverse effects of negative energy balance (NEB). These adaptations are likely to be mediated by significant alterations in hepatic gene expression. To gain new insights into these events an energy balance model was created using differential feeding and milking regimes to produce two groups of cows with either a mild (MNEB) or severe NEB (SNEB) status. Cows were slaughtered and liver tissues collected on days 6–7 of the first follicular wave postpartum. Using an Affymetrix 23k oligonucleotide bovine array to determine global gene expression in hepatic tissue of these cows, we found a total of 416 genes (189 up- and 227 downregulated) to be altered by SNEB. Network analysis using Ingenuity Pathway Analysis revealed that SNEB was associated with widespread changes in gene expression classified into 36 gene networks including those associated with lipid metabolism, connective tissue development and function, cell signaling, cell cycle, and metabolic diseases, the three most significant of which are discussed in detail. SNEB cows displayed reduced expression of transcription activators and signal transducers that regulate the expression of genes and gene networks associated with cell signaling and tissue repair. These alterations are linked with increased expression of abnormal cell cycle and cellular proliferation associated pathways. This study provides new information and insights on the effect of SNEB on gene expression in high-yielding Holstein Friesian dairy cows in the early postpartum period.

Pleiotropic effects of negative energy balance in the postpartum dairy cow on splenic gene expression: repercussions for innate and adaptive immunity

Increased energy demands to support lactation, coupled with lowered feed intake capacity results in negative energy balance (NEB) and is typically characterized by extensive mobilization of body energy reserves in the early postpartum dairy cow. The catabolism of stored lipid leads to an increase in the systemic concentrations of nonesterified fatty acids (NEFA) and β-hydroxy butyrate (BHB). Oxidation of NEFA in the liver result in the increased production of reactive oxygen species and the onset of oxidative stress and can lead to disruption of normal metabolism and physiology. The immune system is depressed in the peripartum period and early lactation and dairy cows are therefore more vulnerable to bacterial infections causing mastitis and or endometritis at this time. A bovine Affymetrix oligonucleotide array was used to determine global gene expression in the spleen of dairy cows in the early postpartum period. Spleen tissue was removed post mortem from five severe NEB (SNEB) and five medium NEB (MNEB) cows 15 days postpartum. SNEB increased systemic concentrations of NEFA and BHB, and white blood cell and lymphocyte numbers were decreased in SNEB animals. A total of 545 genes were altered by SNEB. Network analysis using Ingenuity Pathway Analysis revealed that SNEB was associated with NRF2-mediated oxidative stress, mitochondrial dysfunction, endoplasmic reticulum stress, natural killer cell signaling, p53 signaling, downregulation of IL-15, BCL-2, and IFN-γ; upregulation of BAX and CHOP and increased apoptosis with a potential negative impact on innate and adaptive immunity.

The Oxford ankle foot questionnaire for children: scaling, reliability and validity

We developed the Oxford ankle foot questionnaire to assess the disability associated with foot and ankle problems in children aged from five to 16 years. A survey of 158 children and their parents was carried out to determine the content, scaling, reliability and validity of the instrument. Scores from the questionnaire can be calculated to measure the effect of foot or ankle problems on three domains of children's lives: physical, school and play, and emotional. Scores for each domain were shown to be internally consistent, stable, and to vary little whether reported by child or parent. Satisfactory face, content and construct validity were demonstrated. The questionnaire is appropriate for children with a range of conditions and can provide clinically useful information to supplement other assessment methods. We are currently carrying out further work to assess the responsiveness of questionnaire scores to change over time and with treatment.

