Cost-effectiveness of primary surgical versus primary medical management in the treatment of patients presenting with advanced glaucoma

SYNOPSIS

Advanced glaucoma is associated with sight loss. This within-trial economic evaluation compares medical and surgical management strategies. At 2 years, medication appears more cost-effective though longitudinal outcomes are an important subject in future research.

BACKGROUND/AIMS

Open angle glaucoma (OAG) is a progressive optic neuropathy. Approximately 25% of newly diagnosed patients with OAG present with advanced disease in at least one eye. The vision loss associated with OAG can lead to significant impacts on vision, quality of life and health care resources. The Treatment of Advanced Glaucoma Study is a randomised controlled trial comparing the effectiveness of primary surgical and medical management for newly diagnosed advanced patients with OAG. An economic evaluation was carried out to understand the costs and benefits of each strategy.

METHODS

A cost utility analysis was carried out from a National Health Service perspective over a 2-year time horizon inclusive of patient costs. The primary outcome was patient health-related quality of life measured by the EQ-5D-5L, Health Utilities Index 3 (HUI3) and Glaucoma Utility Index (GUI). Results were expressed as incremental cost per QALY gained.

RESULTS

Trabeculectomy was associated with higher costs and greater effect, the EQ-5D-5L results have an incremental cost per QALY of £45,456. The likelihood of surgery being cost-effective at a £20, 000, £30,000 and £50,000 QALY threshold is 0%, 12% and 56%, respectively. The results for the HUI3, GUI and inclusion of patient costs do not change the conclusions of the study.

CONCLUSION

This is the first study to evaluate management strategies for those presenting with advanced glaucoma. At a 2-year time horizon, medication is the more cost-effective approach for managing glaucoma. Future research can focus on the costs and benefits of the treatments over a longer time horizon.

Primary trabeculectomy versus primary glaucoma eye drops for newly diagnosed advanced glaucoma: TAGS RCT

BACKGROUND

Patients diagnosed with advanced primary open-angle glaucoma are at a high risk of lifetime blindness. Uncertainty exists about whether primary medical management (glaucoma eye drops) or primary surgical treatment (augmented trabeculectomy) provide the best and safest patient outcomes.

OBJECTIVES

To compare primary medical management with primary surgical treatment (augmented trabeculectomy) in patients with primary open-angle glaucoma presenting with advanced disease in terms of health-related quality of life, clinical effectiveness, safety and cost-effectiveness.

DESIGN

This was a two-arm, parallel, multicentre, pragmatic randomised controlled trial.

SETTING

Secondary care eye services.

PARTICIPANTS

Adult patients presenting with advanced primary open-angle glaucoma in at least one eye, as defined by the Hodapp-Parrish-Anderson classification of severe glaucoma.

INTERVENTION

Primary medical treatment - escalating medical management with glaucoma eye drops. Primary trabeculectomy treatment - trabeculectomy augmented with mitomycin C.

MAIN OUTCOME MEASURES

The primary outcome was health-related quality of life measured with the Visual Function Questionnaire-25 at 2 years post randomisation. Secondary outcomes were mean intraocular pressure; EQ-5D-5L; Health Utilities Index 3; Glaucoma Utility Index; cost and cost-effectiveness; generic, vision-specific and disease-specific health-related quality of life; clinical effectiveness; and safety.

RESULTS

A total of 453 participants were recruited. The mean age of the participants was 67 years (standard deviation 12 years) in the trabeculectomy arm and 68 years (standard deviation 12 years) in the medical management arm. Over 65% of participants were male and more than 80% were white. At 24 months, the mean difference in Visual Function Questionnaire-25 score was 1.06 (95% confidence interval -1.32 to 3.43; p = 0.383). There was no evidence of a difference between arms in the EQ-5D-5L score, the Health Utilities Index or the Glaucoma Utility Index. At 24 months, the mean intraocular pressure was 12.40 mmHg in the trabeculectomy arm and 15.07 mmHg in the medical management arm (mean difference -2.75 mmHg, 95% confidence interval -3.84 to -1.66 mmHg; p < 0.001). Fewer types of glaucoma eye drops were required in the trabeculectomy arm. LogMAR visual acuity was slightly better in the medical management arm (mean difference 0.07, 95% confidence interval 0.02 to 0.11; p = 0.006) than in the trabeculectomy arm. There was no evidence of difference in safety between the two arms. A discrete choice experiment updated the utility values for the Glaucoma Utility Index. The within-trial economic analysis found a small increase in the mean EQ-5D-5L score (0.04) and that trabeculectomy has a higher probability of being cost-effective than medical management. The incremental cost of trabeculectomy per quality-adjusted life-year was £45,456. Therefore, at 2 years, surgery is unlikely to be considered cost-effective at a threshold of £20,000 per quality-adjusted life-year. When extrapolated over a patient's lifetime in a model-based analysis, trabeculectomy, compared with medical treatment, was associated with higher costs (average £2687), a larger number of quality-adjusted life-years (average 0.28) and higher incremental cost per quality-adjusted life-year gained (average £9679). The likelihood of trabeculectomy being cost-effective at a willingness-to-pay threshold of £20,000 per quality-adjusted life year gained was 73%.

