Distant delivery of a mindfulness-based intervention for people with Parkinson's disease: the study protocol of a randomised pilot trial.

BACKGROUND: Psychological difficulties, especially depression and anxiety, are the most prevalent non-motor symptoms in Parkinson's disease. Pharmacological treatments for these conditions appear relatively ineffective in Parkinson's disease. Mindfulness courses are increasingly popular and recognised as effective for managing emotional states, and there is growing evidence for the effectiveness of mindfulness courses for people with long-term medical conditions. With this exploratory pilot trial, we want to assess the feasibility of the procedures and processes, including recruitment, most appropriate outcome measure(s), acceptability of type and number of measures, potential nocebo effects, and potential effectiveness and cost-effectiveness of a specially adapted distance-delivered mindfulness-based intervention in people affected by Parkinson's disease. METHODS/DESIGN: This is a pilot two-arm randomised parallel group controlled trial. Sixty participants who meet eligibility criteria will be randomly assigned either to an 8-week mindfulness-based intervention group or a wait-list control group. The mindfulness intervention will include 1-h weekly sessions delivered by a health psychologist trained to facilitate mindfulness courses. Participants in both groups will complete standardised questionnaires assessing anxiety, depression, pain, insomnia, fatigue, and daily activities at four time points (baseline, 4, 8, and 20 weeks). The analysis will also consider potential mechanisms of change, such as acceptance, self-compassion, and tolerance of uncertainty, as well as health economic outcomes. Participants' experiences of the mindfulness interventions will be explored via in-depth interviews. DISCUSSION: A mindfulness-based intervention for people with Parkinson's delivered remotely, through Skype group videoconferences, may represent a viable, more accessible, intervention for people with mobility limitations and people who live in rural areas. The trial will provide important information about the feasibility, potential efficacy and cost-effectiveness, and acceptability of the intervention as well as mechanisms of psychosocial adjustment. The results of this pilot trial will help us design a phase III trial to assess efficacy of an online mindfulness-based intervention in Parkinson's disease and evaluate significance. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02683330.

Anxiety and anxious-depression in Parkinson's disease over a 4-year period: a latent transition analysis.

BACKGROUND: Depression and anxiety in Parkinson's disease are common and frequently co-morbid, with significant impact on health outcome. Nevertheless, management is complex and often suboptimal. The existence of clinical subtypes would support stratified approaches in both research and treatment. METHOD: Five hundred and thirteen patients with Parkinson's disease were assessed annually for up to 4 years. Latent transition analysis (LTA) was used to identify classes that may conform to clinically meaningful subgroups, transitions between those classes over time, and baseline clinical and demographic features that predict common trajectories. RESULTS: In total, 64.1% of the sample remained in the study at year 4. LTA identified four classes, a 'Psychologically healthy' class (approximately 50%), and three classes associated with psychological distress: one with moderate anxiety alone (approximately 20%), and two with moderate levels of depression plus moderate or severe anxiety. Class membership tended to be stable across years, with only about 15% of individuals transitioning between the healthy class and one of the distress classes. Stable distress was predicted by higher baseline depression and psychiatric history and younger age of onset of Parkinson's disease. Those with younger age of onset were also more likely to become distressed over the course of the study. CONCLUSIONS: Psychopathology was characterized by relatively stable anxiety or anxious-depression over the 4-year period. Anxiety, with or without depression, appears to be the prominent psychopathological phenotype in Parkinson's disease suggesting a pressing need to understanding its mechanisms and improve management.

Frequency, prevalence, incidence and risk factors associated with visual hallucinations in a sample of patients with Parkinson's disease: a longitudinal 4-year study.

OBJECTIVE: To examine the prevalence, incidence and risk factors associated with visual hallucinations (VHs) amongst people suffering from Parkinson's disease (PD). METHODS: We recruited 513 patients with PD from movement disorder and PD clinics within three sites in the UK. Patients were interviewed using a series of standardised clinical rating scales at baseline, 12, 24 and 36 months. Data relating to VHs were collected using the North-East Visual Hallucinations Interview. Prevalence rates for VHs at each assessment were recorded. Associations were determined using multiple regression analysis. RESULTS: Cross-sectional prevalence rates for VHs at baseline, 12, 24 and 36 months indicated VHs in approximately 50% of patients. A cumulative frequency of 82.7% of cases at the end of the study period exhibited VHs. The incidence rate for VHs was 457 cases per 1000 population. Longer disease duration, greater impairment in activities of daily living and higher rates of anxiety were most commonly associated with VHs. No factors predictive of VHs could be ascertained. CONCLUSIONS: When examined longitudinally, VHs affect more patients than is commonly assumed in cross-sectional prevalence studies. Clinicians should routinely screen for VHs throughout the disease course. Disease duration, impairment in activities of daily living and anxiety presented as co-morbidities associated with VHs in PD, and therefore those presenting with VHs should be screened for anxiety disorder and vice versa.