The development and validation of a patient-reported questionnaire to assess outcomes of elbow surgery

We developed a questionnaire to assess patient-reported outcome after surgery of the elbow from interviews with patients. Initially, 17 possible items with five response options were included. A prospective study of 104 patients (107 elbow operations) was carried out to analyse the underlying factor structure, dimensionality, internal and test-retest reliability, construct validity and responsiveness of the questionnaire items. This was compared with the Mayo Elbow performance score clinical scale, the Disabilities of the Arm, Shoulder and Hand questionnaire, and the Short-Form (SF-36) General Health Survey. In total, five questions were considered inappropriate, which resulted in the final 12-item questionnaire, which has been referred to as the Oxford elbow score. This comprises three unidimensional domains, 'elbow function', 'pain' and 'social-psychological'; with each domain comprising four items with good measurement properties. This new 12-item Oxford elbow score is a valid measure of the outcome of surgery of the elbow.

Endometrial expression of the insulin-like growth factor system during uterine involution in the postpartum dairy cow

Rapid uterine involution in the postpartum period of dairy cows is important to achieve a short interval to conception. Expression patterns for members of the insulin-like growth factor (IGF) family were determined by in situ hybridisation at day 14+/-0.4 postpartum (n=12 cows) to investigate a potential role for IGFs in modulating uterine involution. Expression in each uterine tissue region was measured as optical density units and data were analysed according to region and horn. IGF-I mRNA was localized to the sub-epithelial stroma (SES) of inter-caruncular and caruncular endometrium. Both IGF-II and IGF-1R expression was detected in the deep endometrial stroma (DES), the caruncular stroma and myometrium. IGFBP-2, IGFBP-4 and IGFBP-6 mRNAs were all localised to the SES of inter-caruncular and caruncular uterine tissue, and in the DES and caruncular stroma, with IGFBP-4 mRNA additionally expressed in myometrium. IGFBP-3 mRNA was only detectable in luminal epithelium. IGFBP-5 mRNA was found in myometrium, inter-caruncular and caruncular SES and caruncular stroma. These data support a role for IGF-I and IGF-II in the extensive tissue remodelling and repair which the postpartum uterus undergoes to return to its non-pregnant state. The differential expression of binding proteins between tissues (IGFBP-3 in epithelium, IGFBP-2, -4, -5 and -6 in stroma and IGFBP-4 and -5 in myometrium) suggest tight control of IGF activity within each compartment. Differential expression of many members of the IGF family between the significantly larger previously gravid horn and the previously non-gravid horn may relate to differences in their rate of tissue remodelling.

Negative energy balance in dairy cows is associated with specific changes in IGF-binding protein expression in the oviduct

Negative energy balance (NEB) during early lactation in dairy cows leads to an altered metabolic state that has major effects on the production of IGF family members. Low IGF-I concentrations are associated with poor fertility and therefore we aimed to determine whether NEB exerts a direct effect on IGF expression in the postpartum oviduct. Multiparous Holstein cows were allocated to two treatments (each n=6) designed using differential feeding and milking regimes to produce either mild NEB (MNEB) or severe NEB (SNEB). Animals were slaughtered in week 2 of lactation when divergent metabolic profiles were evident. Oviducts were collected for RNA analysis by real-time RT-PCR and in situ hybridisation. Quantitative measures in oviduct gene expression were obtained for all members of the IGF family (IGF-I/II, IGF-binding proteins (IGFBP) 1–6 and receptors for IGF types 1 and 2), insulin A/B, GH, glucocorticoid and oestrogen α/β. Expression of IGFBP-2 and IGFBP-6 (both of which have a high affinity for IGF-II) was decreased in SNEB relative to MNEB (P<0.05). No other gene was altered by NEB, but IGF-II, IGFBP-3, IGFBP-5 and IGFBP-6 all showed differential expression in different regions of the oviduct. These results indicate that, in addition to low circulating IGF-I after calving, NEB may also influence IGF availability in the oviduct indirectly through changes in specific IGFBP expression. It is possible that the predicted increased signalling by IGF-II may perturb embryo development, contributing to the high rates of embryonic mortality in dairy cows.

Development of the Oxford ankle foot questionnaire: finding out how children are affected by foot and ankle problems

BACKGROUND

A large number of children are affected by foot and ankle problems owing to congenital deformities, clinical syndromes, neuromuscular conditions or trauma. This study aimed to identify how children's lives are affected by foot and ankle problems from the child's perspective as the first stage in developing a family-assessed instrument.

