Well-being in wounds inventory (WOWI): development of a valid and reliable measure of well-being in patients with wounds

OBJECTIVE

Physical and psychosocial deficits have been reported in people living with chronic wounds. While the negative impact of these factors on an individual's quality of life (QoL) is well documented, there has been little research into the well-being of those living with chronic wounds, despite recent calls for increased attention to this related, yet distinct construct. This paper introduces the Well-being in Wounds Inventory (WOWI) and provides support for the WOWI as a valid and reliable measure of well-being in patients living with chronic wounds.

METHOD

A draft questionnaire was administered to a convenience sample of individuals with chronic wounds (n=85) and the resulting data subject to factor analysis in order to refine the structure of the questionnaire. The reliability, validity and responsiveness of the resulting questionnaire were then tested by administration to a second sample of individuals with wounds (n=49). Socio-demographic data, issues affecting patient well-being and well-being factors, such as, emotions; perceived coping skills; social support; personal control; hope for the future, were measured.

RESULTS

Results confirmed the WOWI as a reliable and valid measure of well-being. Items loaded onto two subscales, 'personal resources' and 'wound worries'. Analysis revealed the WOWI to be highly feasible measure of well-being, with good test-retest reliability and responsiveness to changes in health status.

CONCLUSION

The current study highlights the importance of assessing well-being factors in individuals living with chronic wounds. It introduces the WOWI as a valid and reliable measure of well-being in chronic wound patients. The authors recommend health-care practitioners take account of well-being as part of a holistic treatment plan in order to maximise patient outcomes.

DECLARATION OF INTEREST

This project was funded by Urgo Medical. The authors have no conflict of interest to declare.

Contribution of the Leg Club model of care to the well-being of people living with chronic wounds

OBJECTIVE

Social support impacts well-being. Higher levels of social support encourage treatment adherence and aid healing in people living with chronic wounds. The Leg Club model of care harnesses social support mechanisms to improve patient outcomes. This study investigated whether social support mechanisms available through a Leg Club environment influenced well-being.

METHOD

Participants were community Leg Club members. Socio-demographic data was collected, and the Well-being in Wounds Inventory (WOWI) administered to assess 'wound worries,' 'personal resources,' and 'well-being'. Participants' perceived social situation, length of time attending a Leg Club, wound duration, and feelings about their physical appearance were also measured.

RESULTS

The subjects recruited (n=49) were aged between 50 and 94 years (mean=75.34, standard deviation=10.31). Membership of a Leg Club did impact well-being factors. Time spent at a Leg Club improved 'personal resources' over time. 'Perceived social situation' predicted key aspects of well-being, as did 'time spent attending a Leg Club' and 'feelings about physical appearance.' Social support and relief from social isolation were important aspects of Leg Club membership for participants.

CONCLUSION

Attending a Leg Club enhances well-being in people living with a chronic wound; social support has an important role to play in this relationship. Future research should consider the specific interplay of social support mechanisms of Leg Club, and other relevant wound-related variables to optimise patient well-being and treatment outcomes.

DECLARATION OF INTEREST

The Urgo Foundation funded this project. The authors have no conflicts of interest to declare.

Psychological management of wound pruritus

OBJECTIVE

To explore the psychological treatment options for pruritus in patients with wounds.

METHOD

This study employed a narrative design with a search being completed using the databases Academic Search Complete, Google Scholar, PsycInfo, PsycARTICLES, Medline and CINAHL Plus. All articles between 1980-2013 that included the following search terms: [pruritus OR itch OR itching] AND [management OR psychological interventions OR treatment] AND [wounds OR burns OR wounds burns] were included in the review.

RESULTS

A number of psychological treatments options emerged from the literature search that were suggested to be effective for treating itching. These included methods such as habit reversal, suggestions, relaxation, massage and itch-coping programmes. Each of these methods showed potential for improving the patient experience by reducing itching, although the research evidence is currently somewhat limited.

CONCLUSION

Although itching is a common symptom in wounds, the use of psychological treatments for this may be rather limited. The treatments discussed show promise and their use should be a welcome addition to the healthcare professional's armoury for working with people with wounds.

