Footwear characteristics and foot problems in community dwelling people with stroke: a cross-sectional observational study

PURPOSE

To explore footwear characteristics and foot problems in community dwelling people with stroke as most research to date focused on the general elderly population.

METHODS

Thirty people with mild to moderate stroke (nine men, mean age 68, mean time since onset 67 months) attended a single session to assess footwear and foot problems using established podiatry foot (wear) and ankle assessments.

RESULTS

Most participants wore slippers indoors (n = 17, 57%) and walking shoes outdoors (n = 11, 37%). Over half wore unsupportive ill-fitting shoes indoors and 47% of outdoor shoes fitted badly. All participants had foot problems (mean 6.5 (3.1), 95% CI: 5.4-7.7), including impaired single limb heel raise (93%), reduced range of movement (77%), sensation (47%), and muscle strength (43%). Many had foot-pain, hallux valgus (both 50%), or swollen feet (40%). Foot problems were associated with reduced balance confidence, activity, and community participation (all p < 0.05). A greater proportion of fallers (13/16) than non-fallers (4/14) reported foot problems (p = 0.029).

CONCLUSIONS

Many community-dwelling people with stroke wore poorly fitting shoes; all had foot problems. Foot problems were linked to reduced mobility. Finding more effective pathways to support people with stroke to select supportive, well-fitting indoor and outdoor footwear is indicated.Implications for rehabilitationPeople with stroke often wear unsupportive ill-fitting shoes and experience foot problems.Assessment of foot problems and footwear advice should be considered during stroke rehabilitation particularly when interventions target fall prevention or improvements in balance and mobility.Information on appropriate footwear and signposting that new shoe purchases should include measuring feet to ensure a good fit is recommended.

Exercise- and strategy-based physiotherapy-delivered intervention for preventing repeat falls in people with Parkinson's: the PDSAFE RCT

BACKGROUND

People with Parkinson's disease are twice as likely to experience a fall as a healthy older person, often leading to debilitating effects on confidence, activity levels and quality of life.

OBJECTIVE

To estimate the effect of a physiotherapy programme for fall prevention among people with Parkinson's disease.

DESIGN

A multicentre, pragmatic, investigator-masked, individually randomised controlled trial (RCT) with prespecified subgroup analyses.

SETTING

Recruitment from NHS hospitals and clinics and community and social services in eight English regions with home-based interventions.

PARTICIPANTS

A total of 474 people with Parkinson's disease (i.e. Hoehn and Yahr scale stages 1-4) were recruited: 238 were assigned to a physiotherapy programme and 236 were assigned to usual care. Random allocation was 50 : 50.

INTERVENTIONS

All participants received routine care; the usual-care group received an information digital versatile disc (DVD) and a single advice session at trial completion. The intervention group had an individually tailored, progressive, home-based fall avoidance strategy training programme with balance and strengthening exercises: PDSAFE.

MAIN OUTCOME MEASURES

The primary outcome was the risk of repeat falling, collected by self-report monthly diaries between 0 and 6 months after randomisation. Secondary outcomes included near-falls, falls efficacy, freezing of gait (FoG), health-related quality of life, and measurements taken using the Mini-Balance Evaluation Systems Test (Mini-BESTest), the Chair Stand Test (CST), the Geriatric Depression Scale, the Physical Activity Scale for the Elderly and the Parkinson's Disease Questionnaire.

RESULTS

PDSAFE is the largest RCT of falls management among people with Parkinson's disease: 541 patients were screened for eligibility. The average age was 72 years, and 266 out of 474 (56%) participants were men. Of the 474 randomised participants, 238 were randomised to the intervention group and 236 were randomised to the control group. No difference in repeat falling within 6 months of randomisation was found [PDSAFE group to control group odds ratio (OR) 1.21, 95% confidence interval (CI) 0.74 to 1.98; p = 0.447]. An analysis of secondary outcomes demonstrated better balance (Mini-BESTest: mean difference 0.95, 95% CI 0.24 to 1.67; p = 0.009), functional strength (CST: p = 0.041) and falls efficacy (Falls Efficacy Scale - International: mean difference 1.6, 95% CI -3.0 to -0.19; p = 0.026) with near-falling significantly reduced with PDSAFE (OR 0.67, 95% CI 0.53 to 0.86; p = 0.001) at 6 months. Prespecified subgroup analysis (i.e. disease severity and FoG) revealed a PDSAFE differing effect; the intervention may be of benefit for people with moderate disease but may increase falling for those in the more severe category, especially those with FoG.

LIMITATIONS

All participants were assessed at primary outcome; only 73% were assessed at 12 months owing to restricted funding.

CONCLUSIONS

PDSAFE was not effective in reducing repeat falling across the range of people with Parkinson's disease in the trial. Secondary analysis demonstrated that other functional tasks and self-efficacy improved and demonstrated differential patterns of intervention impact in accordance with disease severity and FoG, which supports previous secondary research findings and merits further primary evaluation.

FUTURE WORK

Further trials of falls prevention on targeted groups of people with Parkinson's disease are recommended.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN48152791.

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. 23, No. 36. See the NIHR Journals Library website for further project information. Sarah E Lamb is funded by the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) at Oxford Health NHS Foundation Trust, the NIHR Oxford Biomedical Research Centre at the Oxford University Hospitals NHS Foundation Trust and CLAHRC Oxford. Victoria A Goodwin is supported by the NIHR Collaborations for Leadership in Applied Health Research and Care in the South West Peninsula (PenCLAHRC). Lynn Rochester is supported by the NIHR Newcastle Biomedical Research Centre based at Newcastle upon Tyne Hospitals NHS Foundation Trust and Newcastle University. The research was also supported by the NIHR Newcastle Clinical Research Facility Infrastructure funding. Helen C Roberts is supported by CLAHRC Wessex and the NIHR Southampton Biomedical Research Centre.

Can a simple clinical test demonstrate head-trunk coordination impairment in neck pain?

BACKGROUND

Sensorimotor impairment in neck pain sufferers is well established. Recent research has identified impairment in head and trunk co-ordination in this population. Presently, no clinically appropriate testing exists to quantify such impairment.

OBJECTIVE

To determine if a simple and clinically relevant test of head-trunk co-ordination can identify dysfunction in neck pain subjects when compared to healthy controls.

STUDY DESIGN

Cross-sectional observational study.

METHODS

Thirty-one neck pain and 29 healthy control subjects were assessed using head- and chest-mounted lasers with a target positioned 90 cm away. Subjects were required to rotate the trunk at least 45° with the head laser to be kept as accurately as possible in the centre of the target while sitting and standing. Maximal deviation of the head to the left and right of the target's centre with each trunk movement was measured.

RESULTS

The neck pain group demonstrated significantly greater head deviation from the centre in all but one test direction (p= <0.03). Head deviation to the same side as trunk rotation was larger in the neck pain group for both sitting and standing (p= <0.01). No significant differences existed between testing in sitting and standing.

CONCLUSION

Differences in trunk-head control exist in persons suffering from neck pain compared to healthy individuals, which can be demonstrated using simple equipment suggesting clinical utility of the measure. Performing the task in standing would seem most suitable as it can avoid influence by reduced thoracic mobility. Further research is required to establish the clinical suitability of this test.