METHODS

This was a qualitative study using focus groups involving children with a variety of foot and ankle problems aged 5-7, 8-11 and 12-15 years, and separate concurrent groups for their parents. The focus groups were child-centred and involved creative activities; there were two main exercises. The first activity involved agreeing or disagreeing with several statements about children with foot and ankle problems; the second activity explored a typical 'day in the life' of a child with a foot or ankle problem. All the groups were audio-recorded and transcribed; grounded theory and comparative content analysis were used to identify and code themes participants reported as important.

RESULTS

The groups ran successfully with children in all ages. Consistent themes identified by all groups were; (i) specific activities that were more difficult; (ii) physical symptoms; (iii) reduced participation in certain life situations; and (iv) self-consciousness. There were few differences in the issues raised by each age group although the life situations children encounter tend to become more complex as they get older; there is also the difficulty of negotiating a larger school campus at senior compared with junior school. There were no differences in the issues raised by children and their parents.

CONCLUSIONS

Focus groups involving creative child-centred activities were used successfully to elicit children's experience of their health problems. In addition to expected activity limitations and physical symptoms some children with foot or ankle problems endure participation restrictions and self-consciousness that are exacerbated by the behaviour of other people or their environment, particularly at school. The findings of this study informed the development of a questionnaire to measure how severely children are affected by foot or ankle problems from the child's perspective.

Influence of negative energy balance on cyclicity and fertility in the high producing dairy cow

The peripartum period is of critical importance to subsequent health and fertility. Most cows enter a state of negative energy balance (NEB) associated with many metabolic changes which have carry over effects on the resumption and normality of estrous cyclicity and the success of subsequent inseminations. A dataset on 500 lactations explored the relationships between metabolic traits measured before and after calving with fertility. Stepwise multiple regression analysis showed that longer calving to conception intervals were associated with altered profiles of IGF-I, urea and body condition score. These relationships between metabolic profiles and fertility differed between first lactation cows (which are still growing but produce less milk) and mature animals. Early postpartum the liver undergoes extensive biochemical and morphological modifications to adapt to NEB, the uterus is extensively remodeled and must clear bacterial infections, and the ovary must resume ovulatory cycles. RNA isolated from liver and uterine tissues harvested 2 weeks postpartum from cows in mild (MNEB) and severe (SNEB) energy balance was used to screen the Affymetrix 23K bovine microarray. In liver, SNEB resulted in differential expression of key genes involved in lipid catabolism, gluconeogenesis, and the synthesis and stability of IGF-I. This was accompanied by reduced systemic concentrations of IGF-I which is likely to impact on ovarian function and early embryo development. Within endometrium, cows in SNEB showed histological evidence for higher levels of inflammation and the microarray analysis identified groups of differentially expressed genes involved in tissue remodeling and immune response. This may delay uterine repair after calving, likely contributing to the observed reduction in fertility.

The use of the Oxford hip and knee scores

The Oxford hip and knee scores have been extensively used since they were first described in 1996 and 1998. During this time, they have been modified and used for many different purposes. This paper describes how they should be used and seeks to clarify areas of confusion.

Comparison of the 40-item Amyotrophic Lateral Sclerosis Assessment Questionnaire (ALSAQ-40) with a short-form five-item version (ALSAQ-5) in a longitudinal survey

OBJECTIVES

To compare results on the 40-item Amyotrophic Lateral Sclerosis Assessment Questionnaire (ALSAQ-40) with those gained on the short-form five-item Amyotrophic Lateral Sclerosis Assessment Questionnaire (ALSAQ-5) in a longitudinal study.

DESIGN

Postal survey. Copies of the ALSAQ-40 which incorporates the five items of the ALSAQ-5, were completed on two occasions. Respondents were also asked to indicate how much change they had experienced since baseline on each of the five domains of the questionnaire.

SETTING

The database of all patient members of the Motor Neurone Disease Association for England, Wales and Northern Ireland.