Coping in Parkinson's disease: an examination of the coping inventory for stressful situations.

BACKGROUND: Parkinson's disease (PD) brings with it a range of stresses and challenges with which a patient must cope. The type of coping strategies employed can impact upon well-being, although findings from coping studies in PD remain inconsistent. The variety of coping scales used without validation in PD has been cited as a possible cause of this inconsistency. The present study sought to examine the validity of the coping inventory for stressful situations (CISS) in a sample of patients with PD. METHODS: Five hundred and twenty-five patients with PD were recruited as part of a longitudinal investigation of mood states in PD. Four hundred and seventy-one participants completed the CISS. Confirmatory factor analysis was used to explore the structural validity of the scale. Internal reliability, test-retest reliability, convergent validity and discriminant validity were assessed using Cronbach's alpha, intraclass correlations and Pearson's correlations. RESULTS: Both three and four factor solutions were examined. The four factor model was found to provide a better fit of the data than the three factor model. The internal reliability, discriminant validity, convergent validity, and test-retest reliability of the CISS scales were shown to be good. Use of emotion-focused coping was associated with greater depression and anxiety whilst, task-oriented coping was associated with better psychological well-being. CONCLUSION: The results provide support for the validity and reliability of the CISS as a measure of coping in patients with PD. Further research into the relationship between coping and well-being is warranted. The identification of helpful and unhelpful coping strategies may guide the development of evidence-based therapies to improve well-being in patients with PD.

Ataxia caused by amiodarone in older people.

Amiodarone is recommended for the cardioversion of atrial fibrillation and prevention of paroxysmal atrial fibrillation in patients with structural heart disease, coronary artery disease or left ventricular dysfunction. It has well-recognised side-effects on the skin, lungs, liver, thyroid and eyes. Neurological side-effects, including ataxia and neuropathy, also occur, and may be more prevalent in older patients. These side-effects are reversible after cessation of amiodarone. Monitoring of amiodarone therapy should include assessment of the central and peripheral nervous system especially in older patients.

The use of articulators in UK dental schools.

The increasing complexity of many restorative procedures often involves articulation of study and working casts to ensure accurate fabrication of restorations. Correct selection and use of articulators can be crucial to successful restoration. The aim of this paper is to determine which articulators are recommended for various restorative procedures in UK dental schools, for use by undergraduate students. A questionnaire-based study of all UK dental schools was carried out, with a 100% response rate. Recommended articulator application for specified procedures was established from the literature and questionnaire results were compared with this. The results indicated that dental schools in the UK generally teach appropriate articulator use for most procedures. However, there are some limited areas of what may be argued to be inappropriate recommendation in some establishments.

Effects of lesions of the human posterior thalamus on ocular fixation during voluntary and visually triggered saccades.

OBJECTIVE: To investigate the role of the posterior thalamus in controlling voluntary and visually triggered eye movements and ocular fixation. METHODS: The latency to initiate saccades to peripheral targets (visually triggered) and in response to verbal commands (voluntary) was measured in three patients with unilateral lesions of the posterior thalamus, in normal controls, and in neurological controls with Parkinson's disease. On half the trials a fixation point offset simultaneously with target onset, and on half it remained visible. RESULTS: Offset of the fixation point simultaneous with target onset decreased saccade latency for both voluntary and visually triggered eye movements in controls, but only for voluntary saccades in patients with thalamic lesions. CONCLUSIONS: These findings suggest that separate neural systems control fixation when making voluntary and visually triggered eye movements, and that the thalamus is involved in the control of fixation for visually triggered but not for voluntary saccades.

Links between vision and somatosensation. Vision can improve the felt position of the unseen hand.

During reaching movements, sensory signals must be transformed into appropriate motor commands. Anatomical, electrophysiological, and neuropsychological evidence suggest that there is no single, supramodal map of space that is used to guide reaching. Instead, movements appear to be planned and controlled within multiple coordinate systems, each one attached to a different body part. Recent neuropsychological investigations demonstrating that somatosensory impairments can be ameliorated by visual cues, and visual impairments by proprioceptive cues, have been interpreted as evidence that arm-centered representations may exist in humans. A critical difference between the findings obtained in the monkey and in humans, however, is that in the latter case, vision of the limb appears be critical for visual somatosensory binding. Here, we report a case study of a patient (C.T.) recovering from unilateral somatosensory impairment, including tactile extinction, who executed reaches toward visually defined or proprioceptively defined locations. We demonstrate that when the target location of a reach was defined proprioceptively, by passively positioning our patient's impaired hand beneath the table surface, vision of the workspace immediately adjacent to the unseen hand dramatically increased the endpoint accuracy of her reaching movements, even though such cues could not possibly signal the position of the target directly.

