Electroconvulsive Therapy - What Do Patients Think Of Their Treatment?

BACKGROUND: The Regulation and Quality Improvement Authority (RQIA) monitors the administration of electroconvulsive therapy (ECT) in Northern Ireland (NI). As part of their inspection methodology RQIA wished to include feedback from ECT patients. The aim of this report is to summarise the opinions of ECT patients over a 1-year period and to compare their feedback about treatment with the standards of best practice, as defined by the Electroconvulsive Therapy Accreditation Service (ECTAS). METHOD: RQIA was granted permission to use the ECTAS patient questionnaire. The questionnaire was distributed to all the ECT clinics in NI and staff were requested to give them to patients who had received a course of ECT. RESULTS: A total of 42 individuals returned questionnaires, 24 females (57.1%) and 18 (42.9%) males. The response rate was 26%. Almost half of respondents were detained under the Mental Health (Northern Ireland) Order 1986 (n=19, 45.2%), with one third receiving ECT as a day patient (n=14, 33.3%). Respondents reported having detailed information about ECT, with ECTAS standards 4.2 and 4.3 being affirmed in over 80% of cases. Eighty percent of respondents (n=34) believed they benefited from ECT. CONCLUSION: The results are mainly favourable towards ECT. The majority felt they benefited from treatment.

Epigenetic regulation of CD133 and tumorigenicity of CD133+ ovarian cancer cells.

The cancer stem cell hypothesis posits that malignant growth arises from a rare population of progenitor cells within a tumor that provide it with unlimited regenerative capacity. Such cells also possess increased resistance to chemotherapeutic agents. Resurgence of chemoresistant disease after primary therapy typifies epithelial ovarian cancer and may be attributable to residual cancer stem cells, or cancer-initiating cells, that survive initial treatment. As the cell surface marker CD133 identifies cancer-initiating cells in a number of other malignancies, we sought to determine the potential role of CD133+ cells in epithelial ovarian cancer. We detected CD133 on ovarian cancer cell lines, in primary cancers and on purified epithelial cells from ascitic fluid of ovarian cancer patients. We found CD133+ ovarian cancer cells generate both CD133+ and CD133- daughter cells, whereas CD133- cells divide symmetrically. CD133+ cells exhibit enhanced resistance to platinum-based therapy, drugs commonly used as first-line agents for the treatment of ovarian cancer. Sorted CD133+ ovarian cancer cells also form more aggressive tumor xenografts at a lower inoculum than their CD133- progeny. Epigenetic changes may be integral to the behavior of cancer progenitor cells and their progeny. In this regard, we found that CD133 transcription is controlled by both histone modifications and promoter methylation. Sorted CD133- ovarian cancer cells treated with DNA methyltransferase and histone deacetylase inhibitors show a synergistic increase in cell surface CD133 expression. Moreover, DNA methylation at the ovarian tissue active P2 promoter is inversely correlated with CD133 transcription. We also found that promoter methylation increases in CD133- progeny of CD133+ cells, with CD133+ cells retaining a less methylated or unmethylated state. Taken together, our results show that CD133 expression in ovarian cancer is directly regulated by epigenetic modifications and support the idea that CD133 demarcates an ovarian cancer-initiating cell population. The activity of these cells may be epigenetically detected and such cells might serve as pertinent chemotherapeutic targets for reducing disease recurrence.

A three centre study of the variability of ankle foot orthoses due to fabrication and grade of polypropylene.