SUBJECTS

Nine hundred and twenty-seven patient members returned questionnaires at baseline, and 764 completed questionnaires at both baseline and follow-up.

RESULTS

Results on the five dimensions of the ALSAQ-40 and ALSAQ-5 were found to be highly correlated, and 95% confidence intervals on mean scores were found to overlap for each dimension. The instruments both provide a similar picture of change in terms of their responsiveness. For example, effect sizes were calculated for patients who claimed their health had deteriorated a little since baseline, and gave almost identical results (e.g. for the Physical functioning domain effect sizes of 0.12 and 0.11 were found on the long and short measures respectively).

CONCLUSIONS

Results suggests that the ALSAQ-5 provides similar results to the ALSAQ-40 yet with considerable economy. In instances where a very brief health status measure is required then the ALSAQ-5 may be the instrument of choice.

Effect of negative energy balance on the insulin-like growth factor system in pre-recruitment ovarian follicles of post partum dairy cows

Post partumnegative energy balance (NEB) in dairy cattle is associated with a delayed return to ovarian cyclicity and reduced fertility. This study compared the IGF system of pre-recruitment ovarian follicles between cows in mild (n= 6) or severe (n= 6) NEB during early lactation. Ovaries were collected in the second weekpost partum, when circulating concentrations of IGF-I and glucose were lower (P< 0.01) in severe NEB cows. mRNA expression for IGF-II, type 1 IGF receptor (IGF-1R) and IGF-binding proteins (IGFBP)-1 to IGFBP-6 was determined byin situhybridisation in individual follicles using radiolabelled oligonucleotide probes. Follicles were classified as very small (1–2.5 mm) or small (2.5–5 mm) and healthy or atretic. Relative mRNA concentrations were measured as optical density (OD) units using image analysis. Thecal IGF-II mRNA expression was highest in very small, healthy follicles (P< 0.05). Granulosa cell IGFBP-2 was the only component to change with EB status, with higher mRNA expression in mild compared with severe NEB cows (P< 0.05). IGFBP-1 and IGFBP-3 mRNA expression were undetectable. IGF-1R, IGFBP-4 and IGFBP-5 mRNA expression were not significantly altered by follicle size or health, but IGFBP-5 tended to increase in atretic follicles. The pattern of IGFBP-6 mRNA expression in theca paralleled that of IGF-II mRNA, with higher (P< 0.05) levels in healthy, very small follicles. In conclusion, the reduced expression of IGFBP-2 mRNA in severe NEB cows may alter the bioavailability of circulating IGF-I and locally produced IGF-II to modulate the pre-recruitment stages of follicles required to maintain normalpost partumovarian cyclicity.

CDIP-58 can measure the impact of botulinum toxin treatment in cervical dystonia

We compared the responsiveness of the Cervical Dystonia Impact Profile (CDIP-58), Medical Outcome Study Short Form-Health Survey (SF-36), Functional Disability Questionnaire (FDQ), and Pain and Activities of Daily Living subscales of the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) in participants with cervical dystonia treated with botulinum toxin A. Subscales of CDIP-58 were more sensitive in detecting statistical and clinical change than comparable subscales of the SF-36, FDQ, and TWSTRS.

Rising to the challenges of achieving day surgery targets

Day surgery provides high quality and efficient care for a wide variety of surgical procedures. Patients appreciate the rapid recovery and effective analgesia, while the health service benefits from a streamlined service with lower costs. Despite the numerous advantages, day surgery practices vary enormously and many patients are still denied this excellent form of care. Fundamental to improving this situation is a change in emphasis, with day surgery becoming the default option for many surgical procedures--rather than being applied selectively--with inpatient care being used only where specifically indicated. Appropriate patient preparation is facilitated by consultant-led, nurse-run pre-assessment using modern selection criteria; only conditions which will still cause problems a few hours beyond the end of the operation should be barriers to day surgery. Pre-assessment also provides an excellent opportunity to begin patient education and ensures that pre-existing pathology is optimally treated. Efficient day surgery is best delivered by a specialised, dedicated, multi-disciplinary team, but consultant anaesthetists have a major role to play in co-ordinating policies and providing leadership. Individual anaesthetists should develop techniques that allow their patients to undergo day surgery with minimum stress, maximum comfort and the optimal chance of early discharge. Improving day surgery rates is a win-win situation, with both clinical and financial benefits.