CONCLUSIONS

Our results suggested that there was no difference between treatment arms in health-related quality of life, as measured with the Visual Function Questionnaire-25 at 24 months. Intraocular pressure was better controlled in the trabeculectomy arm, and this may reduce visual field progression. Modelling over the patient's lifetime suggests that trabeculectomy may be cost-effective over the range of values of society's willingness to pay for a quality-adjusted life-year.

FUTURE WORK

Further follow-up of participants will allow us to estimate the long-term differences of disease progression, patient experience and cost-effectiveness.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN56878850.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 72. See the NIHR Journals Library website for further project information.

Primary trabeculectomy for advanced glaucoma: pragmatic multicentre randomised controlled trial (TAGS)

OBJECTIVE

To determine whether primary trabeculectomy or primary medical treatment produces better outcomes in term of quality of life, clinical effectiveness, and safety in patients presenting with advanced glaucoma.

DESIGN

Pragmatic multicentre randomised controlled trial.

SETTING

27 secondary care glaucoma departments in the UK.

PARTICIPANTS

453 adults presenting with newly diagnosed advanced open angle glaucoma in at least one eye (Hodapp classification) between 3 June 2014 and 31 May 2017.

INTERVENTIONS

Mitomycin C augmented trabeculectomy (n=227) and escalating medical management with intraocular pressure reducing drops (n=226) MAIN OUTCOME MEASURES: Primary outcome: vision specific quality of life measured with Visual Function Questionnaire-25 (VFQ-25) at 24 months.

SECONDARY OUTCOMES

general health status, glaucoma related quality of life, clinical effectiveness (intraocular pressure, visual field, visual acuity), and safety.

RESULTS

At 24 months, the mean VFQ-25 scores in the trabeculectomy and medical arms were 85.4 (SD 13.8) and 84.5 (16.3), respectively (mean difference 1.06, 95% confidence interval -1.32 to 3.43; P=0.38). Mean intraocular pressure was 12.4 (SD 4.7) mm Hg for trabeculectomy and 15.1 (4.8) mm Hg for medical management (mean difference -2.8 (-3.8 to -1.7) mm Hg; P<0.001). Adverse events occurred in 88 (39%) patients in the trabeculectomy arm and 100 (44%) in the medical management arm (relative risk 0.88, 95% confidence interval 0.66 to 1.17; P=0.37). Serious side effects were rare.

CONCLUSION

Primary trabeculectomy had similar quality of life and safety outcomes and achieved a lower intraocular pressure compared with primary medication.

TRIAL REGISTRATION

Health Technology Assessment (NIHR-HTA) Programme (project number: 12/35/38). ISRCTN registry: ISRCTN56878850.

Using systematic data categorisation to quantify the types of data collected in clinical trials: the DataCat project

BACKGROUND

Data collection consumes a large proportion of clinical trial resources. Each data item requires time and effort for collection, processing and quality control procedures. In general, more data equals a heavier burden for trial staff and participants. It is also likely to increase costs. Knowing the types of data being collected, and in what proportion, will be helpful to ensure that limited trial resources and participant goodwill are used wisely.

AIM

The aim of this study is to categorise the types of data collected across a broad range of trials and assess what proportion of collected data each category represents.

METHODS

We developed a standard operating procedure to categorise data into primary outcome, secondary outcome and 15 other categories. We categorised all variables collected on trial data collection forms from 18, mainly publicly funded, randomised superiority trials, including trials of an investigational medicinal product and complex interventions. Categorisation was done independently in pairs: one person having in-depth knowledge of the trial, the other independent of the trial. Disagreement was resolved through reference to the trial protocol and discussion, with the project team being consulted if necessary.

KEY RESULTS

Primary outcome data accounted for 5.0% (median)/11.2% (mean) of all data items collected. Secondary outcomes accounted for 39.9% (median)/42.5% (mean) of all data items. Non-outcome data such as participant identifiers and demographic data represented 32.4% (median)/36.5% (mean) of all data items collected.

CONCLUSION

A small proportion of the data collected in our sample of 18 trials was related to the primary outcome. Secondary outcomes accounted for eight times the volume of data as the primary outcome. A substantial amount of data collection is not related to trial outcomes. Trialists should work to make sure that the data they collect are only those essential to support the health and treatment decisions of those whom the trial is designed to inform.

Baseline Characteristics of Participants in the Treatment of Advanced Glaucoma Study: A Multicenter Randomized Controlled Trial

PURPOSE

To report the baseline characteristics of participants enrolled in TAGS (Treatment of Advanced Glaucoma Study).

DESIGN

Pragmatic randomized control trial (RCT).