DECLARATION OF INTEREST

There were no external sources of funding for this study. The authors have no conflicts of interest to declare.

Negative pressure wound therapy: improving the patient experience Part 2 of 3

Despite the clear benefits of negative pressure wound therapy (NPWT) as a treatment for wounds, it is essential that greater focus is given to the patient experience of this treatment. In particular, it is important that any unpleasant consequences, such as pain, stress, and skin trauma are minimised, so as to promote quality of life and healing. This article presents part two of three studies which aim to explore ways in which the patient experience of NPWT can be improved. In this study, the views of wound care clinicians (n=12) were investigated in greater depth through semi-structured interviews. Findings indicate a pressing need to minimise pain, particularly through ongoing assessment and collaboration with patients, and also through the use of appropriate dressings, films and other products that promote patient comfort. Additionally, it is evident that greater education is needed for both nurses and patients about NPWT, in order to promote high-quality care and patient wellbeing.

The effectiveness of local child weight management programmes: an audit study

BACKGROUND

  Many different child weight management programmes exist, with varying degrees of evaluation to provide evidence of their success. The purpose of this research was to use a standardized approach to audit the effectiveness of weight management intervention programmes in the West Midlands region of the UK, specifically to assess the benefits to participating children in terms of health improvement and behaviour change.

METHODS

  An audit of seven family-based intervention programmes currently in place in the West Midlands. Programmes were audited against the Standard Evaluation Framework.

RESULTS

  The programmes provided a partial data set relating to a change in weight from the baseline to the end of the programme; none of the programmes provided all of the measures indicated by the Standard Evaluation Form as being essential for evaluation. Weight change ranged from an increase in group mean of 0.4 kg to a decrease of 0.9 kg. Body Mass Index SD decreased by 0.1-0.2 points in four programmes and remained unchanged in two programmes. Four programmes collected long-term follow-up data at 6 months. This was often limited because of participant dropout. Improvement in diet and exercise were reported by participants in all programmes which measured these behaviours.

CONCLUSIONS

  Ongoing evaluation of all programmes, using a standard approach, is essential in order to improve the evidence base and support future commissioning.

Mood disorders in patients with acute and chronic wounds: a health professional perspective

OBJECTIVE

This exploratory study surveys a group of practitioners to discover their perspectives on the prevalence of stress, anxiety and mood disorders among their patients with acute and chronic wounds.

METHOD

A questionnaire survey was sent to an convenience sample of 81 health professionals. The questionnaire included items about the health professionals' perceptions of the prevalence of mood disorders among their patients, and their perceptions of potential contributory factors and treatments.

RESULTS

Thirty-nine health professionals (48%), including tissue viability nurses, nurses and podiatrists, responded to the survey. The majority of respondents believed that 50-75% of their patients with chronic wound were suffering from mood problems related to their condition. Despite this, most practitioners believed that few of their patients were actually receiving treatment for these mood- related problems. One quarter of patients with acute wounds were considered to have related problems with mood. Practitioners believed anxiety and feeling helpless were the most common mood problems among their patients, while chronic pain/discomfort of the wound and inability to complete everyday tasks were potential contributory factors to these problems.

CONCLUSION

The findings suggest that the health professionals who responded to the survey were aware of behavioural signs of stress, anxiety and mood problems in their patients with chronic wounds. Furthermore, the majority of practitioners did not feel that their patients were receiving help or treatment for these problems. It is therefore suggested that increased awareness of the behavioural signs of stress, anxiety and mood problems among patients with wounds could help to improve the patient's experience of wound care, as acknowledgement of mood problems could lead to the most appropriate form of treatment or help for individual patients.

The impact of school-day variation in weight and height on National Child Measurement Programme body mass index-determined weight category in Year 6 children

BACKGROUND

In England, the National Child Measurement Programme (NCMP) annually measures the weight and height of Year 6 schoolchildren (age 10-11 years). While measurement protocols are defined, the time of measurement within the school day is not. This study examined the impact of school-day variation in weight and height on NCMP body mass index (BMI)-determined weight category in Year 6 children.