Participant expectations and experiences of a tailored physiotherapy intervention for people with Parkinson's and a history of falls

Purpose: People with Parkinson's are twice as likely to fall as older people within the general population. This longitudinal qualitative study was part of a larger programme of research including a randomised controlled trial to test the effectiveness of a tailored physiotherapy intervention. Specific qualitative aims focused on a subsample of trial participants in the intervention arm of the trial, and comprised the following:To explore the expectations of participants about the intervention.To investigate participants' experiences of the intervention, and its perceived impacts.To understand the facilitators and barriers to engagement.Methods: Two semi-structured interviews were completed with a theoretical sample of people with Parkinson's from the intervention arm, initially after randomisation but before the intervention commenced, and then again six months later.Results: Forty-two participants out of a large clinical trial were interviewed initially, with 37 agreeing to a second interview at six months. Prior experience of rehabilitation plus information accessed through the trial consent procedure informed participants' realistic expectations. Most found the level of the intervention acceptable, and perceived a range of benefits. However, views about equipment provided were more equivocal. The biggest barriers to participation were time and motivation, whilst social support facilitated engagement with the intervention.Conclusions: This study is the first to capture expectations about participation in a programme of exercises and strategies. It highlights that previous challenges to engagement in physical exercises and activities are not a barrier to future participation and provides new insights into the role of equipment and technology in programmes of physical activity for people with Parkinson's. The challenge of ensuring that programmes of exercise and strategies become an embedded feature of everyday life is highlighted, particularly alongside busy social engagements and leisure pursuits.Implications for rehabilitationFor people with Parkinsons, a programme of exercises and strategies has the potential to reduce the risk of falls amongst those with a history of falling.Adherence to such programmes can prove challenging for a variety of reasons, even when participants have realistic expectations about the commitment and effort needed.Clear explanations about the role of equipment and technology within such programmes could enhance adherence.In order to further individualise programmes of exercise for people with Parkinsons, choice regarding social support, reminders and integration into everyday activities should be explored.

Multicentre, randomised controlled trial of PDSAFE, a physiotherapist-delivered fall prevention programme for people with Parkinson's

OBJECTIVE

To estimate the effect of a physiotherapist-delivered fall prevention programme for people with Parkinson's (PwP).

METHODS

People at risk of falls with confirmed Parkinson's were recruited to this multicentre, pragmatic, investigator blind, individually randomised controlled trial with prespecified subgroup analyses. 474 PwP (Hoehn and Yahr 1-4) were randomised: 238 allocated to a physiotherapy programme and 236 to control. All participants had routine care; the control group received a DVD about Parkinson's and single advice session at trial completion. The intervention group (PDSAFE) had an individually tailored, progressive home-based fall avoidance strategy training programme with balance and strengthening exercises. The primary outcome was risk of repeat falling, collected by self-report monthly diaries, 0-6 months after randomisation. Secondary outcomes included Mini-BESTest for balance, chair stand test, falls efficacy, freezing of gait, health-related quality of life (EuroQol EQ-5D), Geriatric Depression Scale, Physical Activity Scale for the Elderly and Parkinson's Disease Questionnaire, fractures and rate of near falling.

RESULTS

Average age is 72 years and 266 (56%) were men. By 6 months, 116 (55%) of the control group and 125 (61.5%) of the intervention group reported repeat falls (controlled OR 1.21, 95% CI 0.74 to 1.98, p=0.447). Secondary subgroup analyses suggested a different response to the intervention between moderate and severe disease severity groups. Balance, falls efficacy and chair stand time improved with near falls reduced in the intervention arm.

CONCLUSION

PDSAFE did not reduce falling in this pragmatic trial of PwP. Other functional tasks improved and reduced fall rates were apparent among those with moderate disease.

TRIAL REGISTRATION NUMBER

ISRCTN48152791.

Follow-up care after treatment for prostate cancer: evaluation of a supported self-management and remote surveillance programme

BACKGROUND

Alternative models of cancer follow-up care are needed to ameliorate pressure on services and better meet survivors' long-term needs. This paper reports an evaluation of a service improvement initiative for the follow-up care of prostate cancer patients based on remote monitoring and supported self-management.

METHODS

This multi-centred, historically controlled study compared patient reported outcomes of men experiencing the new Programme with men experiencing a traditional clinic appointment model of follow-up care, who were recruited in the period immediately prior to the introduction of the Programme. Data were collected by self-completed questionnaires, with follow up measurement at four and eight months post-baseline. The primary outcome was men's unmet survivorship needs, measured by the Cancer Survivors' Unmet Needs Survey. Secondary outcomes included cancer specific quality of life, psychological wellbeing and satisfaction with care. The analysis was intention to treat. Regression analyses were conducted for outcomes at each time point separately, controlling for pre-defined clinical and demographic variables. All outcome analyses are presented in the paper. Costs were compared between the two groups.

RESULTS

Six hundred and twenty-seven men (61%) were consented to take part in the study (293 in the Programme and 334 in the comparator group.) Regarding the primary measure of unmet survivorship needs, 25 of 26 comparisons favoured the Programme, of which 4 were statistically significant. For the secondary measures of activation for self-management, quality of life, psychological well-being and lifestyle, 20 of 32 comparisons favoured the Programme and 3 were statistically significant. There were 22 items on the satisfaction with care questionnaire and 13 were statistically significant. Per participant costs (British pounds, 2015) in the 8 month follow up period were slightly lower in the programme than in the comparator group (£289 versus £327). The Programme was acceptable to patients.

CONCLUSION

The Programme is shown to be broadly comparable to traditional follow-up care in all respects, adding to evidence of the viability of such models.

The trouble with footwear following stroke: a qualitative study of the views and experience of people with stroke

Purpose: Foot problems and suboptimal footwear are risk factors for falls among the elderly. Footwear choice may, therefore, be important for people with balance impairment following stroke, but little is known about their experience. This study explored foot problems experienced following stroke, factors influencing footwear choices and views of footwear in use.Methods: Semi-structured interviews with 15 people with stroke, purposively sampled from respondents to a screening survey.Results: Participants typically experienced impaired mobility with balance problems and felt at risk of falling. Stroke related foot problems, including altered sensation, edema, and foot drop, predominantly on the stroke affected side, influenced footwear priorities. Footwear choices prioritized comfort, security, and convenience, sometimes in tension with concern about appearance. Challenges included choosing appropriate indoor footwear and finding shoes to accommodate their orthoses and edema. Participants highlighted perceived lack of footwear advice from health care professionals and variable experience of shoe shopping.Conclusions: Foot problems, as well as gait and balance impairment, have implications for footwear priorities following stroke, but people felt unsupported in making healthy footwear choices. Health care professionals could be trained to routinely deliver footwear assessment and advice and facilitate referrals to podiatrist, when appropriate.Implications for rehabilitationFoot problems, as well as gait and balance impairment, have implications for footwear priorities following stroke.People with stroke perceive a lack of professional advice about footwear and feel unsupported making healthy footwear choices.Health care professionals could be trained to routinely deliver an initial footwear assessment and advice as part of stroke rehabilitation.A greater transparency and knowledge of referral pathways into podiatry services for Health care professionals and patients would give access to specialist advice where appropriate.

Follow-up care after treatment for prostate cancer: protocol for an evaluation of a nurse-led supported self-management and remote surveillance programme

BACKGROUND

As more men survive a diagnosis of prostate cancer, alternative models of follow-up care that address men's enduring unmet needs and are economical to deliver are needed. This paper describes the protocol for an ongoing evaluation of a nurse-led supported self-management and remote surveillance programme implemented within the secondary care setting.

