Orientation and mobility training for adults with low vision

BACKGROUND

Orientation and mobility (O&M) training is provided to people who are visually impaired to help them maintain travel independence. It teaches them new orientation and mobility skills to compensate for reduced visual information.

OBJECTIVES

The objective of this review was to assess the effects of O&M training, with or without associated devices, for adults with low vision.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library, 2010, Issue 3), MEDLINE (January 1950 to March 2010), EMBASE (January 1980 to March 2010), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to March 2010), System for Information on Grey Literature in Europe (OpenSIGLE) (March 2010), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com) (March 2010), ClinicalTrials.gov (http://clinicaltrials.gov) (March 2010), ZETOC (March 2010) and the reference lists of retrieved articles. There were no language or date restrictions in the search for trials. The electronic databases were last searched on 31 March 2010.

SELECTION CRITERIA

We planned to include randomised or quasi-randomised trials comparing O&M training with no training in adults with low vision.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the search results for eligibility, evaluated study quality and extracted the data.

MAIN RESULTS

Two small studies satisfied the inclusion criteria. They were consecutive phases of development of the same training curriculum and assessment tool. The intervention was administered by a volunteer on the basis of written and oral instruction. In both studies the randomisation technique was inadequate, being based on alternation, and masking was not achieved. Training had no effect in the first study but tended to be beneficial in the second but not to a statistically significant extent. Reasons for differences between studies may have been: the high scores obtained in the first study, suggestive of little need for training and small room for further improvement (a ceiling effect), and the refinement of the curriculum allowing better tailoring to patients' specific needs and characteristics, in the second study.

AUTHORS' CONCLUSIONS

The review found two small quasi-randomised trials with similar methods, comparing training to physical exercise and assessing O&M physical performance by means of a volunteer or a professional, which were unable to demonstrate a difference. Therefore, there is little evidence on which type of O&M training is better for people with low vision who have specific characteristics and needs. Orientation and mobility instructors and scientists should plan randomised controlled trials (RCTs) to compare the effectiveness of different types of O&M training. A consensus is needed on the adoption of standard measurement instruments of mobility performance which are proven to be reliable and sensitive to the diverse mobility needs of people with low vision. For this purpose, questionnaires and performance-based tests may represent different tools that explore people with low vision's subjective experience or their objective functioning, respectively. In fact, it has to be observed that low vision rehabilitation research is increasingly shifting towards the use of quality of life questionnaires as an outcome measure, sometimes with the aim to study complex and multidisciplinary interventions including different types of education and support, of which O&M can be a component. An example of this is an ongoing cluster RCT conducted by Zijlstra et al. in The Netherlands. This trial is designed to compare standardised O&M training with usual O&M care not only for its effectiveness, but also its applicability and acceptability. This study adopts validated questionnaires for patients' subjective assessment of performance during activities of daily living. As performance assessment does not need to be made by an O&M trainer, this allows for masking of assessors and a patient-centred outcome measure.

Systematic review: adherence to a gluten-free diet in adult patients with coeliac disease

BACKGROUND

Coeliac disease is increasingly diagnosed in adult patients who present with atypical symptoms or who are asymptomatic and detected by case screening. Its treatment, a gluten-free diet, can have a considerable impact on daily living. Understanding the factors associated with non-adherence is important in terms of supporting patients with their condition.

AIM

To investigate factors associated with adherence to a gluten-free diet in adults with coeliac disease.

METHODS

A literature search of multiple electronic databases using a pre-determined search string for literature between 1980 and November 2007 identified a possible 611 hits. After checking for relevance, 38 studies were included in this review.

RESULTS

Rates for strict adherence range from 42% to 91% depending on definition and method of assessment and are the lowest among ethnic minorities and those diagnosed in childhood. Adherence is most strongly associated with cognitive, emotional and socio-cultural influences, membership of an advocacy group and regular dietetic follow-up. Screen and symptom-detected coeliac patients do not differ in their adherence to a gluten-free diet.