METHODS

Standing height and weight were measured in morning and afternoon sessions in 74 children, boys (n= 34; height: 141.16 ± 7.45 cm; weight: 36.48 ± 9.46 kg, BMI: 18.19 ± 3.98 kg/m(2) ) and girls (n= 40; height: 144.58 ± 7.66 cm; weight: 42.25 ± 11.29 kg; BMI: 19.97 ± 3.98 kg/m(2) ) aged 11 ± 0.3 years.

RESULTS

In the whole sample, height decreased (Mean =-0.51 cm, 95% CI: -0.39 to -0.64 cm, P= 0.01), weight did not change (Mdn = 36.40 to 36.35, P= 0.09) and BMI increased (Mdn = 18.04 to 18.13, P= 0.01). In girls weight increased (Mdn = 41.40 to 41.60, P= 0.01). BMI percentile increased (Mdn = 57th to 59.5th centile, P= 0.01). One girl increased in BMI category from morning to afternoon according to the clinical cut-offs (≤2nd, >91st and >98th) and three girls increased BMI category according to the population monitoring cut-offs (≤2nd, ≥85th, ≥95th).

CONCLUSIONS

School-day variation in height (and in girls alone, weight) impact upon increased BMI and BMI percentile in afternoon versus morning measurements in Year 6 children. Although not reaching statistical significance, resultant variation in categorization at the individual level may lead to unwarranted follow-up procedures being initiated. Further research with larger samples is required to further explore the impact of daily variability in height and weight upon both clinical and population monitoring BMI-determined weight status categorization in the NCMP.

A discussion of the potential mechanisms for wound dressings' apparent analgesic effects

Evidence has been developing about the potential analgesic effects of wound dressings. Several theories have been formulated as to how a dressing placed over a wound might contribute to pain relief. This paper reviews these potential mechanisms. In all, 10 are discussed here, most of which will probably overlap, leading to a high degree of complexity and interdependence. The psychological components inherent in the biopsychosocial model of pain make a key contribution to any analgesic effects that occur following dressing application. The 10 mechanisms identified in this paper will need significant and rigorous testing to determine which, if any, can be confirmed as analgesic.

Psychological stress and pain in wound care, part 2: a review of pain and stress assessment tools

Several tools are available for the assessment and measurement of stress and pain. While it takes time and money to train practitioners in their use, this will soon be offset by benefits in terms of patient care, satisfaction and reduced costs.

Investigation of systems to prevent diversion of opiate drugs in general practice in the UK

BACKGROUND

Statutory regulations govern the procedures that must be followed by general practitioners (GPs) in the UK to minimise the risk of diversion of prescribed opiate drugs for illicit use. However, evidence presented at the trial of Harold Shipman, a GP convicted of murdering patients with diamorphine, suggests that the regulations and monitoring of GPs' prescribing are failing.

AIM

To assess the policies followed by general practices in Leicestershire and Rutland with regard to the controlled drugs regulations.

METHODS

A semi-structured interview was administered to a purposeful sample of lead GPs to explore how their practices applied the regulations. The controlled drugs registers and drug storage facilities in these practices were inspected. A questionnaire was sent to all the remaining practices to seek information about their application of the regulations, any concerns they had about the regulations, and any suggestions for improving them.

RESULTS

Of the 142 general practices in Leicestershire, the lead GP in 14 took part in the interviews. Respondents expressed dissatisfaction with current policies including the design of controlled drug registers, and generally supported the reintroduction of an inspection scheme. Ninety (70.9%) of the 127 practices to whom the questionnaire was sent responded and, of these, 31 (34.4%) no longer held a supply of controlled drugs. Those that did hold controlled drugs indicated concern about the regulations, confusion about some aspects including the return and disposal of unused drugs, and a desire for advice and support in the implementation of the regulations. Forty two of the 59 respondents who held a supply of controlled drugs (71.2%) would welcome regular inspection.

CONCLUSION

GPs are confused about the controlled drugs regulations and have little support in implementing them. The suspension of inspection schemes has reduced the amount of advice and support available to them and, in consequence, the regulations are interpreted differently in different practices. These findings are cause for concern about the risk of diversion of controlled drugs, and illustrate how patient safety systems can decay when they are not maintained.