METHODS/DESIGN

The evaluation is taking place within a real clinical setting, comparing the outcomes of men enrolled in the Programme with the outcomes of a pre-service change cohort of men, using a repeated measures design. Men are followed up at four and 8 months post recruitment on a number of outcomes, including quality of life, unmet need, psychological wellbeing and activation for self-management. An embedded health economic analysis and qualitative evaluation of implementation processes are being undertaken.

DISCUSSION

The evaluation will provide important information regarding the effectiveness, cost effectiveness and implementation of an integrated supported self-management follow-up care pathway within secondary care.

It takes two: the influence of dance partners on the perceived enjoyment and benefits during participation in partnered ballroom dance classes for people with Parkinson's

PURPOSE

To explore the views of people with Parkinson's and their dance partners on the influence and issues surrounding dancing with an able-bodied dance partner during partnered ball room dance classes.

METHODS

In depth, semi-structured interviews explored purposively selected participants' experiences and views about dance classes. Fourteen people with Parkinson's and their dance partners (six spouses, two friends/relatives, five volunteers) were interviewed within a month of completing the 10-week dance class program. Data were analyzed thematically.

RESULTS

Generally, those partnered with a spouse or an experienced dancer, or when dance couples were able to develop good rapport, gained greater enjoyment and sense of achievement from dance classes in comparison to couples who did not enjoy dancing together or had clashing approaches to dance. Managing and negotiating who would "lead" in a dance was challenging for dance couples particularly among male people with Parkinson's.

CONCLUSIONS

People with Parkinson's experience of the dance classes were influenced by the relationship and compatibility with their dance partner. Dance partnerships may impact on recruitment, enjoyment, outcome and continued participation in dance classes. Potential effects of partnerships should be analyzed and reported in studies evaluating the outcomes of dance classes. Implications for rehabilitation We recommend that health professionals consider involving spouses in Parkinson's dance classes as this may improve recruitment, adherence, enjoyment and overall outcome of the dance classes. If volunteers are needed, aim to recruit those who already have good dancing ability, convey a love of dancing and have the sensitivity and social skills to interact positively with the person with Parkinson's. Consider dance partnership issues when advertising and promoting dance classes. Address partnership issues through open communication and by changing partners if the dance partnership is not working well.

A survey exploring self-reported indoor and outdoor footwear habits, foot problems and fall status in people with stroke and Parkinson's

Background

Ill-fitting shoes have been implicated as a risk factor for falls but research to date has focused on people with arthritis, diabetes and the general older population; little is known about people with neurological conditions. This survey for people with stroke and Parkinson’s explored people’s choice of indoor and outdoor footwear, foot problems and fall history.

Methods

Following ethical approval, 1000 anonymous postal questionnaires were distributed to health professionals, leads of Parkinson’s UK groups and stroke clubs in the wider Southampton area, UK. These collaborators handed out survey packs to people with a confirmed diagnosis of stroke or Parkinson’s.

Results

Three hundred and sixty three completed surveys were returned (218 from people with Parkinson’s and 145 from people with stroke). Most respondents wore slippers indoors and walking shoes outdoors and considered comfort and fit the most important factors when buying footwear. Foot problems were reported by 43 % (95 % confidence intervals 36 to 52 %; stroke) and 53 % (95 % confidence interval 46 to 59 %; Parkinson’s) of respondents; over 50 % had never accessed foot care support. Fifty percent of all respondents reported falls. In comparison to non-fallers, a greater proportion of fallers reported foot problems (57 %), with greater proportions reporting problems impacting on balance and influencing choice of footwear (p < 0.01) in comparison to non-fallers in each case. Forty-seven percent of fallers with foot problems had not accessed foot care support.

Conclusions

Many people with stroke and Parkinson’s wear slippers indoors. A high percentage of these individuals reported both foot problems and falls impacting on footwear habits and choice of footwear; however many did not receive foot care support. These findings highlight that further exploration of footwear and foot problems in these populations is warranted to provide evidence based advice on safe and appropriate footwear to support rehabilitation and fall prevention.

Electronic supplementary material

The online version of this article (doi:10.1186/s13047-016-0170-5) contains supplementary material, which is available to authorized users.

Quantity and quality of interaction between staff and older patients in UK hospital wards: A descriptive study

Background

The quality of staff-patient interactions underpins the overall quality of patient experience and can affect other important outcomes. However no studies have been identified that comprehensively explore both the quality and quantity of interactions in general hospital settings.

Aims & objectives

To quantify and characterise the quality of staff-patient interactions and to identify factors associated with negative interaction ratings.

Setting

Data were gathered at two acute English NHS hospitals between March and April 2015. Six wards for adult patients participated including medicine for older people (n = 4), urology (n = 1) and orthopaedics (n = 1).

Methods

Eligible patients on participating wards were randomly selected for observation. Staff-patient interactions were observed using the Quality of Interactions Schedule. 120 h of care were observed with each 2 h observation session determined from a balanced random schedule (Monday-Friday, 08:00-22:00 h). Multilevel logistic regression models were used to determine factors associated with negative interactions.

Results

1554 interactions involving 133 patients were observed. The median length of interaction was 36 s with a mean of 6 interactions per patient per hour. Seventy three percent of interactions were categorized as positive, 17% neutral and 10% negative. Forty percent of patients had at least one negative interaction (95% confidence interval 32% to 49%). Interactions initiated by the patient (adjusted Odds Ratio [OR] 5.30), one way communication (adjusted OR 10.70), involving two or more staff (adjusted OR 5.86 for 2 staff, 6.46 for 3+ staff), having a higher total number of interactions (adjusted OR 1.09 per unit increase), and specific types of interaction content were associated with increased odds of negative interaction (p < 0.05). In the full multivariable model there was no significant association with staff characteristics, skill mix or staffing levels. Patient agitation at the outset of interaction was associated with increased odds of negative interaction in a reduced model. There was no significant association with gender, age or cognitive impairment. There was substantially more variation at ward level (variance component 1.76) and observation session level (3.49) than at patient level (0.09).

Conclusion

These findings present a unique insight into the quality and quantity of staff-patient interactions in acute care. While a high proportion of interactions were positive, findings indicate that there is scope for improvement. Future research should focus on further exploring factors associated with negative interactions, such as workload and ward culture.

Changing trends in antibiotic resistance for urinary E. coli infections over five years in a university hospital

Objective

We wanted to look at the antibiotic resistance patterns in our university teaching hospital for E. coli cultured from urine to assess the resistance profiles to common antibiotics used in the hospital.

Patients and methods

Results were obtained of all positive urine cultures between January 2007 and December 2011 both from the hospital and urology department. Trends in susceptibility and resistance data for E. coli to trimethoprim, amoxicillin, ciprofloxacin, gentamicin and nitrofurantoin were examined.

Results

A total of 40,722 hospital urine specimens were culture positive in the five-year period, of which 15,311 (37.6%) grew E. coli. Across the hospital there was no evidence of change in resistance to trimethoprim over the five-year period (38.1% in 2007 compared to 36.6% in 2011; p = 0.313). The percentage resistance to amoxicillin rose slightly (52.6% to 54.4%), and this was statistically significant (p = 0.011). Overall there was a statistically significant fall in resistance to ciprofloxacin but resistance has remained stable for the last three years (15.5% to 13.5%, p = 0.013). A trend of increasing resistance to gentamicin (p = 0.002) resulted from the 2007 baseline of 3.4% to 4.9% in 2008, but resistance remained stably low thereafter. Resistance to nitrofurantoin fell significantly (from 10.4% to 1.6%; p ≤ 0.0005).