This study investigates if fabrication techniques employed at different orthotic centres affect the characteristics of the manufactured plastic orthoses. Plaster models were formed from the same master mould. The thickness and bending stiffness of the supplied polypropylene sheets were measured prior to fabrication. An orthotic technician at each of the 3 orthotic centres manufactured 4 homopolymer and 4 copolymer polypropylene ankle-foot orthoses (AFOs), following each centre's fabrication practice. Another technician at one of the orthotic centres manufactured an additional 4 homopolymer and 4 copolymer AFOs. The thickness, the dorsiflexion stiffness and plantarflexion stiffness of the 32 fabricated AFOs were monitored and compared. Analysis of the results suggests: Copolymer polypropylene sheets are supplied marginally thicker than homopolymer polypropylene sheets. The difference between the thickness of the 16 copolymer and 16 homopolymer AFOs was not significant. The thickness of the AFOs manufactured in copolymer was less consistent than homopolymer. Dorsiflexion stiffness of the copolymer AFOs was less consistent than homopolymer AFOs. Although the bending stiffness of the copolymer and homopolymer sheets differed significantly, there was no significant difference between the dorsiflexion stiffness of the copolymer and homopolymer AFOs. Plantarflexion stiffness was consistent for both the copolymer and the homopolymer AFOs and there was no significant difference between the plantarflexion stiffness of the copolymer and homopolymer AFOs. The thickness and flexural stiffness of the AFOs manufactured by 2 technicians at the same centre did not differ. These results are useful benchmarks for the flexural stiffness of AFOs.

Pilot study: data-capturing consistency of two trans-tibial casting concepts, using a manikin stump model: a comparison between the hands-on PTB and hands-off ICECAST compact concepts.

The quality of fit of a trans-tibial patellar tendon bearing (PTB) socket may be influenced by consistency in casting, rectification or alignment. For this study two distinctive different data-capturing concepts were tested in relation to prosthetist performance. The hands-on PTB and hands-off ICECAST compact concept were studied and compared for inter- and intra-prosthetist consistency using a specially designed manikin stump model. A purpose designed digitiser was used to scan a selected surface area of the produced models, 5 for each concept, 10 in total. The extent of casting consistency at each of 936 locations per plaster model was calculated and the level of consistency was quantified. This study has shown that by using the manikin model there is a clear indication that the investigated hands-off concept produces more consistent results than the hands-on concept.

Measurement of the consistency of patellar-tendon-bearing cast rectification.

The quality of fit of a trans-tibial patellar-tendon-bearing (PTB) socket may be influenced by consistency in casting, rectification or alignment. This paper quantifies, for the first time, the variations in the rectified casts between two experienced prosthetists and the variation between the rectified casts of each individual prosthetist. Prosthetists A and B observed the hand casting of a typical trans-tibial amputee. Each prosthetist was supplied with 5 previously measured duplicated plaster models. The two prosthetists rectified the supplied plaster models based on their own interpretation of basic rectification guidelines. Both prosthetists operated in isolation. The re-measured rectified plaster model data was compared with the unrectified data. The extent of rectification at each of 1800 locations per plaster model was calculated. In zones of major rectification, the mean difference between prosthetists was quantified as 2mm and the standard deviation (SD) about that mean was +/- 1mm for each prosthetist. The co-ordinates of the apex of the fibular head for the 10 modified casts indicated that the maximum variation was in the axial direction with a SD of 4.3mm for prosthetist A and a SD of 2.8mm for prosthetist B. The lengths of the 5 plaster models rectified by prosthetist A indicated a SD of 0.2mm whereas the lengths of the 5 plaster models rectified by prosthetist B indicated a SD of 2.9mm.

Total knee replacement: a comparison of ropivacaine and bupivacaine in combined femoral and sciatic block.