Who best to make the assessment? Professionals' and families' classifications of gross motor function in cerebral palsy are highly consistent

AIM

To determine the reliability of family assessment for the Gross Motor Function Classification System (GMFCS) for children with cerebral palsy in the UK.

METHODS

Families of a complete geographically defined population of children with cerebral palsy between 6 and 12 years old were identified from the 4Child epidemiological database. Postal surveys were conducted with the families and any of the child's health professionals that were nominated by the families.

RESULTS

Families of 129/314 eligible children took part in the study (41%). The indices of agreement and reliability between families and professionals were also equivalent to those observed between the professionals (kappa = 0.5, ICC > or = 0.9). Reliability coefficients were higher when more of the professionals classified children using direct observation rather than only reviewing their clinical records.

CONCLUSIONS

Despite excellent reliability, families and professionals did not always agree exactly on a child's GMFCS level. Classifications may differ due to children's varying performance in different environments, in which case families will almost certainly know their children's ability in a broader range of settings. The indices of reliability of family assessment for the GMFCS meet the recommended criteria for use with individuals and groups, indicating that the method is suitable for use in research studies and clinical practice.

Effect of systemic progesterone concentration on the expression of progesterone-responsive genes in the bovine endometrium during the early luteal phase

Increasing evidence indicates an association between the concentration of systemic progesterone during the early luteal phase of the oestrous cycle and embryo survival rate in cattle. We examined the relationship between the concentration of systemic progesterone on Days 4 to 8 post-ovulation and expression of progesterone receptor (PGR), oestrogen receptor α (ESR1) and retinol-binding protein (RBP) mRNA in the bovine endometrium. Heifers were blood sampled from the day of ovulation (Day 0) to Day 8 post-ovulation. On Day 4, animals were divided into low progesterone control (LC) and high progesterone control (HC) groups based on their plasma progesterone concentrations. Half of each group was supplemented with exogenous progesterone resulting in two further groups, low progesterone supplemented (LS) and high progesterone supplemented (HS). Endometrial tissues were recovered from all groups on Day 6 or Day 8 and gene expression was analysed following Northern blotting. Increasing progesterone concentrations were associated with decreased PGR and ESR1 expression. Duration-dependent effects of progesterone supplementation on ESR1 were evident and there was an effect of systemic progesterone concentrations between Day 0 and Day 4 on the expression of RBP at Days 6 and 8. Such progesterone-responsive changes in uterine gene expression are likely to affect embryo development.

How responsive is the Multiple Sclerosis Impact Scale (MSIS-29)? A comparison with some other self report scales

OBJECTIVES

To compare the responsiveness of the Multiple Sclerosis Impact Scale (MSIS-29) with other self report scales in three multiple sclerosis (MS) samples using a range of methods. To estimate the impact on clinical trials of differing scale responsiveness.

METHODS

We studied three discrete MS samples: consecutive admissions for rehabilitation; consecutive admissions for steroid treatment of relapses; and a cohort with primary progressive MS (PPMS). All patients completed four scales at two time points: MSIS-29; Short Form 36 (SF-36); Functional Assessment of MS (FAMS); and General Health Questionnaire (GHQ-12). We determined: (1) the responsiveness of each scale in each sample (effect sizes): (2) the relative responsiveness of competing scales within each sample (relative efficiency): (3) the differential responsiveness of competing scales across the three samples (relative precision); and (4) the implications for clinical trials (samples size estimates scales to produce the same effect size).