METHODS

Participants with newly diagnosed advanced glaucoma in at least 1 eye were recruited. Participants were patients with open angle glaucoma presenting with advanced glaucoma in at least 1 eye as defined by the Hodapp-Parrish-Anderson (HPA) criteria for severe defect. Participants were randomly allocated to receive either primary augmented trabeculectomy or primary medical management. When both eyes were eligible, the same intervention was undertaken in both eyes, and the index eye for analysis was the eye with the less severe visual field mean defect (MD). Main outcome measurements were visual field profile, defined by the HPA classification; clinical characteristics; quality of life, as measured by the National Eye Institute Visual Function Questionnaire 25 (VFQ-25), the EuroQual-5 Dimension (EQ-5D 5L), Health Utility Index-3 (HUI-3), and the Glaucoma Profile Instrument (GPI).

RESULTS

A total of 453 patients were recruited. The mean visual field MD was -15.0 dB ± 6.3 in the index eye and -6.2 dB in the non-index eye. Of index eyes (HPA "severe" classification) at baseline, more than 70% of participants had a MD <-12.00 dB, and nearly 90% had more than 20 points defective at the 1% level. The mean LogMAR visual acuity of the index eye was 0.2 ± 0.3.

CONCLUSIONS

TAGS is the first RCT to compare medical versus surgical treatments for patients presenting with advanced open angle glaucoma in a publicly funded health service. The study will provide clinical, health-related quality of life, and economic outcomes to inform future treatment choices for those presenting with advanced glaucoma.

Treatment of Advanced Glaucoma Study: a multicentre randomised controlled trial comparing primary medical treatment with primary trabeculectomy for people with newly diagnosed advanced glaucoma-study protocol

BACKGROUND

Presentation with advanced glaucoma is the major risk factor for lifetime blindness. Effective intervention at diagnosis is expected to minimise risk of further visual loss in this group of patients.

AIM

To compare clinical and cost-effectiveness of primary medical management compared with primary surgery for people presenting with advanced open-angle glaucoma (OAG).

METHODS

Design: A prospective, pragmatic multicentre randomised controlled trial (RCT).

SETTING

Twenty-seven UK hospital eye services.

PARTICIPANTS

Four hundred and forty patients presenting with advanced OAG, according to the Hodapp-Parish-Anderson classification of visual field loss.

INTERVENTION

Participants will be randomised to medical treatment or augmented trabeculectomy (1:1 allocation minimised by centre and presence of advanced disease in both eyes).

MAIN OUTCOME MEASURES

The primary outcome is vision-related quality of life measured by the National Eye Institute-Visual Function Questionnaire-25 at 24 months. Secondary outcomes include generic EQ-5D-5L, Health Utility Index-3 and glaucoma-related health status (Glaucoma Utility Index), patient experience, visual field measured by mean deviation value, logarithm of the mean angle of resolution visual acuity, intraocular pressure, adverse events, standards for driving and eligibility for blind certification. Incremental cost per quality-adjusted life-year (QALY) based on EQ-5D-5L and glaucoma profile instrument will be estimated.

RESULTS

The study will report the comparative effectiveness and cost-effectiveness of medical treatment against augmented trabeculectomy in patients presenting with advanced glaucoma in terms of patient-reported health and visual function, clinical outcomes and incremental cost per QALY at 2 years.

CONCLUSIONS

Treatment of Advanced Glaucoma Study will be the first RCT reporting outcomes from the perspective of those with advanced glaucoma.

TRIAL REGISTRATION NUMBER

ISRCTN56878850, Pre-results.

Ketamine as the anaesthetic for electroconvulsive therapy: the KANECT randomised controlled trial - CORRIGENDUM

This notice describes a correction to the above mentioned paper.

Obesity in individuals with schizophrenia: a case controlled study in Scotland

BACKGROUND

Despite extensive clinical concern about rates of obesity in patients with schizophrenia, there is little evidence of the extent of this problem at a population level.

AIMS

To estimate levels of obesity in a national population sample by comparing patients with schizophrenia with matched controls.

METHOD

We calculated levels of obesity for each patient with schizophrenia from the national Primary Care Clinical Informatics Unit database (n=4658) matched with age, gender and neighbourhood controls.

RESULTS

We demonstrated a significant increased obesity hazard for the schizophrenia group using Cox regression analysis, with odds ratio (OR) of 1.94 (95% CI 1.81-2.10) (under the assumption of missing body mass index (BMI) indicating non-obesity) and OR=1.68 (95% CI 1.55-1.81) where no assumptions were made for missing BMI data.

CONCLUSIONS

People with schizophrenia are at increased risk of being obese compared with controls matched by age, gender and practice attended. Priority should be given to research which aims to reduce weight and increase activity in those with schizophrenia.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

Ketamine as the anaesthetic for electroconvulsive therapy: the KANECT randomised controlled trial

BackgroundKetamine has recently become an agent of interest as an acute treatment for severe depression and as the anaesthetic for electroconvulsive therapy (ECT). Subanaesthetic doses result in an acute reduction in depression severity while evidence is equivocal for this antidepressant effect with anaesthetic or adjuvant doses. Recent systematic reviews call for high-quality evidence from further randomised controlled trials (RCTs).AimsTo establish if ketamine as the anaesthetic for ECT results in fewer ECT treatments, improvements in depression severity ratings and less memory impairment than the standard anaesthetic.MethodDouble-blind, parallel-design, RCT of intravenous ketamine (up to 2 mg/kg) with an active comparator, intravenous propofol (up to 2.5 mg/kg), as the anaesthetic for ECT in patients receiving ECT for major depression on an informal basis. (Trial registration: European Clinical Trials Database (EudraCT): 2011-000396-14 and clinicalTrials.gov: NCT01306760)ResultsNo significant differences were found on any outcome measure during, at the end of or 1 month following the ECT course.ConclusionsKetamine as an anaesthetic does not enhance the efficacy of ECT.