BACKGROUND: Femoral and sciatic nerve block may improve post-operative analgesia following total knee replacement. OBJECTIVES: To compare the post-operative analgesia following primary total knee replacement provided by spinal anaesthesia alone or in combination with femoral and sciatic nerve block with bupivacaine or ropivacaine. METHODS: Seventy-five patients were randomised into one of three groups: spinal anaesthesia only; spinal anaesthesia and combined femoral and sciatic nerve block with 1 mg x kg(-1) bupivacaine 7.5 mg x ml(-1) to each nerve; spinal anaesthesia and combined femoral and sciatic nerve block with 1 mg x kg(-1) ropivacaine 7.5 mg x ml(-1) to each nerve. RESULTS: The mean (SD) time to first morphine request was significantly prolonged for both groups receiving combined femoral and sciatic block, 912 (489) min for the bupivacaine group and 781 (394) min for the ropivacaine group (P<0.001) compared with 413 (208) min for the group receiving spinal anaesthesia alone. Morphine consumption was significantly reduced in both groups receiving combined femoral and sciatic block. There were no systemic or neurological sequelae in any of the groups. CONCLUSIONS: Femoral and sciatic blockade following intrathecal bupivacaine/diamorphine provided superior analgesia when compared with intrathecal bupivacaine/diamorphine alone. There were no significant clinical differences between the group receiving bupivacaine 7.5 mg x ml(-1) and the group receiving ropivacaine 7.5 mg x ml(-1).

Ultrasound study of the motion of the residual femur within a trans-femoral socket during daily living activities other than gait.

This study analyses the residual femur motion of a single amputee within a transfemoral socket during a series of daily living activities. Two simultaneously transmitting, socket mounted transducers were connected to two ultrasound scanners. Displacement measurements of the ultrasound image of the femur were video recorded and measured on "paused" playback. Abduction/adduction and flexion/extension of the residual femur within the socket at any instant during these activities were estimated, knowing the relative positions of the two transducers and the position of the residual femur on the ultrasound image. Consistent motion patterns of the residual femur within the trans-femoral socket were noted throughout each monitored daily living activity of the single amputee studied. Convery and Murray (2000) reported that during level walking, relative to the socket, the residual femur extends 6 degrees and abducts 9 degrees by mid-stance while flexing 6 degrees and adducting 2 degrees by toe-off. Uphill/downhill, turning to the right and stepping up/down altered this reported pattern of femoral motion by approximately 1 degree. During the standing activity from a seated position the femur initially flexed 4 degrees before moving to 7 degrees extension, while simultaneously adducting 6 degrees. During the sitting activity from a standing position the femur moved from 7 degrees extension and 6 degrees adduction to 3 degrees flexion and 1 degree abduction. The activity of single prosthetic support to double support introduced only minor femoral motion whereas during the activity of prosthetic suspension the femur flexed 8 degrees while simultaneously adducting 9 degrees. Additional studies of more amputees are required to validate the motion patterns presented in this investigation.

Efficacy and uptake of ropivacaine and bupivacaine after single intra-articular injection in the knee joint.

The efficacy of ropivacaine 100 mg (5 mg ml(-1)), 150 mg (7.5 mg ml(-1)) and 200 mg (10 mg ml(-1)) and bupivacaine 100 mg (5 mg ml(-1)) given by intra-articular injection into the knee after the end of surgery was studied in 72 ASA I-II patients scheduled for elective knee arthroscopy under general anaesthesia in a randomized, double-blind study. Kapake (paracetamol 1 g and codeine 60 mg) was given as a supplementary analgesic. Pain scores were assessed 1-4 h after surgery and a verbal rating scale of overall pain severity was assessed on second postoperative day. Ropivacaine or bupivacaine concentrations were determined in peripheral venous plasma up to 3 h after injection in eight patients in each group. Verbal rating pain scores were lower with ropivacaine 150 mg compared with bupivacaine 100 mg (P<0.05). There was a tendency for lower analgesic consumption and pain scores with all doses of ropivacaine (not significant). The mean (SD) maximum total plasma concentrations of ropivacaine were 0.64 (0.25), 0.78 (0.43), and 1.29 (0.46) mg litre(-1) after 100, 150 and 200 mg. The corresponding unbound concentrations were 0.018 (0.009), 0.024 (0.020) and 0.047 (0.022) mg litre(-1). Both were proportional to the dose. The maximum total concentration after bupivacaine 100 mg was 0.57 (0.36) mg litre(-1). The time to reach maximum plasma concentration was similar for all doses and varied between 20 and 180 min. All concentrations were well below the threshold for systemic toxicity.