Conclusions

The number of E. coli-positive urine cultures from hospital in-patients remained broadly stable over this five-year period. Resistance to trimethoprim and amoxicillin remains high. Gentamicin resistance remains low, but the statistically significant rise over the five-year period suggests resistance rates should continue to be carefully monitored. Nitrofurantoin resistance is very low and has significantly decreased. This narrow-spectrum antibiotic should be considered the mainstay for treating uncomplicated urinary tract infections in females.

The True NTH Prostate Cancer Survivorship Care programme: Development and evaluation of a model for delivering follow-up care to men with prostate cancer

42

Background: Increasing use of prostate specific antigen (PSA), improvements in treatment and aging population have led to the escalating incidence of prostate cancer. 5 year survival rate is relatively high and men who have completed treatment require long-term follow-up to detect recurrence or progression of disease, monitor adverse effects of treatment and identify and address psychosocial needs. Studies demonstrate men have a range of unmet physical and psychosocial needs, and health services are struggling to cope with the growing numbers. Changes is critical for long-term sustainability of the health system in many developed nations Methods: This presentation presents a model of follow up care centered on remote surveillance of PSA combined with promoting patient self-management. This initiative is part of the True NTH programme of developments initiated in the UK with funding from Movember Foundation and Prostate Cancer UK. Traditional face to face clinic follow up consultations are replaced with: patient directed individually tailored care and surveillance programme which involves: a 4 hour preparatory patient workshop, remote assessment of unmet needs and symptoms and surveillance of PSA, patient information resources, survivorship care plan, communication of treatment summary and management plan to primary care, and rapid recall system for assessment in secondary care should the need arise. The care programme is mediated through clinician and patient access to an IT portal enabling communication. Results: The second part of the presentation will describe the evaluation protocol. A historical cohort design is comparing a group of men receiving clinic follow up care (N = 300) with men enrolled on the care programme (N = 300) in 3 centers. Patient-reported outcomes are collected at baseline, 4 months and 8 months. Health economic evaluation will compare costs of clinic based follow up with those of the care programme from both a health service and patient perspective. Conclusions: The evaluation will generate data on impact, acceptability and cost of this model of follow-up care.

A critical review of the effectiveness of environmental assessment and modification in the prevention of falls amongst community dwelling older people

Introduction

The potential of environmental assessment and modification to reduce falls has recently received attention within the gerontology literature. Research investigating the clinical effectiveness of this intervention in falls prevention reports conflicting results. Discrepancies are due to variation in the risk profile of study participants and the health care background of the person providing the environmental intervention or the intensity of the intervention provided.

Method

The purpose of this paper is to compare and contrast two systematic reviews, which include meta-analyses, of environmental interventions for falls prevention in community dwelling older people, using the critical appraisal skills programme tool for systematic reviews.

Findings

Both reviews found that: environmental assessment and modification was effective in falls prevention; intervention was effective with high but not low risk participants; and that high intensity environmental assessment was effective, whereas low intensity intervention was not. Environmental interventions which were delivered by occupational therapists were deemed high intensity, probably because their underpinning theoretical frameworks focus on the impact of the environment on function.

Conclusion

We discuss possible reasons why occupational therapist led environmental assessment and modification is clinically effective in falls prevention, for people at high risk of falls, whereas non occupational therapist led intervention is not.

A multi-centre, randomised controlled trial of the effectiveness of PDSAFE to prevent falls among people with Parkinson's: study protocol

Background

Falls amongst people with Parkinson’s (PwP) result in significant disability and reduced quality of life. There is emerging evidence that exercise-based and physiotherapeutic interventions are of benefit for improving fall risk factors, such as balance. However, the benefit, in terms of preventing falls, is mixed. The development of effective interventions has been identified as the highest research priority for this population.

The aim of this trial is to establish the effectiveness and cost-effectiveness of a novel, home-based physiotherapy programme, compared with usual care, on falls amongst PwP.

Methods/Design

A UK multi-centre, community-based, single blind, randomised controlled trial with twelve month follow-up, and nested economic evaluation and qualitative studies will be undertaken. Six hundred PwP who live in their own home, have had one or more falls in the previous year and an MMSE score of ≥24 will be recruited. Those living in care homes and those needing assistance from another person to walk indoors will not be eligible.

The intervention is a physiotherapist delivered, individually tailored and progressive, home-based programme (PDSAFE) comprising task orientated movement strategy training, functional lower limb strengthening and balance training, of six months duration. Unsupervised daily home exercises and strategies will be practised and supported using technology. Control participants will receive usual care.

Data collection will include falls, cognitive state, balance and mobility, fear of falling, freezing of gait, mood, quality of life, carer quality of life and resource use. Data will be collected at baseline, three, six and twelve months. Longitudinal semi-structured interviews will be undertaken with forty participants to explore the expectations and experiences of participants.

The primary outcome is risk of repeat falling at six months post-randomisation.

Discussion

The aims of this trial are to establish the effectiveness and cost-effectiveness of a novel, home-delivered physiotherapy intervention (PDSAFE) compared with usual care on risk of falling for PwP who have a history of falling. PDSAFE is a novel intervention that builds upon the existing literature and targeting known risk factors, being the first study that uses a novel delivery modus (technology) in conjunction with traditional physiotherapeutic approaches.

Trial registration

Current Controlled Trials ISRCTN48152791

A design to investigate the feasibility and effects of partnered ballroom dancing on people with Parkinson disease: randomized controlled trial protocol

BACKGROUND

Self-help and physical leisure activities has become increasingly important in the maintenance of safe and functional mobility among an increasingly elderly population. Preventing the cycle of deterioration, falling, inactivity, dependency, and secondary complications in people with Parkinson disease (PD) is a priority. Research has shown that people with PD are interested in dance and although the few existing trials are small, initial proof of principle trials from the United States have demonstrated beneficial effects on balance control, gait, and activity levels. To our knowledge, there has been no research into long-term effects, cost effectiveness, the influence on spinal posture and turning, or the personal insights of dance participants.

OBJECTIVE

The purpose of this study was to determine the methodological feasibility of conducting a definitive phase III trial to evaluate the benefits of dance in people with PD. We will build on the proof of principle trials by addressing gaps in knowledge, focusing on areas of greatest methodological uncertainty; the choice of dances and intensity of the program; for the main trial, the availability of partners, the suitability of the currently envisaged primary outcomes, balance and spinal posture; and the key costs of delivering and participating in a dance program to inform economic evaluation.

METHODS

Fifty participants (mild-to-moderate condition) will be randomized to the control (usual care) or experimental (dance plus usual care) groups at a ratio of 15:35. Dance will be taught by professional teachers in a dance center in the South of England. Each participant in the experimental group will dance with his or her spouse, a friend, or a partner from a bank of volunteers. A blinded assessor will complete clinical measures and self-reported ability at baseline, and at 3 and 6 months after randomization. A qualitative study of a subgroup of participants and partners will examine user's views about the appropriateness and acceptability of the intervention, assessment protocol, and general trial procedures. Procedures for an economic evaluation of dance for health care will be developed for the main trial.

RESULTS

Recruitment began in January 2013 and the last participant is expected to complete the trial follow-up in June 2014.

CONCLUSIONS

Findings from our study may provide novel insights into the way people with PD become involved in dance, their views and opinions, and the suitability of our primary and secondary outcomes.