Detecting objective and subjective cognitive effects of electroconvulsive therapy: intensity, duration and test utility in a large clinical sample

BACKGROUND

Electroconvulsive therapy (ECT) is an effective treatment for depression but the extent and persistence of cognitive side-effects remain uncertain. It has been reported that there is little evidence that impairments last longer than up to 15 days post-ECT. However, relatively few studies have followed patients for even as long as 1 month post-ECT. Here we report results from a brief cognitive battery given prior to ECT and repeated five times up to 6 months post-ECT.

METHOD

In a retrospective case-note study of routinely collected clinical data 126 patients treated with ECT completed two neuropsychological tests [Cambridge Neuropsychological Test Automated Battery (CANTAB) spatial recognition memory (SRM) and Mini Mental State Examination (MMSE)] and two subjective reports of memory function, prior to ECT. Patients were reassessed following ECT and at 1, 3 and 6 months post-ECT although not all patients completed all assessments.

RESULTS

Performance relative to pre-ECT baseline was significantly poorer at each post-ECT assessment up to 3 months post-ECT using the CANTAB SRM, but was improved at 6 months. Conversely, MMSE score showed improvements relative to baseline from 1 month post-ECT. Mood and subjective memory scores improved following ECT and were correlated with one another, but not with either neuropsychological measure.

CONCLUSIONS

The CANTAB SRM task revealed reversible cognitive deficiencies relative to a pre-ECT baseline for at least 3 months following ECT, while MMSE score and patients' subjective reports showed only improvement. Visuospatial memory scores eventually exceeded baseline 6 months post-ECT.

Multiple behavioural impulsivity tasks predict prospective alcohol involvement in adolescents

AIMS

We investigated reciprocal prospective relationships between multiple behavioural impulsivity tasks (assessing delay discounting, risk-taking and disinhibition) and alcohol involvement (consumption, drunkenness and problems) among adolescents. We hypothesized that performance on the tasks would predict subsequent alcohol involvement, and that alcohol involvement would lead to increases in behavioural impulsivity over time.

DESIGN

Cross-lagged prospective design in which impulsivity and alcohol involvement were assessed five times over 2 years (once every 6 months, on average).

SETTING

Classrooms in secondary schools in North West England.

PARTICIPANTS

Two hundred and eighty-seven adolescents (51.2% male) who were aged 12 or 13 years at study enrolment.

MEASUREMENTS

Participants reported their alcohol involvement and completed computerized tasks of disinhibition, delay discounting and risk-taking at each assessment. Cross-sectional and prospective relationships between the variables of interest were investigated using cross-lagged analyses.

FINDINGS

All behavioural impulsivity tasks predicted a composite index of alcohol involvement 6 months later (all Ps < 0.01), and these prospective relationships were reliable across the majority of time-points. Importantly, we did not observe the converse relationship across time: alcohol involvement did not predict performance on behavioural impulsivity tasks at any subsequent time point.

CONCLUSIONS

Several measures of impulsivity predict escalation in alcohol involvement in young adolescents, but alcohol use does not appear to alter impulsivity.

Learning on the IGT follows emergence of knowledge but not differential somatic activity

The importance of unconscious autonomic activity vs. knowledge in influencing behavior on the Iowa Gambling Task (IGT) has been the subject of debate. The task's developers, Bechara and colleagues, have claimed that behavior on the IGT is influenced by somatic activity and that this activity precedes the emergence of knowledge about the task contingencies sufficient to guide behavior. Since then others have claimed that this knowledge emerges much earlier on the task. However, it has yet to be established whether somatic activity which differentiates between advantageous and disadvantageous choices on the IGT is found before this point. This study describes an experiment to determine whether knowledge sufficient to guide behavior precedes differential autonomic activity or vice versa. This experiment used a computerized version of the IGT, knowledge probes after every 10 trials and skin conductance recording to measure somatic activity. Whereas in previous reports the majority of participants end the task with full conceptual knowledge of the IGT contingencies we found little evidence in support of this conclusion. However, full conceptual knowledge was not critical for advantageous deck selection to occur and most participants had knowledge sufficient to guide behavior after approximately 40 trials. We did not find anticipatory physiological activity sufficient to differentiate between deck types in the period prior to acquiring this knowledge. However, post-punishment physiological activity was found to be larger for the disadvantageous decks in the pre-knowledge period, but only for participants who displayed knowledge. Post-reward physiological activity distinguished between the advantageous and disadvantageous decks across the whole experiment but, again, only in participants who displayed knowledge and then only in later trials following their display of knowledge.