RESULTS

We studied 245 people (64 rehabilitation; 77 steroids; 104 PPMS). The most responsive physical and psychological scales in both rehabilitation and steroids samples were the MSIS-29 physical scale and the GHQ-12. However, the relative ability of different scales to detect change in the two samples was variable. Differing responsiveness implied more than a twofold impact on sample size estimates.

CONCLUSIONS

The MSIS-29 was the most responsive physical and second most responsive psychological scale. Scale responsiveness differs notably within and across samples, which affects sample size calculations. Results of clinical trials are scale dependent.

Prevalence and incidence of adults consulting for shoulder conditions in UK primary care; patterns of diagnosis and referral

OBJECTIVES

To estimate the national prevalence and incidence of adults consulting for a shoulder condition and to investigate patterns of diagnosis, treatment, consultation and referral 3 yr after initial presentation.

METHODS

Prevalence and incidence rates were estimated for 658469 patients aged 18 and over in the year 2000 using a primary care database, the IMS Disease Analyzer-Mediplus UK. A cohort of 9215 incident cases was followed-up prospectively for 3 yr beyond the initial consultation.

RESULTS

The annual prevalence and incidence of people consulting for a shoulder condition was 2.36% [95% confidence interval (CI) 2.32-2.40%] and 1.47% (95% CI 1.44-1.50%), respectively. Prevalence increased linearly with age whilst incidence peaked at around 50 yr then remained static at around 2%. Around half of the incident cases consulted once only, while 13.6% were still consulting with a shoulder problem during the third year of follow-up. During the 3 yr following initial presentation, 22.4% of patients were referred to secondary care, 30.8% were prescribed non-steroidal anti-inflammatory drugs and 10.6% were given an injection by their general practitioner (GP). GPs tended to use a limited number of generalized codes when recording a diagnosis; just five of 426 possible Read codes relating to shoulder conditions accounted for 74.6% of the diagnoses of new cases recorded by GPs.

CONCLUSIONS

The prevalence of people consulting for shoulder problems in primary care is substantially lower than community-based estimates of shoulder pain. Most referrals occur within 3 months of initial presentation, but only a minority of patients are referred to orthopaedic specialists or rheumatologists. GPs may lack confidence in applying precise diagnoses to shoulder conditions.

Quality of life in older people: a structured review of generic self-assessed health instruments

OBJECTIVE

To review evidence relating to the measurement properties of multi-item generic patient or self-assessed measures of health in older people.

METHODS

Systematic literature searches to identify instruments. Pre-defined criteria relating to reliability, validity and responsiveness.

RESULTS

122 articles relating to 15 instruments met the inclusion criteria. The most extensive evidence was found for the SF-36, COOP Charts, EQ-5D, Nottingham Health Profile (NHP) and SIP. Four instruments have evidence of both internal consistency and test-retest reliability--NHP, SF-12, SF-20, SF-36. Four instruments lack evidence of reliability--HSQ-12, IHQL, QWB, SQL. Most instruments were assessed for validity through comparisons with other instruments, global judgements of health, or clinical and socio-demographic variables. Five instruments lack evidence of responsiveness--GQL, HSQ-12, IHQL, QLI and QWB.

CONCLUSION

There is good evidence for reliability, validity and responsiveness for the SF-36, EQ-5D and NHP. There is more limited evidence for the COOP, SF-12 and SIP. The SF-36 is recommended where a detailed and broad ranging assessment of health is required, particularly in community dwelling older people with limited morbidity. The EQ-5D is recommended where a more succinct assessment is required, particularly where a substantial change in health is expected. Instrument content should be assessed for relevance before application. The concurrent evaluation of generic instruments in older people is recommended.

Assessment of the Lequesne index of severity for osteoarthritis of the hip in an elderly population

OBJECTIVE

To assess the measurement properties of the Lequesne index of severity for osteoarthritis of the hip (LISOH) together with its overall usefulness with reference to the original stated aims.