TRIAL REGISTRATION

International Standard Randomized Controlled Trial Number (ISRCTN): 63088686; http://www.controlled-trials.com/ISRCTN63088686/63088686 (Archived by WebCite at http://www.webcitation.org/6QYyjehP7).

A primary care specialist genetics service: a cluster-randomised factorial trial

BACKGROUND

GPs do not have the confidence to identify patients at increased genetic risk. A specialist primary care clinical genetics service could support GPs with referral and provide local clinics for their patients.

AIM

To test whether primary care genetic-led genetics education improves both non-cancer and cancer referral rates, and primary care-led genetics clinics improve the patient pathway.

DESIGN AND SETTING

Cluster-randomised factorial trial in 73 general practices in the south of England.

METHOD

Practices randomised to receive case scenario based seminar (intervention) or not (control), and referred patients a primary (intervention) or secondary (control) care genetic counsellor (GC)-led appointment.

OUTCOME MEASURES

GP referral and clinic attendance rates (primary), appropriate cancer and case scenario referral rates, patient satisfaction, clinic costs, and case management (secondary).

RESULTS

Eighty-nine and 68 referrals made by 36 intervention and 37 control practices respectively. There was a trend towards an overall higher referral rate among educated GPs (referral rate ratio [RRR] 1.34, 95% confidence interval [CI] = 0.89 to 2.02; P = 0.161), and they made more appropriate cancer referrals (RRR 2.36, 95% CI = 1.07 to 5.24; P = 0.035). No indication of difference in clinic attendance rates (odds ratio 0.91, 95% CI = 0.43 to 1.95; P = 0.802) or patient satisfaction (P = 0.189). Patients spent 49% less travelling (£3.60 versus £6.62; P<0.001) and took 33% less time (39.7 versus 57.7 minutes; P<0.001) to attend a primary than secondary care appointment; 83% of GC-managed appointments met the 18-week referral to treatment, NHS target.

CONCLUSION

An integrated primary care genetics service both supports GPs in appropriate cancer referral and provides care in the right place by the right person.

Interspecific hybrids of Hordeum marinum ssp. marinum x H. bulbosum are mitotically stable and reveal no gross alterations in chromatin properties

Interspecific hybrids between the related wild barley species Hordeum marinum and H. bulbosum were generated and tested regarding their chromosomal stability and chromatin properties. Unlike in H. vulgare x H. bulbosum hybrid embryos, there was no effect of temperature on uniparental chromosome elimination or retention during hybrid seed development and 7 chromosomes from each parent were detected according to genomic in situ hybridization analyses. The centromere-specific histone H3 gene (CENH3) of both parental genomes is active in hybrid plants. Indirect immunostaining of flow-sorted 2C nuclei indicated that no major reorganization of histone H3 methylation (K4, K9 and K27), H3K9 acetylation and histone H2A ubiquitination marks or location of active RNA polymerase II sites occurred after interspecific hybridization.

Role of T-cell immunity to embryonal stem (ES) cell antigen SOX2 in the progression of myeloma

8522

Background: Clinical outcome in patients (pts) with asymptomatic plasma-proliferative disorders, monoclonal gammopathy of undetermined significance (MGUS) and asymptomatic myeloma (AMM), is highly variable. There is a need to identify specific tumor or host related features that predict the risk of disease progression. In prior studies, we have shown that patients with MGUS commonly mount a T cell immune response against SOX2, an antigen critical for pluripotency of ES cells. Methods: Patients with MGUS/AMM were enrolled in a prospective observational clinical protocol (SWOG S0120). All patients underwent detailed staging evaluation at registration and were observed without therapy. The presence of T cell immunity to SOX2 in freshly isolated blood / marrow mononuclear cells was analyzed using an overlapping peptide library at study entry. Results: Anti-SOX2 T cell responses were detected in 39/109 (36%) pts tested. Progression to symptomatic MM was observed in only 2 of 39 patients with anti-SOX2 immunity compared to 17 of 59 pts lacking these responses, resulting in 2-yr progression-free survival 96 v 63% (p=0.003). Responses to viral antigens and polyclonal mitogens as controls were preserved in patients lacking SOX2 immunity indicating that the absence of immunity to SOX2 was not due to global immune-suppression. Immunity to SOX2 correlated with features of lower risk including serum-M component < 1.5 g/dL (p=0.008), marrow plasmacytosis < 10% (p<0.001) and normal serum free light chain ratio (p=0.01). Conclusions: These data demonstrate in the context of a prospective trial that T cell immunity to stem cell genes strongly correlates with a reduced risk of progression to clinical myeloma. These data point to SOX2 as a potential target for the prevention of disease progression in MGUS/AMM.

No significant financial relationships to disclose.

Chromosomal location and inheritance of stem rust resistance transferred from Hordeum bulbosum into cultivated barley (H. vulgare)

Stem rust, caused by Puccinia graminis f. sp. tritici, is an important disease on barley (Hordeum vulgare). Host resistance has effectively controlled stem rust, primarily through use of gene Rpg1. However, virulence to Rpg1 is present in North America, and a new race (TTKSK, or Ug99) from eastern Africa threatens barley production. A search for novel resistance was previously conducted, and an interspecific barley breeding line (212Y1) with introgressed chromatin from H. bulbosum was identified as carrying resistance to races MCCF and QCCJ. This study evaluated the inheritance of resistance in 212Y1 using populations from crosses to Morex (Rpg1 donor) and Q21861 (rpg4 donor) and the pathogen races MCCF (avirulent on Rpg1 and rpg4) and QCCJ (virulent on Rpg1 and avirulent on rpg4), and determined the chromosomal position of the introgression using genomic in situ hybridization (GISH) and chromosome-specific polymerase chain reaction (PCR)-based markers. Progeny from the 212Y1/Q21861 F(2) population segregated for resistant and susceptible plants, indicating different gene loci. Genetic analyses of Morex/212Y1 F(3) families fit a 7 homozygous resistant (HR):8 segregating:1 homozygous susceptible (HS) family segregation ratio to race MCCF, indicating that two genes controlled resistance. Plants in segregating families were in 3R:1S (Rpg1), 13R:3S (Rpg1+212Y1), and 1R:3S (212Y1) ratios. Genetic analyses of the same F(3) families fit a 1HR:2 segregating:1HS family segregation ratio to race QCCJ, indicating monogenic inheritance. Plants in segregating families were in a 1R: 3S ratio, indicating recessive inheritance in 212Y1. The introgression from H. bulbosum into H. vulgare was positioned on chromosome 6HS based on GISH and the PCR-based markers. No known stem rust resistance gene has previously been mapped to that region. Thus, it is proposed to name this novel gene from H. bulbosum as rpg6.

Which obese children should have a sleep study?

BACKGROUND

The UK government has recommended the development of obesity services for children. As obesity is common, studying every obese child for obstructive sleep apnoea (OSA) would be challenging and full paediatric sleep services are not available in every area in Europe. The purpose of this study was to consider how well clinical features predict significant OSA in obese children in order to help prioritise the need for sleep studies and subsequent treatment.

METHODS

Consecutive children referred for obesity management aged 2-16 years with a body mass index (BMI) of >2.5 z scores for age were offered a sleep study using overnight oximetry and audiovisual recordings. Significant OSA was defined as > or = 5 dips/h of >4% oxygen saturation or > or = 5 respiratory-event related arousals/h.

RESULTS

Forty-one of 158 (26%) children (mean BMI z score 3.7) had significant OSA and 95% of these had either reported apnoea, restless sleep or tonsillar hypertrophy (TH). Nineteen percent of all children had none of these features. BMI was not related to OSA.