Learning on the IGT follows emergence of knowledge but not differential somatic activity

The importance of unconscious autonomic activity vs. knowledge in influencing behavior on the Iowa Gambling Task (IGT) has been the subject of debate. The task's developers, Bechara and colleagues, have claimed that behavior on the IGT is influenced by somatic activity and that this activity precedes the emergence of knowledge about the task contingencies sufficient to guide behavior. Since then others have claimed that this knowledge emerges much earlier on the task. However, it has yet to be established whether somatic activity which differentiates between advantageous and disadvantageous choices on the IGT is found before this point. This study describes an experiment to determine whether knowledge sufficient to guide behavior precedes differential autonomic activity or vice versa. This experiment used a computerized version of the IGT, knowledge probes after every 10 trials and skin conductance recording to measure somatic activity. Whereas in previous reports the majority of participants end the task with full conceptual knowledge of the IGT contingencies we found little evidence in support of this conclusion. However, full conceptual knowledge was not critical for advantageous deck selection to occur and most participants had knowledge sufficient to guide behavior after approximately 40 trials. We did not find anticipatory physiological activity sufficient to differentiate between deck types in the period prior to acquiring this knowledge. However, post-punishment physiological activity was found to be larger for the disadvantageous decks in the pre-knowledge period, but only for participants who displayed knowledge. Post-reward physiological activity distinguished between the advantageous and disadvantageous decks across the whole experiment but, again, only in participants who displayed knowledge and then only in later trials following their display of knowledge.

Effects of 0.4 g/kg alcohol on attentional bias and alcohol-seeking behaviour in heavy and moderate social drinkers

Alcohol intoxication is known to influence attentional biases for alcohol-related cues and alcohol-seeking behaviour. It is unknown if heavier drinkers are more or less sensitive to these effects of alcohol, or whether the effects of alcohol on attentional bias are associated with subsequent alcohol-seeking behaviour. In the present study, 55 social drinkers were administered either 0.4 g/kg alcohol or placebo in a repeated measures, double-blind experimental design. Participants completed a visual probe task with eye movement monitoring (to measure attentional bias) and a bogus taste test (to measure alcohol-seeking) in both alcohol and placebo sessions. Heavy drinkers showed an attentional bias for alcohol cues that was unaffected by alcohol, whereas in moderate drinkers attentional bias was present after alcohol administration, but was absent after placebo. All participants voluntarily consumed more beer during the taste test after administration of alcohol compared with placebo. The effects of alcohol on attentional bias were unrelated to the effects of alcohol on beer consumption. Results are consistent with the development of tolerance, rather than sensitization, to the acute effects of alcohol on attentional biases in heavy drinkers. However, alcohol-induced increases in attentional bias were not related to the effects of alcohol on the motivation to drink.

Alcohol expectancy moderates attentional bias for alcohol cues in light drinkers

AIMS

Theoretical models suggest that attentional bias for alcohol-related cues develops because cues signal the availability of alcohol, and the expectancy elicited by alcohol cues is responsible for the maintenance of attentional bias among regular drinkers. We investigated the moderating role of alcohol expectancy on attentional bias for alcohol-related cues.

DESIGN

Within-subjects experimental design.

SETTING

Psychology laboratories.

PARTICIPANTS

Adult social drinkers (n=58).

MEASUREMENTS

On a trial-by-trial basis, participants were informed of the probability (100%, 50%, 0%) that they would receive beer at the end of the trial before their eye movements towards alcohol-related and control cues were measured.

FINDINGS

Heavy social drinkers showed an attentional bias for alcohol-related cues regardless of alcohol expectancy. However, in light social drinkers, attentional bias was only seen on 100% probability trials, i.e. when alcohol was expected imminently.

CONCLUSIONS

Attentional bias for alcohol-related cues is sensitive to the current expectancy of receiving alcohol in light social drinkers, but it occurs independently of the current level of alcohol expectancy in heavy drinkers.

The effects of priming restrained versus disinhibited behaviour on alcohol-seeking in social drinkers

BACKGROUND

Deficient response inhibition (disinhibition) may play a causal role in alcohol abuse, with impaired inhibition occurring prior to, and acting as a risk factor for, subsequent alcohol problems. We experimentally primed either disinhibited or restrained behaviour while participants completed a Stop-Signal task, before examining the effects on alcohol-seeking behaviour.

METHODS

Fifty three social drinkers completed a Stop-Signal task following instructions that either emphasised rapid responding at the expense of successful inhibition (Disinhibition group) or vice versa (Restrained group). Subsequent ad lib alcohol-seeking was measured with a bogus taste test.

RESULTS

As predicted, participants in the Disinhibition group consumed more beer during the taste test compared to participants in the Restrained group. Furthermore, within the Restrained group only, correlations indicated that those participants who responded more cautiously during the Stop-Signal task subsequently consumed less beer.

CONCLUSIONS

An experimental manipulation of response set during a response inhibition task, emphasising either restrained or disinhibited responding, has a causal influence on alcohol-seeking behaviour in social drinkers.