Plasma aluminum levels during sucralfate prophylaxis for stress ulceration in critically ill patients on continuous venovenous hemofiltration: a randomized, controlled trial

OBJECTIVE

To investigate plasma aluminum levels in critically ill patients requiring continuous venovenous hemofiltration (CVVH), while receiving sucralfate for stress ulcer prophylaxis.

DESIGN

Randomized, controlled study.

SETTING

Cardiothoracic intensive care unit.

PATIENTS

Twenty postoperative cardiac surgical patients

INTERVENTIONS

Twenty patients requiring CVVH support for acute renal failure were randomized into two groups for concurrent stress ulcer prophylaxis. Group 1 (n = 10) received nasogastric sucralfate, and group 2 patients received intravenous ranitidine. Plasma aluminum samples were analyzed at baseline and on days 1, 4, 8, and 14.

MEASUREMENTS AND MAIN RESULTS

In both the sucralfate and ranitidine groups, clinical characteristics, number of days the patients were on CVVH support (median, 5.5 [range, 2-32] days, and median, 3 [range, 2-18] days, respectively) and duration of prophylaxis (median, 12 [range, 4-42] days, and median, 16 [range, 3-62] days, respectively) were similar. There were no significant differences in the baseline aluminum concentrations (median, 0.37 [range, 0.15-1.63] micromol/L, vs. median, 0.32 [range, 0.11-1.0] micromol/L; p =.79). On initiation of therapy, aluminum levels in the sucralfate group increased dramatically on day 1 (median, 0.87 [range, 0.26-4.4] micromol/L) and peaked on day 4 (median, 2.84 [range, 1.52-4.44] micromol/L) with seven of the ten patients exhibiting levels of >2 micromol/L. In the ranitidine group, there were no significant elevations in aluminum levels above baseline. Analysis of the two groups at the four time points revealed that aluminum levels in the sucralfate group were up to 14 times higher, with the confidence intervals suggesting that the true value may be 2-27 times higher (p <.0001). On cessation of CVVH, a rapid decline in aluminum levels was observed. No clinical manifestations of these potentially toxic levels were observed.

CONCLUSIONS

The use of sucralfate for stress ulcer prophylaxis in patients requiring CVVH results in toxic elevations in plasma aluminum levels. Alternative agents should be considered for prophylaxis in these patients.

The constituent structure of autobiographical memory: autobiographical fluency in people with chronic epilepsy

A total of 59 people with chronic epilepsy recalled autobiographical episodes and personal facts (such as the names of friends or teachers) from various lifetime periods. Also tested was their verbal fluency and their fluency in generating items from semantic categories (animals, vegetables, US presidents, and British prime ministers). Results of a cluster analysis and a common factor analysis confirmed a dissociation between the retrieval of autobiographical information and that of nonpersonal semantic information. There was a similar dissociation between the recall of personal episodes and the recall of the personal information, but the corresponding factors were highly correlated with one another. Finally, verbal fluency performance was significantly correlated with the retrieval of personal information, personal episodes, and common objects, but not with that of public figures. The constituent structure of autobiographical fluency is extremely robust across different populations.

Epilepsy and the family: a review of current literature

Although the negative effect of epilepsy on patient's psychosocial well-being has been increasingly documented in the last decade, the influence of the condition on the family has attracted much less interest. This paper reviews the present state of family research, examining the influence of both childhood and adulthood epilepsy on the psychological and social well-being of family members. Studies indicate that epilepsy may cause high levels of psychosocial difficulties for all family members, including stigmatization, stress, psychiatric morbidity, marital problems, poor self esteem and restriction of social activities. Studies also suggest that the family environment may be an important intervening factor between the condition and the outcome for the family unit, and a number of family factors are reviewed which have been suggested to mediate this relationship, with recommendations being made for their use in intervention studies. Shortcomings of the family studies to date are discussed and these include: concentration on examination of issues around family life, studies being based on reports from single members of the family and the selection of subjects from clinical populations. Recommendations are made concerning methodological and conceptual issues that need addressing for future research.