The efficacy and safety of epidural infusions of levobupivacaine with and without clonidine for postoperative pain relief in patients undergoing total hip replacement.

UNLABELLED: We assessed the efficacy and tolerability of epidural infusions of levobupivacaine, levobupivacaine plus clonidine, and clonidine for postoperative analgesia in 86 patients undergoing total hip replacement. For each group, an epidural cannula was inserted before surgery and 15 mL of 0.75% plain levobupivacaine was administered. Three hours later, an epidural infusion (6 mL/h) of levobupivacaine 0.125% (L), levobupivacaine 0.125% plus clonidine 8.3 microg/mL (LC) or clonidine alone (8.3 microg/mL) (C) was initiated. Morphine consumption was recorded for the following 24 h as were visual analog pain scores and the degree of sensory and motor blockade. The mean (median) morphine consumption was lowest in the combination group (LC),14 (7) mg; higher in the clonidine group (C), 23 (21) mg; and highest in the levobupivacaine group (L), 37 (36) mg (P = 0.022). The median times until the first request for analgesia which were 2. 9, 5.9, and 12.5 h for Groups L, C, and LC, respectively (P < or = 0. 01). There were no statistical differences among the groups regarding the maximum degree of postoperative motor blockade. On average, the systolic blood pressure in the two clonidine groups was slightly lower than in those from the levobupivacaine group. We conclude that the epidural administration of a combination of levobupivacaine plus clonidine is well tolerated and gives better analgesia than either drug used alone. IMPLICATIONS: In patients undergoing total hip replacement, the addition of the alpha(2)-adrenergic agonist clonidine to epidural infusions of levobupivacaine significantly improved postoperative analgesia.

The calibration of ultrasound transducers used to monitor motion of the residual femur within a trans-femoral socket during gait.

During gait the motion of the residual femur within a trans-femoral socket may be estimated using video recorded data from two ultrasound transducers attached to the socket wall. This paper reviews possible measurement errors and identifies the magnitude of the inaccuracies. Inaccuracies due to equipment limitations and those due to human error are identified and quantified. Ranges of flexion/extension and abduction/adduction of the residual femur within the socket during gait have been estimated with a cumulative level of inaccuracy of <1 degree.

Ultrasound study of the motion of the residual femur within a trans-femoral socket during gait.

This study analyses the motion of the residual femur within a trans-femoral socket during gait using ultrasound data from two simultaneously transmitting transducers connected to two ultrasound scanners. Calibration tests accurately established the orientation of the two transducers mounted on the lateral wall of the socket. Relative positions of the ultrasound image of the femur were measured on video playback. Motion of the residual femur, relative to the lateral wall of the socket, at any instant during gait may be estimated, if the relative positions of the two transducers and the motion of the ultrasound image are known. A consistent pattern of femoral motion during 10 gait cycles is displayed graphically. The femoral motion in this paper is expressed as abduction/adduction or flexion/extension relative to the socket. However, without a full gait analysis study, the orientation of the socket relative to the ground or relative to the pelvis cannot be determined. Only one ultrasound scanner may be available for clinical use. Hence data collection may be restricted to only one transducer during gait. In order to simulate the single transducer mode, the ultrasound data recorded during the 10 previous gait cycles, was averaged at any instant of the gait cycle. The angular orientation of the femur was calculated based on the averaged data. Similar patterns of femoral motion were obtained irrespective of the technique adopted.

Ventilatory characteristics in mechanically ventilated patients during manual hyperventilation for chest physiotherapy.

We measured the tidal volumes and peak inflation pressures generated during manual hyperventilation for chest physiotherapy in 25 adult ventilated patients. The average tidal volume ranged from 711 to 1511 ml, with a mean (SD) of 1120 (274) ml. There was a negative correlation (p < 0.05) between the average tidal volume and the lung injury, as measured by the Murray lung injury score. The average peak inflation pressure ranged from 37 to 74 cmH2O with a mean (SD) of 51.5 (7.6) cmH2O. There was a positive correlation (p < 0.05) between average peak inflation pressure and the lung injury score. Mean (SD) PaO2 improved by 18.3 (14.3) kPa from baseline after physiotherapy (p < 0.05). Mean (SD) PaCO2 decreased by 0.1 (0.4) kPa. As the lung score increases higher inflation pressures and smaller tidal volumes are used suggesting an increased potential for barotrauma or volutrauma in susceptible lungs.