Neuropsychological consequence of soccer play in adolescent U.K. School team soccer players

To assess mild head injury effects in adolescent soccer players, neuropsychological performance across school team soccer players, rugby players and noncontact sport players was assessed in a quasi-experimental cross-sectional design. One hundred eighty-five males were tested (ages 13-16; response rate 55%) and 86 contributed data to the analyses after exclusion for recent concussion and overlapping sports participation. Soccer players showed lower premorbid intellectual functioning, but neither soccer players nor rugby players showed neuropsychological decrement compared with noncontact sport players. Cumulative heading did not predict neuropsychological performance. While no specific attribute of soccer was linked with neuropsychological impairment, head injury predicted reduced attention for all participants.

Risk-taking but not response inhibition or delay discounting predict alcohol consumption in social drinkers

Impulsivity and risk-taking are multi-dimensional constructs that have been implicated in heavy drinking and alcohol problems. Our aim was to identify the specific component of impulsivity or risk-taking that explained the greatest variance in heavy and problem drinking among a sample of young adults recruited from a university population. Participants (N=75) completed a test battery comprising two commonly used response inhibition tasks (a Go/No-Go task and a Stop signal task), a delay discounting procedure, and the Balloon Analogue Risk Task (BART) as a measure of risk-taking. Participants also completed the Barratt Impulsivity Scales (BIS) as a measure of trait impulsivity. In a hierarchical multiple regression model, risk-taking was identified as the only behavioural measure that predicted alcohol use and problems. In a secondary analysis, we demonstrated that risk-taking predicted unique variance in alcohol use and problems over and above that explained by trait impulsivity. Results suggest that among young adults, a behavioural measure of risk-taking predicts variance in alcohol consumption and alcohol problems, even when individual differences in trait impulsivity are statistically controlled. However, behavioural measures of response inhibition and delay discounting do not predict unique variance in alcohol use in young adult social drinkers.

An ERP analysis of recognition and categorization decisions in a prototype-distortion task

BACKGROUND

Theories of categorization make different predictions about the underlying processes used to represent categories. Episodic theories suggest that categories are represented in memory by storing previously encountered exemplars in memory. Prototype theories suggest that categories are represented in the form of a prototype independently of memory. A number of studies that show dissociations between categorization and recognition are often cited as evidence for the prototype account. These dissociations have compared recognition judgements made to one set of items to categorization judgements to a different set of items making a clear interpretation difficult. Instead of using different stimuli for different tests this experiment compares the processes by which participants make decisions about category membership in a prototype-distortion task and with recognition decisions about the same set of stimuli by examining the Event Related Potentials (ERPs) associated with them.

METHOD

Sixty-three participants were asked to make categorization or recognition decisions about stimuli that either formed an artificial category or that were category non-members. We examined the ERP components associated with both kinds of decision for pre-exposed and control participants.

CONCLUSION

In contrast to studies using different items we observed no behavioural differences between the two kinds of decision; participants were equally able to distinguish category members from non-members, regardless of whether they were performing a recognition or categorisation judgement. Interestingly, this did not interact with prior-exposure. However, the ERP data demonstrated that the early visual evoked response that discriminated category members from non-members was modulated by which judgement participants performed and whether they had been pre-exposed to category members. We conclude from this that any differences between categorization and recognition reflect differences in the information that participants focus on in the stimuli to make the judgements at test, rather than any differences in encoding or process.

Do UK university football club players suffer neuropsychological impairment as a consequence of their football (soccer) play?

Male players from football and rugby clubs and sportsmen from a variety of noncontact sports clubs at a UK university were compared on biographical and neuropsychological test measures. A data analysis paradigm was developed and employed to control the inflation of Type 1 error rate due to multiple hypotheses testing. Rugby players sustained most head injuries in their chosen sport, but neuropsychological tests of attention, memory, and executive function provided no evidence of performance impairment attributable to the number of head injuries sustained or the football, rugby, or noncontact sport groups. Footballers' heading frequency was related to the number of football head injuries sustained, but no relationship was detected between footballers' heading frequency and their neuropsychological test performance. Following discussion of pertinent methodological limitations it is concluded that there was no evidence in this dataset of neuropsychological impairment consistent with either mild head injury incidence or football heading frequency. However, a need for further research examining the long-term neuropsychological consequences of such head injuries was identified.

Repetition priming affects guessing not familiarity

BACKGROUND

The claim that recollection and familiarity based memory processes have distinct retrieval mechanisms is based partly on the observation that masked repetition and semantic priming influence estimates of familiarity derived from know responses but have no effect on estimates of recollection derived from remember responses. Close inspection of the experiments on which this claim is based reveal the effect size to be small, potentially the result of a type-2 error, and/or inflated due to participants not having the opportunity to report guesses. This paper re-evaluates these claims by attempting a partial replication of two such Experiments.

METHODS

In Experiment 1 participants made remember, know, and guess responses following primed and unprimed target words. In Experiment 2 participants made sure, unsure, and guess following primed and unprimed target words.

RESULTS

In Experiment 1 the repetition priming effect occurred only for guess responses and only for unstudied items. In Experiment 2 the priming effect occurred for both unsure and guess responses, but again only for unstudied items.