Attitudes towards, and knowledge of, clinical effectiveness in nurses, midwives, practice nurses and health visitors

The dual concepts of evidence-based practice and clinical effectiveness have become ever more important for nurses, midwives and health visitors in recent years. In order that suitable initiatives can be derived and future policy shaped and evaluated it is important that the current level of knowledge and attitudes towards these concepts are recorded. The current study set out to examine these variables in a large, representative sample (n = 370, response rate = 74%) of nurses, midwives and health visitors. Results indicated that although a positive attitude towards evidence-based practice exists, individuals consider themselves to be lacking in certain key skills. Specifically, these appeared to be related to research-based skills. However, despite this, respondents indicated a large take up of evidence-based practice, although this may have been greater were it not for the considerable clinical workload. The necessity for greater dissemination of key research principles to nurses, midwives and health visitors by members of their own profession is emphasized.

Twenty questions task and frontal lobe dysfunction

Performance on the Twenty Questions task has been assumed to be deficient in those with frontal lobe damage, although few studies have specifically examined this. In the present study, 88 participants with frontal lobe epileptic dysfunction were assessed on this task, as were 57 participants with temporal lobe epileptic disturbance and 28 participants with no evidence of any neurological damage. Results indicated that those with either left or bifrontal lobe damage were more impaired on several indexes of test performance. Analysis also revealed that participants with orbitofrontal damage were impaired on the measure of "first guess" as compared to groups with damage to other regions of the prefrontal cortex (p <.05). Overall, the results support the utility of the Twenty Questions task in assessing frontal lobe damage and may suggest that qualitatively different deficits may be recorded depending on the region of frontal lobe dysfunction.

Neuropsychological test performance in frontal-lobe epilepsy: the influence of aetiology, seizure type, seizure frequency and duration of disorder

Although frontal-lobe epilepsy accounts for a sizeable proportion of all partial epilepsies the neuropsychological characteristics have proved difficult to document. A possible explanation for this may lie in the impact of seizure-related variables. However, these have rarely been addressed in a frontal-lobe epilepsy sample. In this report the neuropsychological sequelae of the aetiology of epilepsy, seizure spread, seizure frequency and duration of disorder were examined in a sample of 74 subjects with frontal-lobe epilepsy (42 with left, 32 with right). Only a few significant results were revealed and in these cases the possibility of greater cortical dysfunction rather than specific frontal impairment would offer a viable solution. Further studies are needed in order that firmer conclusions concerning the impact of the variables investigated on neuropsychological performance in a sample of subjects with frontal-lobe epilepsy can be drawn.

Age at onset and neuropsychological function in frontal lobe epilepsy

PURPOSE

Previous studies into the cognitive consequences of frontal lobe epileptic dysfunction may have proved inconclusive, due to a factor not commonly accounted for: Damage or disturbance during different epochs of development may give rise to different levels of neuropsychological dysfunction. In this study, we investigated the influence of age at onset on cognitive performance in a group of subjects with frontal lobe epilepsy (FLE).

METHODS

Seventy-four subjects (42 with left, and 32 with right) FLE were classified into early (0-6 years), intermediate (7-11 years) or late onset (> or =12 years) and their performance recorded on a battery of measures assessing both executive and motor skills.

RESULTS

On the measures of executive functioning, no consistent pattern emerged, whereas on the measures of motor skill, the results suggested that a right-sided early onset (i.e., 0-6 years) did not impair performance compared to a later lesion within the same hemisphere. Furthermore, this sparing of performance was not observed within the left hemisphere.

CONCLUSIONS

Overall, the results suggest that individuals with differing ages of epilepsy onset will be differentially impaired on certain cognitive tasks. Several tentative ramifications of these results are suggested.

Patient satisfaction with specialized epilepsy assessment and treatment

The need for the assessment of patient satisfaction with specialized epilepsy services has been recognized for a number of years, in order to complement the management and medical benefits already demonstrated. We report a detailed study of patient satisfaction with the services provided in a specialised epilepsy assessment unit in the U.K. Patients were interviewed to assess their perceptions of the quality of service and the benefits they had derived from attending the unit. Close relatives were also contacted for their evaluation of the service provided. In all, 76 patients and 52 close relatives provided their views on the services offered. The results showed a positive appraisal of treatment. Almost 90% believed that their medical and social situation had been improved by attendance at the unit. However the need to assess more objective measures of "satisfaction' are stressed, in order that future developments in care can be appropriately planned.