CONCLUSION

If only obese children with reported apnoea, restless sleep or TH have a sleep study, 95% of all obese children with significant OSA will be identified using this method.

Predicting people with stroke at risk of falls

BACKGROUND

falls are common following a stroke, but knowledge about predicting future fallers is lacking.

OBJECTIVE

to identify, at discharge from hospital, those who are most at risk of repeated falls.

METHODS

consecutively hospitalised people with stroke (independently mobile prior to stroke and with intact gross cognitive function) were recruited. Subjects completed a battery of tests (balance, function, mood and attention) within 2 weeks of leaving hospital and at 12 months post hospital discharge.

RESULTS

122 participants (mean age 70.2 years) were recruited. Fall status at 12 months was available for 115 participants and of those, 63 [55%; 95% confidence interval (CI) 46-64] experienced one or more falls, 48 (42%; 95% CI 33-51) experienced repeated falls, and 62 (54%) experienced near-falls. All variables available at discharge were screened as potential predictors of falling. Six variables emerged [near-falling in hospital, Rivermead leg and trunk score, Rivermead upper limb score, Berg Balance score, mean functional reach, and the Nottingham extended activities of daily living (NEADL) score]. A score of near-falls in hospital and upper limb function was the best predictor with 70% specificity and 60% sensitivity.

CONCLUSION

participants who were unstable (near-falls) in hospital with poor upper limb function (unable to save themselves) were most at risk of falls.

Analysis of the quality of wrist movement during a simple tracking task

Objective assessment of stroke-patients' ability to control arm movements is vital for evidence-based therapy and progress monitoring. This study compares three different indices to quantify the quality of wrist movement during a task involving tracking a target on a screen. Each method is assessed in terms of agreement between assessors (Bland and Altman limits of agreement); repeatability of readings by the same assessor (reliability coefficient); and external validity on data collected from a sample of people with impaired upper limb function and an age matched unimpaired control group. The three indices were the root mean square difference between the wrist movement and the target signal, the cross correlation between these two signals, and an estimate of the signal-to-noise ratio in the wrist movement. External validity was investigated by calculating the correlation between each measure for wrist movement, and upper limb function assessed by the action research arm test. The results of the Bland and Altman limits of agreement show that all indices were similar in performance. The cross correlation had the highest reliability coefficient for the impaired group. In terms of external validity, the cross correlation and signal-to-noise indices showed the strongest association with functional performance and may thus be the more relevant for future clinical investigations.

A randomised controlled trial of a home based exercise programme to reduce the risk of falling among people with Parkinson's disease

OBJECTIVE

To evaluate the effectiveness of a personalised home programme of exercises and strategies for repeat fallers with Parkinson's disease (PD).

METHOD

Patients with a confirmed diagnosis of idiopathic PD, independently mobile, living at home in the community, experiencing more than one fall in the previous 12 months and with intact gross cognitive function were invited to participate in this randomised controlled trial. Usual care was compared with a personalised 6 week, home based exercise and strategy programme. The primary outcomes were rates of falling at 8 weeks and 6 months. Whether participants had repeat fallen, nearly fallen or experienced injurious falls were also examined. Functional Reach, the Berg Balance Test, PD Self-assessment Scale and the Euro Quol were rated by a blinded assessor.

RESULTS

Participants were randomised to the exercise (n = 70) and control (n = 72) groups. There was a consistent trend towards lower fall rates in the exercise group at both 8 weeks and 6 months and lower rates of injurious falls needing medical attention at 6 months. Lower rates of repeat near falling were evident for the exercise group at 8 weeks (p = 0.004) and 6 months (p = 0.007). There was a positive effect of exercises at 6 months on Functional Reach (p = 0.009) and quality of life (p = 0.033). No significant differences were found on other secondary outcomes measures.

CONCLUSION

There was a trend towards a reduction in fall events and injurious falls with a positive effect of exercises on near falls and quality of life.

Elimination of chromosomes in Hordeum vulgare x H. bulbosum crosses at mitosis and interphase involves micronucleus formation and progressive heterochromatinization

Uniparental chromosome elimination occurs in several interspecific hybrids of plants. We studied the mechanism underlying selective elimination of the paternal chromosomes during the development of Hordeum vulgare x H. bulbosum hybrid embryos that is restricted to an early stage of development. In almost all embryos most of the H. bulbosum chromatin undergoes a fast rate of elimination within nine days after pollination. There are differences in the mitotic behaviour between the parental chromosomes, with H. bulbosum chromatids segregating asymmetrically at anaphase. We provide evidence for a chromosome elimination pathway that involves the formation of nuclear extrusions during interphase in addition to postmitotically formed micronuclei. The chromatin structure of nuclei and micronuclei differs and heterochromatinization and disintegration of the nuclear envelope of micronuclei are the final steps of chromosome elimination.

Cost-effectiveness of referral for generic care or problem-solving treatment from community mental health nurses, compared with usual general practitioner care for common mental disorders: Randomised controlled trial

BACKGROUND

UK general practitioners (GPs) refer patients with common mental disorders to community mental health nurses.

AIMS

To determine the effectiveness and cost-effectiveness of this practice.

METHOD

Randomised trial with three arms: usual GP care, generic mental health nurse care, and care from nurses trained in problem-solving treatment; 98 GPs in 62 practices referred 247 adult patients with new episodes of anxiety, depression and life difficulties, to 37 nurses.

RESULTS

There were 212 (86%) and 190 (77%) patients followed up at 8 and 26 weeks respectively. No significant differences between groups were found in effectiveness at either point. Mean differences in Clinical Interview Schedule - Revised scores at 26 weeks compared with GP care were -1.4 (95% CI -5.5 to 2.8) for generic nurse care, and 1.1 (-2.9 to 5.1) for nurse problem-solving. Satisfaction was significantly higher in both nurse-treated groups. Mean extra costs per patient were 283 pound (95% CI154-411) for generic nurse care, and 315 pound (183-481) for nurse problem-solving treatment.

CONCLUSIONS

GPs should not refer unselected patients with common mental disorders to specialist nurses. Problem-solving should be reserved for patients who have not responded to initial GP care.

Identification of all chromosome arms and their involvement in meiotic homoeologous associations at metaphase I in 2 Hordeum vulgare L. x Hordeum bulbosum L. hybrids

We have identified all Hordeum bulbosum chromosomes in 2 diploid Hordeum vulgare x Hordeum bulbosum hybrids using suitable probes and fluorescence in situ hybridization. Using the parental idiograms allowed us to carry out a full analysis of chromosome associations among all chromosome arms in the hybrids. Association frequencies were generally lower for the short arms than for the long arms. There were also significant differences among the chromosome arms in association frequencies, partly correlated with the absolute length of the chromosome arm, as well as with the frequency of recombinant lines, which were recovered from partially fertile interspecific hybrids. The H. bulbosum idiogram will be useful for further chromosome association studies and will enable the identification of H. bulbosum chromosomes involved in chromosome addition or substitution lines.

A trial of problem-solving by community mental health nurses for anxiety, depression and life difficulties among general practice patients. The CPN-GP study

OBJECTIVES

To compare the effectiveness of community mental health nurse (CMHN) problem-solving and generic CMHN care, against usual general practitioner (GP) care in reducing symptoms, alleviating problems, and improving social functioning and quality of life for people living in the community with common mental disorders; and to undertake a cost comparison of each CMHN treatment compared with usual GP care.