Socket/stump interface dynamic pressure distributions recorded during the prosthetic stance phase of gait of a trans-tibial amputee wearing a hydrocast socket.

Force sensing resistors (FSR) have been used to measure dynamic stump/socket interface pressures during the gait of a trans-tibial amputee. A total of 350 pressure sensors were attached to the inner wall of a hydrocast socket. Data were sampled at 150 Hz during approximately 0.8 seconds of prosthetic stance of gait. The dynamic pressure distributions within a hand cast socket reported by Convery and Buis (1998) are compared with those monitored within a hydrocast socket for the same amputee. The pressure gradients within the hydrocast socket are less than that of the hand cast Patellar-Tendon-Bearing (PTB) socket. The proximal "ring" of high pressure in the hand cast PTB socket is replaced with a more distal pressure in the hydrocast socket.

Comparison of bending stiffness of six different colours of copolymer polypropylene.

This paper compares the bending stiffness of 5 different colours of copolymer polypropylene (CCP) with that of natural copolymer polypropylene (NCP). Flesh coloured and natural sheets are supplied thicker than other pigmented sheet. The bending stiffness of a specimen may be defined as EI, i.e. the product of E, Young's modulus of elasticity and I, the 2nd moment of area. Strips of "as supplied" (AS) and "post-draped" (PD) specimen were clamped and subjected to bending to assess the effect of pigmentation on bending characteristics. The gradient of the graph of bending deflection delta versus bending moment enables EI to be estimated. The process of thermoforming polypropylene reduces EI, the bending stiffness. However, the manual draping and vacuum procedure introduces so many variables that it is difficult to quantify the effect of pigmentation. The E of a bent specimen may be estimated from the gradient of the graph of deltaI versus bending moment. In the case of AS sheet, the effect of pigmentation on E is inconclusive. PD specimens indicate a significant reduction in E due to thermoforming. This was verified by an electron-microscope study of AS and PD specimens. Draping an ankle-foot orthosis (AFO) results in a non-uniform wall thickness. The results of this study with respect to the effects of pigmentation on the bending stiffness of AFOs are inconclusive. More detailed studies require to be completed in order to confirm which factors are responsible for this non-uniformity in wall thickness and consequent variation in bending stiffness.

Test apparatus for the measurement of the flexibility of ankle-foot orthoses in planes other than the loaded plane.

Previous publications have reported on the flexibility of ankle-foot orthoses (AFO) only in the same plane as the applied load. This paper reports on a test apparatus developed to detect the flexibility of an AFO in 5 degrees of freedom when subjected to a plantar/dorsiflexion moment, a medial/lateral moment or a torque. A moment applied to an AFO in one plane induces angulation and translation in all planes.

Conventional patellar-tendon-bearing (PTB) socket/stump interface dynamic pressure distributions recorded during the prosthetic stance phase of gait of a trans-tibial amputee.

Force sensing resistors (FSR) have been used to measure dynamic stump/socket interface pressures during the gait of a trans-tibial amputee. A total of 350 pressure sensor cells were attached to the inner wall of a patellar-tendon-bearing (PTB) socket. Data was sampled at 150 Hz during the approximate 0.8 seconds of prosthetic stance of gait. A total of 42,000 pressures were recorded during a single prosthetic stance. This paper describes the distribution of the pressure patterns monitored during the prosthetic stance phase of gait.

Low-dose intra-articular ketorolac for pain relief following arthroscopy of the knee joint.