CONCLUSIONS

The existing evidence for factors associated with non-adherence to a gluten-free diet is of variable quality. Further and more rigorous research is needed to characterize those individuals most likely to be non-adherent to assist them better with their treatment.

The management of common gastrointestinal disorders in general practice A survey by the European Society for Primary Care Gastroenterology (ESPCG) in six European countries

BACKGROUND

Gastrointestinal (GI) disorders account for 10% of all consultations in primary care. Little is known about the management of GI disorders by general practitioners (GP) across different European countries.

AIM AND METHODS

We undertook a postal survey of randomly selected samples of GPs in six European countries (UK, Holland, Spain, Greece, Poland, Czech Republic) to determine patterns of diagnosis, management and service use in GI disorders.

RESULTS

We received 939 responses, response rate 32%. Over 80% of GPs were aware of at least three national guidelines for gastrointestinal disease. The availability of open access endoscopy ranged from 28% (Poland) to over 80% (Holland, Czech and UK). For uninvestigated dyspepsia the preferred first line management was proton pump inhibitor therapy (33-82%), Helicobacter pylori test and treat (19-47%), early endoscopy (5-32%), specialist referral (2-21%). Regarding irritable bowel syndrome, 23% of respondents were familiar with one or more diagnostic criteria, but between 7% (Netherlands) and 32% (Poland) would ask for a specialist opinion before making the diagnosis.

CONCLUSION

The wide variation between GPs both between and within countries partly reflects variations in health care systems but also differing levels of knowledge and awareness, factors which are relevant to educational and research policy.

Review article: medication non-adherence in ulcerative colitis--strategies to improve adherence with mesalazine and other maintenance therapies

BACKGROUND

Significant number of patients with ulcerative colitis (UC) fail to comply with treatment.

AIMS

To review issues surrounding medication non-adherence in inflammatory bowel disease (IBD), including the clinical and health service implications in the UK, and discuss strategies for optimizing medication adherence.

METHODS

Articles cited were identified via a PubMed search, utilizing the words IBD, adherence, compliance, medication and UC.

RESULTS

Medication non-adherence is multifactorial involving factors other than dosing frequency. Male gender (OR: 2.06), new patient status (OR: 2.14), work and travel pressures (OR: 4.9) and shorter disease duration (OR: 2.1), among others are proven predictors of non-adherence in UC. These indicators can identify 'at-risk' patients and allow an individually tailored treatment approach to be introduced that optimizes medication adherence. A collaborative relationship between physician and patient is important; several strategies for improving adherence have been proven effective including open dialogue that takes into consideration the patient's health beliefs and concerns, providing educational (e.g. verbal/written information, self-management programmes) and behavioural interventions (e.g. calendar blister packs, cues/reminders).

CONCLUSIONS

Educational and behavioural interventions tailored to individual patients can optimize medication adherence. Additional studies combining educational and behavioural interventions may provide further strategies for improving medication adherence rates in UC.

Primary lymphoma of the breast involving both axillae with bilateral breast carcinoma

Background

Primary Non-Hodgkin's Lymphoma (PHNL) of the breast is a rare entity, while secondary involvement of the breast with diffuse disease of Non-Hodgkin's lymphoma (NHL) is more common. However, PNHL is the most frequent haematopoietic tumour of the breast. Diagnostic criteria for PNHL of the breast are presence of technically adequate pathologic specimens, close association of mammary tissue and lymphomatous infiltrate, no prior diagnosis of an extarammamary lymphoma, and no evidence of concurrent widespread disease, except for ipsilateral axillary lymph nodes if concomitant with the primary lesion.

Case presentation

A 57-year-old woman was recalled because her screening mammograms revealed three separate lesions in her right breast and one in the left. Histology of the lesions confirmed lymphoma in one breast with ductal carcinoma in the other.