DESIGN

A pragmatic, randomised controlled trial with three arms: CMHN problem-solving, generic CMHN care and usual GP care.

SETTING

General practices in two southern English counties were included in the study. CMHNs were employed by local NHS trusts providing community mental health services.

PARTICIPANTS

Participants were GP patients aged 18--65 years with a new episode of anxiety, depression or reaction to life difficulties and had to score at least 3 points on the General Health Questionnaire-12 screening tool. Symptoms had to be present for a minimum of 4 weeks but no longer than 6 months.

INTERVENTIONS

Patients were randomised to one of three groups: (1) CMHN problem-solving treatment, (2) generic CMHN treatment, or (3) usual GP care. All three groups of patients remained free to consult their GPs throughout the course of the study, and could be prescribed psychotropic drug treatments.

MAIN OUTCOME MEASURES

Patients were assessed at baseline, and 8 weeks and 26 weeks after randomisation. The primary outcome measure was psychological symptoms measured on the Clinical Interview Schedule -- Revised. Other measures included social functioning, health-related quality of life, problem severity and satisfaction. The economic outcomes were evaluated with a cost--utility analysis.

RESULTS

Twenty-four CMHNs were trained to provide problem-solving under supervision, and another 29 were referred patients for generic support. In total, 247 patients were randomised to the three arms of the study, referred by 98 GPs in 62 practices. All three groups of patients were greatly improved by the 8-week follow-up. No significant differences were found between the groups at 8 weeks or 26 weeks in symptoms, social functioning or quality of life. Greater satisfaction with treatment was found in the CMHN groups. CMHN care represented a significant additional health service cost and there were no savings in sickness absence.

CONCLUSIONS

The study found that specialist mental health nurse support is no better than support from GPs for patients with anxiety, depression and reactions to life difficulties. The results suggest that healthcare providers could consider adopting policies of restricting referrals of unselected patients with common mental disorders to specialist CMHNs, although there may be other roles in primary care that CMHNs could play effectively. Further research should address the predictors of chronicity in common mental disorders and target extra treatment. More research is also needed into the effectiveness and cost-effectiveness of problem-solving treatment for other disorders, of facilitated self-help treatments for common mental disorders and of CMHN care for people with severe and enduring mental illnesses, as well as the prevention of mental disorders.

Quality of life and functional long-term outcome after partial pancreatoduodenectomy: pancreatogastrostomy versus pancreatojejunostomy

BACKGROUND

To determine the effects of pancreatogastrostomy (PG) versus pancreatojejunostomy (PJ) as types of reconstruction after partial pancreatoduodenectomy on postoperative quality of life and long-term gastrointestinal morbidity, the outcomes of 104 patients (PG, n = 63; PJ, n = 41) were evaluated.

METHODS

To compare the two groups, the European Organization for Research and Treatment of Cancer Quality-of-Life Questionnaire (QLQ-PAN 26) standard and an additional self-developed questionnaire were used. The mean time after surgery was 6.4 +/- 3.4 years.

RESULTS

In the PG group, there was a significant reduction of gastric acid reflux, gastroduodenal ulcers, and pain compared with before surgery. However, a significant increase in steatorrhea, intolerance toward larger meals, and aversion against certain foods were observed. In the PJ group, no significant change of preoperative symptoms was present except for jaundice. The incidence of diabetes mellitus and the need for pancreatic enzyme substitution had increased significantly but similarly in both groups. The global quality of life was identical in both groups of patients.

CONCLUSIONS

This analysis demonstrates that the global quality of life was not affected by the type of reconstruction after partial pancreatoduodenectomy. Patients who underwent PG had a significant reduction of gastric reflux, pain, and abdominal discomfort compared with before surgery. Patients in both groups showed an impaired exocrine and endocrine pancreatic function of a similar extent.

Recent progress in barley improvement using wild species of Hordeum

In this review we describe recent progress in barley (Hordeum vulgare) improvement through hybridisation with its wild relatives. We have focused on one species in the secondary genepool of cultivated barley, namely H. bulbosum. This wild species has desirable traits, such as disease resistance, that are worthwhile transferring to its cultivated relative. Progress has been achieved through developing partially fertile interspecific hybrids that have been selfed or backcrossed to barley. We present the results of cytogenetic and molecular analyses that have enabled us to characterise and produce agronomically useful recombinant lines obtained from the hybrids.

Mapping of Rym14Hb, a gene introgressed from Hordeum bulbosum and conferring resistance to BaMMV and BaYMV in barley

Hordeum bulbosum represents the secondary gene pool of barley and constitutes a potential source of various disease resistances in barley breeding. Interspecific crosses of H. vulgare x H. bulbosum resulted in recombinant diploid-barley progeny with immunity to BaMMV after mechanical inoculation. Tests on fields contaminated with different viruses demonstrated that resistance was effective against all European viruses of the soil-borne virus complex (BaMMV, BaYMV-1, -2). Genetic analysis revealed that resistance was dominantly inherited. Marker analysis in a F5 mapping family was performed to map the introgression in the barley genome and to estimate its size after several rounds of recombination. RFLP anchor-marker alleles indicative of an H. bulbosum introgression were found to cover an interval 2.9 cM in length on chromosome 6HS. The soil-borne virus resistance locus harboured by this introgressed segment was designated Rym14(Hb). For marker-assisted selection of Rym14(Hb) carriers, a diagnostic codominant STS marker was derived from an AFLP fragment amplified from leaf cDNA of homozygous-resistant genotypes inoculated with BaMMV.

Nurse-led inpatient care: opening the 'black box'

With recent evaluations contradicting early reports of improved outcomes from nurse-led inpatient care, the 'black box' of nurse-led care must be opened in order to examine the model of treatment. We present findings on the processes of care in one nurse-led unit (NLU), compared with an acute ward. Patterns and quality of nursing care were quantified using bar-code technology to measure type, frequency and duration of nursing activities and Quality Patient Care Scale to measure the quality of care. NLU quality matched, but did not exceed, quality on the acute ward. Patterns of care differed between wards, but activities associated with therapeutic nursing were no more frequent on the NLU. These findings support the hypothesis that disappointing outcomes in recent evaluations may be linked to failure to implement a therapeutic model of nursing.

An integrated care pathway for fractured neck of femur patients

Fractured neck of femur is a common traumatic condition, particularly among older women. An acute trust developed an integrated care pathway for these patients, led by a consultant and a senior nurse. Multidisciplinary team members were trained and outcomes for patients on discharge seem to be improving. But some medical staff have been slow to get involved with the project.

The back home trial: general practitioner-supported leaflets may change back pain behavior

STUDY DESIGN

A single-blind randomized controlled trial of a leaflet developed for people with acute low back pain was compared with the usual general practitioner management of back pain.

OBJECTIVE

To test the effectiveness of a patient information leaflet on knowledge, attitude, behavior, and function.

SUMMARY OF BACKGROUND DATA

Despite the commonality of back pain in general practice, little evidence on the effectiveness of simple interventions such as leaflets and advice on self-management has been reported. On the basis of a five-stage needs analysis, a simple leaflet was developed that considered the views of patients and health professionals.

METHODS

For this study, 64 patients with acute back pain were assigned to the leaflet or control group. The participants were visited at home after 2 days, 2 weeks, then 3, 6, and 12 months, where they completed a range of self-report measures. Behavioral aspects were discretely recorded by a "blinded" researcher. Primary outcomes were knowledge, attitude, behavior, and function.