The control of bimanual reach-to-grasp movements in hemiparkinsonian patients.

The basal ganglia are thought to participate in the control and programming of a variety of motor behaviours. However, the precise nature of this participation still remains to be clarified. This paper examines the proposal that the basal ganglia may serve to scale the amplitude of limb movements, with basal-ganglia dysfunction leading to the inappropriate scaling of intended motor activity. Several authors have suggested that examining the loss of function in Parkinson's-disease (PD) patients offers perhaps the best way of learning about the role played by the basal ganglia in human motor function. While it has previously been reported that PD patients underscale the transport phase of their reach-to grasp movements, it has generally been assumed that the grasp component is normal. In this paper we demonstrate, using a group of hemiparkinson patients, that the scaling of the grasp component is also underscaled in PD patients.

Reaching movements may reveal the distorted topography of spatial representations after neglect.

It has been proposed that patients with spatial neglect fail to respond appropriately toward stimuli opposite their brain lesion because they have an impairment of directing attention. However, a disorder of 'intention' - or movement initiation - has also been demonstrated in this condition. Recently, the paths of neglect patients' reaches have been shown to be abnormally curved, but it is unclear whether this impairment is visual or motor. Here, we show for the first time that reaches to and from identical positions executed by three patients recovering from neglect are significantly more curved to visually defined targets compared to when the same targets are defined proprioceptively. These findings indicate that abnormal hand paths in neglect result from an impairment in the visual representation of space used to guide reaches but without any general failure of spatial representation of target position. Furthermore, the curved hand paths reveal how the topography of that representation is distorted in spatial neglect.

Tooth colour analysis by a new optoelectronic system.

The difficulties in assessing and comparing tooth shades are well documented. This pilot study introduces an alternative method of photoelectric tooth colour measurement, the silicon photodiode array apparatus. This apparatus was used to determine colorimetric values for samples of acrylic resin teeth and the results compared with colour values obtained using a conventional photoelectric tristimulus colorimeter. Whilst a significant difference was found between some colorimetric data produced by the two types of apparatus for the same sample these differences existed purely at the mathematical level and would not be perceived by a human observer.

Measurement of vertebral rotation in adolescent idiopathic scoliosis using three-dimensional magnetic resonance imaging.

STUDY DESIGN: This report examines a technique for measurement of axial vertebral rotation using magnetic resonance imaging. OBJECTIVES: To assess the reproducibility of three-dimensional magnetic resonance imaging in the measurement of vertebral rotation at individual endplates in patients with adolescent idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: Deformity in the sagittal and coronal planes in patients with adolescent idiopathic scoliosis can be readily assessed from plain radiographs, but the degree of deformity in the axial plane is more difficult to determine. Plain film techniques have inherent inaccuracies because of loss of definition of anatomic landmarks, and the use of computed tomography is limited by the high radiation dose associated. Magnetic resonance imaging provides a means of imaging scoliotic deformity that allows multiplanar reconstruction and that involves no use of ionizing radiation. METHODS: Ten patients with adolescent idiopathic scoliosis were imaged in a Siemens 1-Tesla impact scanner. Three-dimensional volume images of the apical five vertebrae were obtained in the axial plane and were postprocessed through multiplanar reconstruction. Sections through the superior and inferior endplates of each vertebra were selected in the sagittal and coronal planes, allowing axial reconstructions to be obtained in the plane of each endplate. Vertebral rotation was measured by identifying datum points on the inner surfaces and at the junction of the laminas and comparing the angle subtended by these points with a vertical drawn by the computer. Measurements were obtained from the single scanning sequence on two occasions by one observer and on one occasion by a second observer. Interobserver and intraobserver error was evaluated and correlation with readings obtained from plain films using Perdriolle's torsiometer method assessed. RESULTS: The interobserver variation had a mean of 3.02 degrees (range, 0-10 degrees) and a 95% confidence interval of [2.51 degrees, 3.53 degrees]. The intraobserver variation had a mean of 2.56 degrees (range, 0-7 degrees) and a 95% confidence interval of [1.83 degrees, 3.29 degrees]. The mean difference between measurements obtained from magnetic resonance imaging and plain film was 3.29 degrees (range, 0-12 degrees) with a 95% confidence interval of [1.43 degrees, 5.15 degrees]. CONCLUSIONS: The degree of vertebral rotation can be accurately and reproducibly assessed by three-dimensional magnetic resonance imaging. Measurements can be made through individual endplates that allow assessment of the relative amount of intervertebral and intravertebral deformity.

Understanding business processes.

Presents a background to process understanding which offers potential benefits to the NHS. Considers the various business processes found in health care organizations, noting that the management of cross-functional processes is an area in which improvements can be made. Outlines the kind of problems which can result from mismanagement of such processes and the potential benefits of process improvement.