Conclusion

Most of reported cases in literature have been involving the right breast, and almost all the patients were females. NHLs of the breast typically present as unilateral mass; the frequency of bilateral disease at first presentation ranges from 5–25%. Our objective is to report a case of primary lymphoma of the breast involving both axillae with concomitant bilateral primary breast cancer which has not been reported yet to our best of knowledge in literature.

Validation of a brief symptom questionnaire (ReQuest in Practice) for patients with gastro-oesophageal reflux disease

BACKGROUND

A clinical need exists for a means of assessing symptom control in patients with gastro-oesophageal reflux disease. The ReQuest questionnaire has been extensively validated for symptom assessment in both erosive and non-erosive gastro-oesophageal reflux disease but was designed for research purposes. We derived a shorter version (ReQuest in Practice) that would be more convenient for clinical practice.

AIM

To validate ReQuest in Practice in patients suffering from gastro-oesophageal reflux disease.

METHODS

Multicentre, non-interventional, crossover comparison. Patients completed ReQuest in Practice followed by ReQuest or vice versa. Before and after a planned endoscopy, patients completed the health-related quality of life questionnaire GERDyzer. Internal consistency and the Intraclass Correlation Coefficient were calculated. Construct validity was evaluated by correlation with ReQuest and GERDyzer.

RESULTS

There was high internal consistency of ReQuest in Practice (Cronbach's alpha: 0.9) and a high Intraclass Correlation Coefficient of 0.99. The measurement error of ReQuest in Practice was 4.1. High correlation between ReQuest in Practice and ReQuest (Spearman correlation coefficient: 0.9) and GERDyzer (Spearman correlation coefficient: 0.8) demonstrated construct validity.

CONCLUSIONS

ReQuest in Practice was proven to be valid and reliable. Its close correlation with ReQuest makes it a promising tool to guide the clinical management of patients across the full spectrum of both erosive and non-erosive gastro-oesophageal reflux disease.

Guidelines on the irritable bowel syndrome: mechanisms and practical management

BACKGROUND

IBS affects 5-11% of the population of most countries. Prevalence peaks in the third and fourth decades, with a female predominance.

AIM

To provide a guide for the assessment and management of adult patients with irritable bowel syndrome.

METHODS

Members of the Clinical Services Committee of The British Society of Gastroenterology were allocated particular areas to produce review documents. Literature searching included systematic searches using electronic databases such as Pubmed, EMBASE, MEDLINE, Web of Science, and Cochrane databases and extensive personal reference databases.

RESULTS

Patients can usefully be classified by predominant bowel habit. Few investigations are needed except when diarrhoea is a prominent feature. Alarm features may warrant further investigation. Adverse psychological features and somatisation are often present. Ascertaining the patients' concerns and explaining symptoms in simple terms improves outcome. IBS is a heterogeneous condition with a range of treatments, each of which benefits a small proportion of patients. Treatment of associated anxiety and depression often improves bowel and other symptoms. Randomised placebo controlled trials show benefit as follows: cognitive behavioural therapy and psychodynamic interpersonal therapy improve coping; hypnotherapy benefits global symptoms in otherwise refractory patients; antispasmodics and tricyclic antidepressants improve pain; ispaghula improves pain and bowel habit; 5-HT(3) antagonists improve global symptoms, diarrhoea, and pain but may rarely cause unexplained colitis; 5-HT(4) agonists improve global symptoms, constipation, and bloating; selective serotonin reuptake inhibitors improve global symptoms.

CONCLUSIONS

Better ways of identifying which patients will respond to specific treatments are urgently needed.

Guidelines on the irritable bowel syndrome: mechanisms and practical management

BACKGROUND

IBS affects 5-11% of the population of most countries. Prevalence peaks in the third and fourth decades, with a female predominance.

AIM

To provide a guide for the assessment and management of adult patients with irritable bowel syndrome.

METHODS

Members of the Clinical Services Committee of The British Society of Gastroenterology were allocated particular areas to produce review documents. Literature searching included systematic searches using electronic databases such as Pubmed, EMBASE, MEDLINE, Web of Science, and Cochrane databases and extensive personal reference databases.