Clinical analysis of a CAD/CAM system for custom seating: a comparison with hand-sculpting methods

A CAD/CAM system for manufacturing custom seating inserts was evaluated within a moderately to severely disabled population. Using the Otto Bock Shape System, 25 CAD/CAM seats were manufactured at a remote facility and compared to 9 seats manufactured using hard-sculpting techniques. Clinician and client questionnaires were completed for each seat to assess satisfaction, fitting/manufacturing times, and to collect demographic data. The CAD/CAM method was significantly better (p < 0.05) than the hand-sculpting method in terms of on-site fabrication time. No significant differences were found for initial fitting time, final fitting time, clinician insert rating, and client satisfaction. These results support the CAD/CAM method as an effective and clinically efficient technique for making custom wheelchair seats.

General neuropsychological characteristics of frontal lobe epilepsy

The neuropsychological characteristics of frontal lobe epilepsy have rarely been reported, with neuropsychological indicators usually being related to subjects with other forms of neurological damage. In this study we assessed the performance of 74 subjects with frontal lobe epilepsy (42 with left, 32 with right frontal epileptic foci) on a series of measures thought to be sensitive to frontal lobe dysfunction and compared to 57 subjects with temporal lobe epilepsy (31 with left, 26 with right epileptic foci). The results indicated a number of measures that could be considered sensitive to frontal lobe epileptic dysfunction. However, the pattern of results did not indicate consistent deficits to be associated with frontal lobe epileptic dysfunction. There are a number of unique factors associated with epilepsy that need to be considered, and these may account for the variable pattern of results obtained. In particular, the rapid propagation of frontal lobe seizures both bilaterally and to other cortical regions has to be considered.

The role of the right temporal lobe in card sorting: a case study

It has been demonstrated previously that performance on the modified Wisconsin Card Sorting Task (Nelson, 1976) is compromised by hippocampal sclerosis, particularly of the right hemisphere (Corcoran and Upton, 1993). Further evidence in support of this claim is presented here in the form of a case study. The findings from this case demonstrated that performance on the same task was not impaired following a right sided frontal lobectomy but was found to be deficient consequent to seizure recurrence in the right temporal lobe and following right temporal lobe removal. The clinical and theoretical significance of this case is discussed.

Neuropsychological effects of tiagabine, a potential new antiepileptic drug

The neuropsychological effects of the GABA-reuptake blocker, tiagabine-HCl, were tested in an open trial of 22 adult patients with refractory partial epilepsy followed by a double-blind, placebo-controlled, cross-over trial in 12 subjects. Nineteen patients completed the initial open titration and fixed-dose phase of the study and 11 patients completed the double-blind phase. The median daily tiagabine dose was 32 mg during the open fixed dose and 24 mg during the double-blind periods. Neuropsychological evaluation did not show any significant effect on cognitive function in the open or double-blind phases. In this group of patients no statistically significant difference in the frequency of the total number of seizures or complex partial seizures was found in the open or double-blind stages. Seizure severity was significantly less in the open fixed dose than in the baseline period, but was not significantly different between the two double-blind periods. Reported side effects were transient, most commonly aggression/irritability, lethargy, headache and drowsiness. No significant EEG changes were observed.