Process improvement and information management.

Notes the importance of continuous improvement as a concept to guide management and that this concept requires numerous components to make it work. Picks out the role of information management as a key area, citing factors such as the creation of an "information culture" as being of major importance. Looks at the path followed by some Trusts in pursuit of this "information culture" wherein staff gained an improved insight into the use of information as a management tool.

Evaluation of gastric antral motor performance in patients with dysmotility-like dyspepsia using real-time high-resolution ultrasound.

Although manometric antral hypomotility and delayed gastric emptying have been reported separately in patients with dyspepsia, relationships between symptoms, antral contractility and emptying rate have not been sought. The present study therefore aimed to evaluate, simultaneously, gastric antral excursion characteristics and emptying in a sub-group of patients with severe functional dyspepsia using high-resolution real-time ultrasound. The circumference of the relaxed and contracted antrum was measured at 15-min intervals after ingestion of a 360 mL mixed nutrient meal in 36 chronic dyspepsia patients with symptoms of post-prandial bloating and epigastric distension, and in 25 healthy volunteers. Antral emptying (measured as the rate of decrease in circumference of the relaxed antrum) was slower in patients than normals (P = 0.02). In both groups, the average values for antral excursion were similar but the range of excursion in patients was significantly wider than in controls (F < 0.001), with 11 patients showing values above, and 8 showing values below the normal range. There was no relationship between antral emptying and antral excursion in either patients or volunteers. In conclusion, patients with severe functional dyspepsia show a wide range of antral performance characteristics, suggesting not only that the mechanisms responsible for the control of antral motor function are disturbed but also that the cause of the symptoms and the disturbed antral motor function are probably not directly related.

Evaluation of human postprandial antral motor function using ultrasound.

We used high-resolution ultrasound to characterize postprandial antral excursion characteristics in 15 healthy volunteers. Antral circumference was repeatedly measured in the sagittal plane anterior to the abdominal aorta, at 15-min intervals following ingestion of a standard meal. At each recording period, the maximal and minimal antral circumference was noted. In seven volunteers, antral circumference was studied continuously for 5 min at each 15-min recording period to assess the frequency and regularity of antral excursions. Antral circumference increased immediately after meal ingestion from preprandial values of 64 +/- 2.6 (means +/- SE) to 138 +/- 3.1 mm and then gradually decreased with meal emptying to 72 +/- 2.6 mm at 90 min. The continuous recordings of antral images revealed that antral circumference transiently decreased at regular intervals; the interval between successive excursions was 20.1 +/- 0.2 s. There was no change in the excursion interval with emptying. The excursion amplitude decreased from 33 +/- 3.9 mm immediately post-meal ingestion to 13 +/- 1.5 mm at 90 min (r2 = 0.62 +/- 0.07). The ratio between the excursion amplitude and circumference of the relaxed antrum changed only slightly with time (slope = 0.0009 +/- 0.00003). Comparison of repeat studies in 10 volunteers showed a low intra-individual variation for postprandial antral circumference and excursion amplitude.

Measurement of urinary oestrogens and 20 alpha-dihydroprogesterone during ovarian cycles of black (Diceros bicornis) and white (Ceratotherium simum) rhinoceroses.

The development of a sensitive enzyme-immunoassay for 20 alpha-dihydroprogesterone (20 alpha-DHP) and its use in determining reproductive status in black and white rhinoceroses is reported. 20 alpha-DHP in hydrolysed urine diluted in parallel to standards, and high-performance liquid chromatography (HPLC) confirmed the presence of 20 alpha-DHP and the absence of pregnanediol-3 alpha-glucuronide (PdG) in urine collected from rhinoceroses after oestrus. Conjugated oestrone was identified by HPLC as the major urinary oestrogen in the black rhineroceros and conjugated oestradiol-17 beta was the most abundant in the white rhinoceros. In African species, the black (Diceros bicornis), and northern (Ceratotherium simum cottoni) and southern (Ceratotherium simum simum) white rhinoceroses, excretion of 20 alpha-DHP and oestrogen followed a cyclic pattern. Excretion of 20 alpha-DHP was low before mating, at the time of peak oestrogen excretion, but high after oestrus. In the black rhinoceros, the follicular phase was 3-4 days and the luteal phase was 18 days, suggesting a cycle of 21-22 days. The interoestrus interval in the northern subspecies of white rhinoceros was 25 days, which correlated well with the interval between peaks of oestradiol-17 beta excretion. The interval between urinary oestrogen peaks in the southern subspecies of white rhinoceros suggested a cycle length of 32 days. This paper provides the first description of the pattern of excretion of urinary oestrogens and progesterone metabolites in African rhinoceroses.