The systemic administration of nonsteroidal anti-inflammatory agents has been shown to improve analgesia following arthroscopy of the knee joint. Ketorolac 60 mg, when given intra-articularly, provides better postoperative analgesia than an identical dose administered systemically. We compared the postoperative analgesic effect of ketorolac 10 mg given intravenously with 5 mg intra-articularly in 60 patients undergoing arthroscopy of the knee joint under general anaesthesia. Patients were randomly allocated in a double-blind manner to receive 0.25% bupivacaine 20 ml and ketorolac 5 mg intra-articularly (n = 27) or intravenous ketorolac 10 mg followed by 0.25% bupivicaine 20 ml (n = 30) at the end of surgery. There were no differences between the groups in terms of their physical characteristics or in the nature of procedure performed. There was no statistical difference between the two groups in time to first analgesia or postoperative visual analogue pain scores at 1, 2 and 4 h (p = 0.6). The median consumption of a standard analgesic was reduced in the intra-articular group in the second 24-h period but this did not achieve statistical significance (p = 0.08). Only five patients in total needed postoperative morphine. A reduced amount of locally applied ketorolac (5 mg) provides similar analgesia to a higher systemic dose (10 mg) following knee arthroscopy.

The cost-effectiveness of a cardiovascular risk reduction program in general practice.

An economic evaluation was conducted alongside a randomised controlled trial of two lifestyle interventions and a routine care (control) group to assess the cost-effectiveness of a general practice-based lifestyle change program for patients with risk factors for cardiovascular disease. Routine care was the base case comparator because it represents 'current therapy' for cardiovascular disease (CVD). A 'no care' control group was not considered a clinically acceptable alternative to lifestyle interventions. The interventions consisted of an education guide and video for GPs to assess individual patient risk factors and plan a program for risk factor behavior change. Each patient received a risk factor assessment, education materials, a series of videos to watch on lifestyle behaviors and some patients received a self-help booklet. Eighty-two general practitioners were randomised from 75 general practices in Sydney's Western Metropolitan Region to (i) routine care (n = 25), (ii) video group (n = 29) or (iii) video + self help group (n = 28). GPs enrolled patients into the trial who met selection criteria for being at risk of CVD. There were 255 patients in the routine care (control) group, 270 in the video (intervention) group and 232 in the video + self help (intervention) group enrolled in the trial. Outcome measures included patient risk factor status: blood pressure, body mass index, cholesterol and smoking status at entry to trial and after 1 year. Changes in risk factors were used to estimate quality adjusted life years (QALYs) gained. One hundred and thirty patients in the routine care group, 199 in the video group and 155 in the video + self help group remained in the trial at the 12-month review and had complete data. The cost per QALY for males ranged from $AUD152,000 to 204,000. Further analysis suggests that a program targeted at 'high risk' males would cost approximately $30,000 per QALY. The lifestyle interventions had no significant effect on cardiovascular risk factors when compared to routine patient care. There remains insufficient evidence that lifestyle programs conducted in general practices are effective. Resources for general practice-based lifestyle programs may be better spent on high risk patients who are contemplating changes in risk factor behaviours.

Calibration problems encountered while monitoring stump/socket interface pressures with force sensing resistors: techniques adopted to minimise inaccuracies.

Force sensing resistors (FSR) have been used to measure dynamic pressures at the interface between appliance and patient. Inaccuracies using FSRs have been reported. This paper summarises both the calibration problems encountered and the techniques adopted to minimise inaccuracies. It is considered that, by calibrating the transducers attached to the socket, and by adopting a strict test protocol, FSRs may provide a guide to the dynamic pressure distribution applied to the trans-tibial stump during gait.

Potential problems of manufacture and fitting of polypropylene ultralightweight below-knee prostheses.

The clinical evaluation of an ultralightweight polypropylene below-knee prosthesis conducted by the University of Strathclyde identified a number of potential problems which can arise from the use of polypropylene. This paper describes the problems associated with manufacture, loss of alignment and fitting, and indicates handling techniques to minimize these problems.