RESULTS

Patients can usefully be classified by predominant bowel habit. Few investigations are needed except when diarrhoea is a prominent feature. Alarm features may warrant further investigation. Adverse psychological features and somatisation are often present. Ascertaining the patients' concerns and explaining symptoms in simple terms improves outcome. IBS is a heterogeneous condition with a range of treatments, each of which benefits a small proportion of patients. Treatment of associated anxiety and depression often improves bowel and other symptoms. Randomised placebo controlled trials show benefit as follows: cognitive behavioural therapy and psychodynamic interpersonal therapy improve coping; hypnotherapy benefits global symptoms in otherwise refractory patients; antispasmodics and tricyclic antidepressants improve pain; ispaghula improves pain and bowel habit; 5-HT(3) antagonists improve global symptoms, diarrhoea, and pain but may rarely cause unexplained colitis; 5-HT(4) agonists improve global symptoms, constipation, and bloating; selective serotonin reuptake inhibitors improve global symptoms.

CONCLUSIONS

Better ways of identifying which patients will respond to specific treatments are urgently needed.

Visual field loss increases the risk of falls in older adults: the Salisbury eye evaluation

PURPOSE

Falls are a serious and preventable problem in older adults. Impaired vision has been linked to risk of falls; however, the impact of deficits in specific components of vision on the risk of falls is not well known.

METHODS

Data on falls for up to 20 months were provided by 2375 individuals participating in the Salisbury Eye Evaluation (SEE). Visual acuity, contrast sensitivity, visual field, and stereoacuity were tested by using standard measures. To aid in the assessment, each participant recorded falls on a calendar that was sent every month to the SEE clinic. beta-Binomial regression analysis was used.

RESULTS

Worse visual field scores were associated with the risk of falling (OR = 1.08 for a 10-point loss of points, 95% CI 1.03-1.13). When both central (</= 20 degrees radius) and peripheral visual fields were in the same model, only the peripheral visual field was associated with falls (OR = 1.06, 95% CI 1.01-1.10). Visual acuity, contrast sensitivity, and stereoacuity were not associated with falls after adjustment for demographic and health variables.

CONCLUSIONS

Visual field loss is the primary vision component that increases the risk of falls. This finding highlights the importance of visual field deficits in the risk of falls and supports other findings on decrements in mobility and increased risk of bumping with worsening visual field function. Persons with visual field loss may benefit from mobility training to reduce the risk of falling.

The Amsler chart: absence of evidence is not evidence of absence

Early detection of the onset or progression of macular disease is likely to become increasingly important as new treatment modalities are introduced. Current best practice involves issuing patients with an Amsler chart for daily or weekly observation with the instruction to attend for immediate assessment should any new distortion be perceived. However the sensitivity of Amsler charts in detecting macular disease can be less than 50%, implying that presentation may be delayed in over half of patients with advancing disease relying on the Amsler chart to detect progression. A likely explanation for this is the phenomenon of perceptual completion whereby regular objects are "filled-in" across the scotoma. Although alternative tests have been developed and shown to have greater sensitivity, at present no straightforward, cheap, home-based test of macular disease progression is available. The development of such a self-diagnostic tool should be a research priority.

A prospective cohort study of health outcomes following whiplash associated disorders in an Australian population

OBJECTIVE

To define health outcomes of whiplash associated disorders (WAD) at three months, six months, and two years after injury and to examine predictors of these outcomes.

DESIGN

Prospective cohort study.

SETTING

New South Wales, Australia.

SUBJECTS

People with compensable motor crash injuries who reported whiplash as one of their injuries.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Functional Rating Index (FRI), Short Form 36 (SF-36) at three months, six months, and two years after injury, ascertained by telephone interview.

RESULTS

At three months, 33.6% of the cohort was recovered (as defined by FRI<or=25), increasing marginally at six months (38.9% recovered), but more significantly at two years (51.7% recovered, p = 0.001). The mean physical component score of the SF-36 improved at each time point (p = 0.002), while the mean mental component score did not (p = 0.59). Predictors of recovery at two years (as defined by global perceived effect) included a lower FRI index at baseline (p = 0.001) and closure of the claim at two years (p = 0.02).