CONCLUSION

The data are consistent with the view that remembering and knowing do not correspond to confidence ratings; and suggest that contrary to earlier findings, recollection and familiarity do not differ in retrieval mechanisms. As such the effects of repetition priming on subjective reports of remembering should not be cited as evidence for the distinction between recollection and familiarity based memory processes.

Neuropsychological Impairment as a Consequence of Football (Soccer) Play and Football Heading: Preliminary Analyses and Report on University Footballers

Previous research has claimed neuropsychological impairment occurs as a result of professional and amateur football play, and, specifically, football heading. However, much of this research exhibits substantial methodological problems. By investigating less committed amateur level footballers, the current study sought to gain some insight into the developmental history of any neuropsychological consequences of football play. University football, rugby and noncontact sports players were compared on a range of biographical and neuropsychological test variables. While playing their chosen sports, rugby players sustained many more head injuries than footballers and noncontact sportsmen, but footballers did not sustain significantly more head injuries than noncontact sportsmen. The number of head injuries sustained predicted Trails B and TAP Divided Attention latencies in a positive fashion. After controlling for the number of head injuries sustained, sport group effects were detected with TAP Divided Attention accuracy scores, with footballers exhibiting poorest performance. After controlling for the number of head injuries sustained, the total amount of heading done by footballers predicted the number of Wisconsin Card Sorting category shifts in a negative fashion. Nevertheless, over interpretation of all of these results should be resisted because of the exploratory nature of the analyses and the possibility that the sport groups may differ in ways other than just the nature of their sports activities.

Neuropsychological impairment as a consequence of football (soccer) play and football heading: A preliminary analysis and report on school students (13–16 years)

Footballers run the risk of incurring mild head injury from a variety of sources, including the intentional use of the head to play the ball, known as heading. This paper presents a preliminary exploratory analysis of data collected to examine whether cumulative incidence of mild head injury, or cumulative heading frequency, are related to neuropsychological functioning in male adolescent footballers. In a quasi-experimental cross-sectional design, neuropsychological test scores of school team footballers were compared with those of similarly aged rugby players and noncontact sport players. Cumulative mild head injury incidence was estimated using self-reports, and cumulative heading was estimated using a combination of observation and self-reports. No participants had sustained a head injury within 3 months of testing. There was no relationship between head injury and neuropsychological performance, and there were no decrements in either the footballers or the rugby players in comparison with the noncontact sport players. Within the footballers, cumulative heading did not predict any of the neuropsychological test scores. These findings indicate the absence of neuropsychological impairment arising due to cumulative mild head injury incidence, or cumulative heading. Although these null findings may be reassuring to players, parents, and football organizers, we stress that they are preliminary. Further data is being collected from the same populations to provide more reliable effect estimates.

Understanding and measuring powered wheelchair mobility and manoeuvrability. Part I. Reach in confined spaces

PURPOSE

To determine: (1) what wheelchair manoeuvrability factors are important and (2) the effects of powered wheelchair design on the ability to reach in a confined space.

METHOD

The relative importance of five aspects of wheelchair manoeuvrability was determined through a survey of users of wheelchairs (N = 52) and health care professionals and others (N = 89). A single young, non-disabled subject undertook repeated trials of reach distance on to a counter at the end of a corridor whose width could be adjusted by moving Styrofoam walls.

RESULTS

Reaching, moving in confined spaces and avoiding collisions were more important than speed and avoiding the need to drive backwards. The rear wheel drive powered wheelchair was found to allow the greatest reach when driving backwards into the space and the wheelchair which moved in a sideways direction allowed greatest reach in the narrowest corridor.

CONCLUSIONS

The survey concluded that manoeuvring in small spaces and reaching without collisions were important. The powered wheelchair with sideways capability afforded the greatest reach in confined spaces except when the rear wheel drive chair was driven in backwards. The survey respondents did not place a high priority on avoiding backwards driving but some people find this difficult to do safely.

Some decks are better than others: the effect of reinforcer type and task instructions on learning in the Iowa Gambling Task

The Iowa Gambling Task (Bechara, Damasio, Damasio, & Anderson, 1994) has become widely used as a laboratory test of "real-life" decision-making. However, aspects of its administration that have been varied by researchers may differentially affect performance and the conclusions researchers can draw. Some researchers have used facsimile money reinforcers while others have used real money reinforcers. More importantly, the instructions participants receive have also been varied. While no differences have been reported in performance dependent on reinforcer type, no previous comparison of participants' instructions has been conducted. This is despite one set of instructions giving participants a clear hint about the nature of the task. Additionally, in previous research one set of instructions have not been used exclusively with one reinforcer type making any differential or cumulative effects of these factors difficult to interpret. The present study compared the effects of instruction and reinforcer type on IGT performance. When participants received instructions without a hint performance was affected by reinforcer type. This was not the case when the instructions included a hint. In a second IGT session performance was improved in participants who had received the hint instructions compared with those who had not.