RESULTS

In all, 272 home visits were undertaken. The findings show that at 2 weeks, knowledge about sitting posture was greater in the leaflet group (P = 0.006), which transferred to a behavioral difference (sitting with lumbar lordosis support) when participants were unaware that they were being observed (P = 0.009). This difference remained significant at 3 months. Patients in the leaflet group also were better at maintaining a wide base of support when lifting a light object than the control subjects throughout all five assessments. There were no significant differences in the functional outcomes tested.

CONCLUSIONS

This trial demonstrates that written advice for patients can be a contributory factor in the initial general practitioner consultation because it may change aspects of knowledge and behavior. This has implications for the management of acute back pain, with potential health gain.

Mechanical methods of reducing blood transfusion in cardiac surgery: randomised controlled trial

OBJECTIVE

To assess the effectiveness of two mechanical methods of blood conservation in reducing the need for allogeneic red blood cells or coagulation products during cardiac surgery.

DESIGN

Randomised controlled trial.

SETTING

Regional cardiac centre in a teaching hospital in Southampton.

PARTICIPANTS

263 adults aged 18-80 years undergoing elective coronary artery bypass surgery entered the study, of whom 252 completed the trial. All patients received routine perioperative care. Patients were allocated to one of three treatment groups: intraoperative cell salvage, intraoperative cell salvage with acute perioperative normovolaemic haemodilution, or no mechanical blood conservation. There were 84 patients in each group.

MAIN OUTCOME MEASURES

Numbers of patients who received allogeneic blood or coagulation products, and the mean number of units of blood transfused per patient.

RESULTS

Of the patients in the intraoperative cell salvage group, 26 were given a transfusion of allogeneic blood, compared with 43 in the control group (odds ratio 0.43 (95% confidence interval 0.23 to 0.80)). The mean number of units of allogeneic blood transfused per patient in the intraoperative cell salvage group was 0.68 units (SD=1.55), compared with 1.07 (1.56) units in the control group. 32 of the patients in the intraoperative cell salvage group were given any blood product, compared with 47 in the control group (odds ratio 0.47 (0.25 to 0.89); P=0.019). Combining acute perioperative normovolaemic haemodilution with intraoperative cell salvage conferred no additional benefits.

CONCLUSIONS

An intraoperative cell salvage device should be used in elective coronary artery bypass grafting. Pharmacological strategies may achieve further reductions in blood transfusions. Yet further reductions in blood transfusions could be achieved if the lower safe limit of haemoglobin concentration in patients undergoing cardiac surgery were known.

The first epidermal growth factor-like domain of the low-density lipoprotein receptor contains a noncanonical calcium binding site

Removal of cholesterol-containing particles from the circulation is mediated by the low-density lipoprotein (LDL) receptor. Upon ligand binding, the receptor-ligand complex is endocytosed, and the ligand is released. The important biological role of the LDL receptor (LDLR) has been highlighted by the identification of more than 400 LDLR mutations that are associated with familial hypercholesterolemia. The extracellular region of the LDLR is modular in nature and principally comprises multiple copies of ligand binding, epidermal growth factor-like (EGF), and YWTD-type domains. This report describes characterization of the calcium binding properties of the tandem pair of EGF domains. While only the C-terminal EGF module contains the consensus sequence associated with calcium binding, a noncanonical calcium binding site in the N-terminal domain has been revealed using solution NMR spectroscopy. The calcium dissociation constants for the N- and C-terminal sites have been measured under physiologically relevant pH and ionic strength conditions using a combination of solution NMR, intrinsic protein fluorescence, and chromophoric chelator methods to be approximately 50 microM and approximately 10-20 microM, respectively. Identification of the novel calcium binding motif in LDLR sequences from other species suggests that it may confer specificity within the LDLR gene family. Comparison of the K(d) for the C-terminal site with the calcium concentration in late vesicles indicates that the binding properties of this module may be tuned to titrate upon endocytosis of the LDL receptor-ligand complex, and thus calcium binding may play a role in the ligand dissociation process.

The relationship between cannabis use and DSM-IV cannabis abuse and dependence: results from the National Longitudinal Alcohol Epidemiologic Survey

The purpose of-this study was to determine the risk of Diagnostic and Statistical Manual of Mental Disorders--Fourth Edition (DSM-IV) cannabis abuse and dependence at different levels of cannabis use in a nationally representative sample of the U.S. general population. Two separate logistic regression analyses were conducted to determine the association between cannabis use, and abuse and dependence. The risk of cannabis abuse and dependence was found to increase with the frequency of smoking occasions and slightly decreased with age. More severe comorbidity was associated with dependence compared to abuse, suggesting that cannabis might be used to self-medicate major depression. The strength of the association between cannabis use and abuse was also increased as a function of the number of joints smoked among females, but not males. These results were discussed in terms of differential societal reactions, the self-medication hypothesis, and gender biases in diagnosing cannabis abuse.

Direct measurement of recombination frequency in interspecific hybrids between Hordeum vulgare and H. bulbosum using genomic in situ hybridization

Two different genotypes of diploid Hordeum vulgare x H. bulbosum hybrids, which differ in their pattern of meiotic metaphase pairing behaviour, were investigated at MI and AI by genomic in situ hybridization (GISH). One hybrid, 102C2, showed a high frequency of bivalents at metaphase I whereas the other, 103K5, showed a high frequency of univalents. The GISH analysis of both hybrids established that pairing occurred only between chromosomes of different parental genomes and revealed that pairing frequency greatly exceeded recombination. Hybrid 102C2 had a significantly higher recombination frequency than 103K5, but in both hybrids recombination involved only distal chromosome regions. However, an interesting finding is that the ratio of recombination to pairing frequency in 103K5 (1:8.9) is twice as high compared with 102C2 (1:17). The hybrids also differed in chromosome stability; little chromosome elimination occurred in 102C2 but 103K5 showed extensive chromosome loss. It appears that the high frequency of bound arms at MI favours retention of H. bulbosum chromosomes and maintains stability of chromosome numbers in PMCs. Various ideas are put forward to explain the discrepancy between meiotic pairing frequency and recombination in these hybrids.

Silent aspiration after coronary artery bypass grafting

BACKGROUND

"Silent" aspiration was recognized to be a more frequent complication at this hospital in patients who have had coronary artery bypass grafting than in the general surgical population.

METHODS

A case-control retrospective study covering a 4.5-year period was conducted to determine risk factors for pharyngeal dysfunction resulting in silent aspiration.

RESULTS

Significant predictors of silent aspiration were age, history of cerebral vascular disease, insulin-dependent diabetes mellitus, myocardial infarction, and chronic obstructive pulmonary disease. Intraaortic balloon pump and number of units of fresh-frozen plasma were the only independent intraoperative factors associated with silent aspiration in a model using continuous variables directly. Cold fibrillation was used in 7 of 53 study cases but no control patients, so it could not be modeled. Postoperative complications occurring with greater frequency included neurologic complications, adverse pulmonary outcomes, repeat surgical interventions, infection, and death. Using an Aspiration Risk Profile developed from the retrospective study, in a detailed prospective study of 10 patients, 3 of 4 patients with postoperative dysphagia had objective evidence of stroke.

CONCLUSIONS

These findings suggest that postoperative coronary artery bypass graft dysphagia may be the result of intraoperative cerebral injury, and that careful postoperative clinical evaluation of coronary artery bypass graft patients with risk factors may result in early diagnosis of pharyngeal dysfunction with the goals of preventing silent aspiration and reducing morbidity, mortality, and hospital cost.