CONCLUSION

Whiplash injury had a large effect on the health of this Australian cohort of whiplash sufferers, with only 50% of the cohort recovered at two years. Physical measures of health appear to improve over time, whereas mental measures of health did not. Despite this, this cohort is largely able to participate in activities and work at two years. Prevention of chronic disability may lie with concentration of resources to those who score highly on the FRI at baseline. In addition, chronic psychological ill health may be prevented by directing treatment to those with poor scores on sensitive measures of psychological ill health at baseline.

Orientation and mobility training for adults with low vision

BACKGROUND

Orientation and mobility (O&M) training is provided to people who are visually impaired to help them maintain travel independence. It teaches them new orientation and mobility skills to compensate for reduced visual information.

OBJECTIVES

The objective of this review was to assess the effects of (O&M) training, with or without associated devices, for adults with low vision.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Group Trials Register) in The Cochrane Library, MEDLINE, SIGLE, EMBASE, National Research Register, Zetoc, LILACS, and the reference lists of articles. Updated searches were in 2006.

SELECTION CRITERIA

We planned to include randomised or quasi-randomised trials comparing (O&M) training with no training in adults with low vision.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the search results for eligibility, evaluated study quality and extracted the data.

MAIN RESULTS

Two small studies satisfied the inclusion criteria. They were consecutive phases of development of the same training curriculum and assessment tool. The intervention was administered by a volunteer on the basis of written and oral instruction. In both studies the randomisation technique was inadequate, being based on alternation, and masking was not achieved. Training had no effect in the first study while it was found to be beneficial in the second. Reasons for this may have been: the high scores obtained in the first study, suggestive of little need for training and small room for further improvement (a ceiling effect), and the refinement of the curriculum allowing better tailoring to patients' specific needs and characteristics, in the second study.

AUTHORS' CONCLUSIONS

The review found two small trials with similar methods, comparing (O&M) training to physical exercise, which were unable to demonstrate a difference. Therefore, there is little evidence on which type of orientation and mobility training is better for people with low vision who have specific characteristics and needs. Orientation and mobility instructors and scientists should plan randomised controlled studies to compare the effectiveness of different types of (O&M) training. A consensus is needed on the adoption of standard measurement instruments of mobility performance which are proved to be reliable and sensitive to the diverse mobility needs of people with low vision. For this purpose, questionnaires and performance-based tests may represent different tools that explore people with low vision's subjective experience or their objective functioning, respectively.

New standardised texts for assessing reading performance in four European languages

AIMS

To develop standardised texts for assessing reading speed during repeated measurements and across languages for normal subjects and low vision patients.

METHODS

10 texts were designed by linguistic experts in English, Finnish, French, and German. The texts were at the level of a sixth grade reading material (reading ages 10-12 years) and were matched for length (830 (plus or minus 2) characters) and syntactic complexity, according to the syntactic prediction locality theory of Gibson. 100 normally sighted native speaking volunteers aged 18-35 years (25 per language) read each text aloud in randomised order. The newly designed text battery was then applied to test the reading performance of 100 normally sighted native speaking volunteers aged 60-85 years (25 per language).

RESULTS

Reading speed was not significantly different with at least seven texts in all four languages. The maximum reading speed difference between texts, in the same language was 6.8% (Finnish). Average reading speeds (SD) in characters per minute are, for the young observer group: English 1234 (147), Finnish 1263 (142), French 1214 (152), German 1126 (105). The group of older readers showed statistically significant lower average reading speeds: English 951 (97), Finnish 1014 (179), French 1131 (160), German 934 (117).

CONCLUSION

The authors have developed a set of standardised, homogeneous, and comparable texts in four European languages (English, Finnish, French, German). These texts will be a valuable tool for measuring reading speed in international studies in the field of reading and low vision research.