Consent and the individual detained in custody

It has been acknowledged that autonomy is one of the prima facie principles in modern medical practice and integral to the interchange between doctor and patient even if that meeting does not fulfil the normal criteria for a consultation. The lead having been taken by other jurisdictions, the General Medical Council, the UK national regulatory body for doctors, has now acknowledged the concept of informed consent that was first espoused in cases such as Rogers v. Whitaker. In regard to the concept of informed consent, there are three pertinent issues that the Forensic Physician should consider in deciding upon the adequacy of this: Did that person have capacity in the eyes of the law? The Forensic Physician may be asked to examine individuals whose age span ranges from the newly born to the elderly and there will be potential conflict of interest between parent and child or elderly people and their carers. Even if adequate information was imparted, did a person under the (significant) influence of alcohol or drugs understand the likely implications that would flow from their decision? Was the individual concerned given appropriate information beforehand--in other words, was the consent truly informed? Was the consent given voluntarily? Voluntariness is probably the most significant ethical worry likely to confront the doctor, particularly when examining an individual for fitness to be detained or fitness to be interviewed, both categories of which make up the main work load in this sub-specialty. The thorny ethical dilemmas faced in this specialty are considered and how the professional standard originally defined in Hunter v Hanley and re-iterated in the Bolam test (with subsequent modification in Bolitho) affect the way in which the clinician deals with the problems is likely to face.

Product development: using a 3D computer model to optimize the stability of the Rocket powered wheelchair

A three-dimensional (3D) lumped-parameter model of a powered wheelchair was created to aid the development of the Rocket prototype wheelchair and to help explore the effect of innovative design features on its stability. The model was developed using simulation software, specifically Working Model 3D. The accuracy of the model was determined by comparing both its static stability angles and dynamic behavior as it passed down a 4.8-cm (1.9") road curb at a heading of 45 degrees with the performance of the actual wheelchair. The model's predictions of the static stability angles in the forward, rearward, and lateral directions were within 9.3, 7.1, and 3.8% of the measured values, respectively. The average absolute error in the predicted position of the wheelchair as it moved down the curb was 2.2 cm/m (0.9" per 3'3") traveled. The accuracy was limited by the inability to model soft bodies, the inherent difficulties in modeling a statically indeterminate system, and the computing time. Nevertheless, it was found to be useful in investigating the effect of eight design alterations on the lateral stability of the wheelchair. Stability was quantified by determining the static lateral stability angles and the maximum height of a road curb over which the wheelchair could successfully drive on a diagonal heading. The model predicted that the stability was more dependent on the configuration of the suspension system than on the dimensions and weight distribution of the wheelchair. Furthermore, for the situations and design alterations studied, predicted improvements in static stability were not correlated with improvements in dynamic stability.

A guideline for the design of a four-wheeled walker

More people use assistive technology devices to compensate for mobility impairments than for any other general type of impairment. Increasing numbers of people with mobility or balance problems use walkers with four wheels. Four-wheeled walkers are often outfitted with seats to make it possible to travel longer distances with intermediate resting periods. The dangers of sitting on a parked walker are well known. Many physiotherapists tell walker users to park the walker against a wall to prevent injury in case the user forgets to apply the brakes or the brakes fail. To design a safer walker that can be used for sitting, the demands placed on it must be measured. With these data, three modes of walker instability must be considered: first, the brakes may hold but the wheels may slide along the ground; second, the entire walker may tip over; and third, the brakes may fail to hold the wheels in place, and they may begin to roll. Mathematical models can be constructed to simulate how different walker designs will perform. By this process, design improvements can be made for existing walkers, and future walker designs can also be proposed.

Technology to assist elderly people's safe mobility

A grab bar shape has been presented that appears to provide an effective alternative to knurled finishes. This grab bar has been incorporated into a system that can be easily positioned anywhere in a room to help an ambulatory disabled person rise from a bed or other surface. The problem of lifting nonambulatory elderly people has been addressed by means of a modular mobile lifting system that offers the advantage of overhead lifting at lower cost than traditional movement devices for nonambulatory people. The author suggests that low-technology solutions are worthy of academic effort and that movement devices for elderly people must also address the needs of their formal and informal caregivers.

Specifications for a mass producible static lounge chair for the elderly

An adjustable seating rig was used to create the three-dimensional shape of a static lounge chair. Elderly subjects from long-term care and rehabilitation hospital wards tested the chair. Questionnaires and video tapes were used to evaluate their comfort, posture, safety and ease of ingress/egress. The test shape was modified on the basis of results and retested to a total of four shapes. Contours and specifications of the final chair are presented.

Chairs for the elderly--design considerations

Ageing brings a number of normal physical changes and sometimes is accompanied by diseases that affect physical functions and abilities. Therefore, the elderly require special consideration in the design of chairs. Requirements for three types of chairs for the elderly are presented. A description of a typical user of each chair provides a reference for the level of ability that must be accommodated. Features of the chairs that promote comfort, safety, ease of ingress and egress and ease of propulsion (where applicable) are discussed in relation to some of the special problems experienced by some of the older members of the population.

Biofeedback training of knee control in the above-knee amputee

Learning to control a prosthetic knee is a difficult task for the above-knee amputee. A biofeedback training system was designed to help with this problem. The system was found to be useful with several aspects of knee control. Fifteen patients completed a biofeedback training program. Two of these patients did not benefit to the same degree as the other thirteen.