METHOD

Postal questionnaire was sent to a random sample of 5500 Oxfordshire residents, aged 65 and above. Respondents with hip symptoms at baseline (but without verification of a diagnosis) were sent an identical follow-up questionnaire 12 months later. The questionnaire included a general health section, including the Short Form-36 survey, and a hip section which began with a screening question about hip pain. Respondents who reported having a prolonged episode of hip pain were asked to complete the LISOH.

RESULTS

At baseline, response rate of 66.3% (3341/5039) was obtained from eligible participants; 19.2% (610/3175) of respondents reported having hip pain. Internal reliability (Cronbach's alpha) was 0.84 (95% CI: 0.81-0.86) for all 11 items of the LISOH; however, factor analysis identified two factors (sub-scales): "function and mobility" and "pain and discomfort". Rasch analysis revealed that the two factors were only unidimensional when applied to sub-groups of respondents. Convergent validity of the LISOH was questionable, as the "function and mobility" factor was more highly correlated with SF-36 bodily pain score than was the "pain and discomfort" factor. The assessment of sensitivity over time was problematic due to changing patterns of symptomatic weight-bearing joints over time.

CONCLUSIONS

The current study identifies major limitations with the LISOH--particularly if used as a single composite measure.

Capturing the true burden of dystonia on patients: the Cervical Dystonia Impact Profile (CDIP-58)

OBJECTIVES

To develop a new rating scale for measuring the health impact of cervical dystonia (CD) that includes patients' perceptions and complements existing observer dependent clinician rating scales.

METHODS

Scale development was in three stages. In Stage 1, a large pool of items was generated from patient interviews (n = 25), expert opinion, and literature review. In Stage 2, these items were administered by postal survey to people with CD. The resulting data were analyzed using Rasch item analysis to construct, from the item pool, a rating scale that satisfied criteria for rigorous measurement. In Stage 3, the measurement properties of this rating scale were examined in an independent sample of people with CD.

RESULTS

In Stage 1, 150 items concerning the health impact of CD were generated. In Stage 2, 556 people completed questionnaires (87% response rate) and a 58-item rating scale measuring the health impact of CD in eight areas was constructed (CD Impact Profile, CDIP-58). In Stage 3, CDIP-58 data from 391 people (87% response rate) were received. Analyses supported the measurement of eight unidimensional constructs (infit mean square range 0.62 to 1.50), item calibration (33.37 to 67.56), and patient separation statistics (2.59 to 3.38). Items demonstrated stable calibrations in subgroups of people with CD supporting the stability of the CDIP-58.

CONCLUSIONS

The CDIP-58 is a reliable and valid patient-based rating scale measuring the health impact of CD in eight health dimensions.

Child or family assessed measures of activity performance and participation for children with cerebral palsy: a structured review

BACKGROUND

There is a need to measure children's 'activity performance and participation' as defined in the World Health Organization's International Classification of Functioning, Disability and Health for Children and Youth (WHO ICF). The aim of this review is to identify instruments that are suitable for use in postal surveys with families of children with cerebral palsy.

METHODS

We conducted a structured review of instruments that use child or family self-assessment of 'activity performance and participation'. The review involved a systematic search for instruments using multiple published sources. Appraisal of the instruments used the predefined criteria of appropriateness, validity, reliability, responsiveness, precision, interpretability, acceptability and feasibility.

RESULTS

There are relatively few child or family assessed instruments appropriate for measuring children's activities and participation. Seven instruments were identified that could potentially be administered by mail. The Assessment of Life Habits for Children (LIFE-H) was the most appropriate instrument as assessed by its content but the reliability of child or family self-assessment is not known. If the LIFE-H were shown to be a reliable self-report measure then the LIFE-H would be the recommended choice. Currently, the Activities Scale for Kids and the condition-specific Lifestyle Assessment Questionnaire for cerebral palsy (LAQ-CP) provide the broadest description of what and how frequently children with cerebral palsy perform a range of activities and thereby indicate participation. The LAQ-CP also provides additional contextual information on the impact of any disability on the participation of the family unit.

CONCLUSION

There remains much scope for developing valid and reliable self-assessed measures corresponding to the WHO ICF dimensions of activities and participation.