The excitatory amino acid antagonist D-CPP-ene (SDZ EAA-494) in patients with epilepsy

The amino acids L-glutamate and L-aspartate have been shown to be excitatory neurotransmitters in mammalian central nervous systems. Antagonists acting selectively at excitatory amino acid receptors have shown antiepileptic properties in several animal models. We report the results of the first therapeutic trial of the competitive NMDA antagonist, D-CPP-ene (SDZ EAA-494), in eight patients with intractable complex partial seizures. All patients withdrew prematurely because of side-effects, including poor concentration (8), sedation (7), ataxia (6), depression (3), dysarthria (2), amnesia (2) and unilateral choreo-athetosis in a patient with contralateral Sturge-Weber syndrome. Seizures were unchanged in four patients and worse in three. A further patient with apparent improvement in seizures in the first week developed complex partial status epilepticus on withdrawal of DCPP-ene. EEG on treatment (5) or in the immediate post-treatment period (2) showed slowing of background activity and, in five cases, an increase in epileptiform activity. Serum concentrations of DCPP-ene were found to be unpredictable and higher than expected from pharmacokinetic data on normal subjects. There was no clear relationship between serum concentrations and the severity of side-effects. Preliminary experience with DCPP-ene in patients with refractory partial seizures is not promising. Evaluation of related compounds is warranted.

A role for the hippocampus in card sorting?

This study examines the performance of three groups of patients with epilepsy on three measures typically used to assess the integrity of the frontal lobes: the Modified Wisconsin Card Sorting Test (MWCST), verbal fluency and the Stroop test. The groups comprised sixteen patients with clearly defined hippocampal sclerosis, thirteen patients with unilateral temporal lobe seizure onset and eighteen patients with unilateral frontal lobe onset. Results demonstrated that performance on the MWCST was most compromised by hippocampal sclerosis. These patients took longer to complete the task, achieved fewer categories and made more perseverative errors than patients in the other groups. In contrast, verbal fluency and performance on the Stroop test were less affected by the presence of hippocampal sclerosis. These results have both clinical and theoretical significance. It is argued that patients with hippocampal damage perform poorly on the MWCST because of the heavy working memory requirements of the test. Cautious use of this test as a tool to localise seizure origin in patients with complex partial seizures is therefore recommended. The findings are discussed in terms of Gray's (1982) model of the hippocampus as a comparator of actions.

The impact of chronic epilepsy on the family

The emotional impact of intractable epilepsy on family members is a neglected topic, with the majority of studies confined to childhood epilepsy. Our clinical experience suggests that family members, particularly parents, may at times be under considerable emotional strain, especially when seizures are frequent and accompanied by injury. The purpose of this study was to explore the psychological and physical well-being, satisfaction with social circumstances and perceived level of support in families with an adult member with intractable epilepsy. Forty-four families were administered rating scales of mood and answered questions relating to their social situation and physical health. Levels of stress and dissatisfaction with their social situation was high, particularly in primary carers (the mother in most instances). Respite periods away from their caring role were few and the perceived level of support was low. Poor emotional adjustment was associated with severity of tonic and atonic seizures and episodes of status. Additionally, perceived low levels of support were associated with depression.

Exercise training improves insulin sensitivity in the obese Zucker rat

The effect of exercise on in vivo insulin sensitivity was examined in lean and obese Zucker rats. Rats (6 to 7 weeks of age) were swum two hours per day or kept sedentary for 8 weeks. Exercise decreased body weight gain as well as percent of fat in both genotypes. Sedentary obese rats had 62% higher gastrocnemius citrate synthase activity per gram of muscle than did lean rats. Exercise increased activity of this oxidative enzyme similarly in both genotypes. Compared to lean rats, obese rats had higher plasma-insulin levels and were less sensitive to insulin during an insulin tolerance test. Although training had no effect on plasma-insulin levels, exercise trained obese rats showed a greater drop in plasma glucose relative to sedentary controls following intravenous injection of three concentrations of insulin. It was concluded that moderate exercise training improved the insulin sensitivity of the obese Zucker rat.

Effect of hepatic microsomal enzyme inducers on the metabolism of misonidazole in rats

Pretreatment of rats with the hepatic microsomal enzyme inducers, phenobarbital or phenytoin, increased the metabolism of the hypoxic cell radiosensitizer, misonidazole. The increase was reflected in the ratio of O-demethylated metabolite to unchanged drug in the 24-hour urine collection and was more extensive with phenobarbital. No inducement was observed after pretreatment with dexamethasone or misonidazole. Such pretreatment with inducers prior to misonidazole therapy would be clinically important since the incidence of neurotoxicity may be reduced without impairment of the radiosensitizing effect.