Comparing proxy rated quality of life of people living with dementia in care homes.

BACKGROUND: Improving quality of life (QOL) for people with dementia is a priority. In care homes, we often rely on proxy ratings from staff and family but we do not know if, or how, they differ in care homes. METHODS: We compared 1056 pairs of staff and family DEMQOL-Proxy ratings from 86 care homes across England. We explored factors associated with ratings quantitatively using multilevel modelling and, qualitatively, through thematic analysis of 12 staff and 12 relative interviews. RESULTS: Staff and family ratings were weakly correlated (ρs = 0.35). Median staff scores were higher than family's (104 v. 101; p < 0.001). Family were more likely than staff to rate resident QOL as 'Poor' (χ2 = 55.91, p < 0.001). Staff and family rated QOL higher when residents had fewer neuropsychiatric symptoms and severe dementia. Staff rated QOL higher in homes with lower staff:resident ratios and when staff were native English speakers. Family rated QOL higher when the resident had spent longer living in the care home and was a native English. Spouses rated residents' QOL higher than other relatives. Qualitative results suggest differences arise because staff felt good care provided high QOL but families compared the present to the past. Family judgements centre on loss and are complicated by decisions about care home placement and their understandings of dementia. CONCLUSION: Proxy reports differ systematically between staff and family. Reports are influenced by the rater:staff and family may conceptualise QOL differently.

Relationship between speaking English as a second language and agitation in people with dementia living in care homes: Results from the MARQUE (Managing Agitation and Raising Quality of life) English national care home survey.

OBJECTIVE: As not speaking English as a first language may lead to increased difficulties in communication with staff and other residents, we (1) tested our primary hypotheses that care home residents with dementia speaking English as a second language experience more agitation and overall neuropsychiatric symptoms, and (2) explored qualitatively how staff consider that residents' language, ethnicity, and culture might impact on how they manage agitation. METHODS: We interviewed staff, residents with dementia, and their family carers from 86 care homes (2014-2015) about resident's neuropsychiatric symptoms, agitation, life quality, and dementia severity. We qualitatively interviewed 25 staff. RESULTS: Seventy-one out of 1420 (5%) of care home residents with dementia interviewed spoke English as a second language. After controlling for dementia severity, age, and sex, and accounting for care home and staff proxy clustering, speaking English as a second language compared with as a first language was associated with significantly higher Cohen-Mansfield Agitation Inventory (adjusted difference in means 8.3, 95% confidence interval 4.1 to 12.5) and Neuropsychiatric inventory scores (4.1, 0.65 to 7.5). Staff narratives described how linguistic and culturally isolating being in a care home where no residents or staff share your culture or language could be for people with dementia, and how this sometimes caused or worsened agitation. CONCLUSIONS: Considering a person with dementia's need to be understood when selecting a care home and developing technology resources to enable dementia-friendly translation services could be important strategies for reducing distress of people with dementia from minority ethnic groups who live in care homes.

Relative risks of cardiovascular disease in people prescribed olanzapine, risperidone and quetiapine.

Antipsychotics may confer long term benefits and risks, including cardiovascular disease (CVD) risk. Several studies using routine clinical data have reported associations between antipsychotics and CVD but potential confounding factors and unclear classification of drug exposure limits their interpretation. METHOD: We used data from The Health Improvement Network, a large UK primary care database to determine relative risks of (CVD) comparing similar groups of people only prescribed olanzapine versus either risperidone or quetiapine. We included participants over 18 between 1995 and 2011. To assess confounding factors we created propensity scores for being prescribed each antipsychotic. We used propensity score matching and Poisson regression to calculate the CVD incidence rate ratios for olanzapine versus the other two drugs. RESULTS: We identified 18,319 people who received a single antipsychotic during follow-up (n=5090 risperidone, 7797 olanzapine and 4613 quetiapine). In unmatched analyses, the CVD incidence rate ratio (IRR) for olanzapine versus risperidone was 0.63 (0.51-0.77) but the propensity score matched IRR was 0.78 (0.61-1.02). In the unmatched olanzapine versus quetiapine analysis the IRR adjusted for age and sex for olanzapine was 1.52 (1.16-1.98) but the propensity score matched analysis gave an IRR of 1.08 (0.79-1.46). CONCLUSIONS: After propensity score matching, we found no statistical differences in CVD incidence between olanzapine and either risperidone or quetiapine. Analyses which did not account for confounding factors produced very different results. Researchers must address confounding factors when designing observational studies to assess adverse outcomes of drugs, including antipsychotics.

Comparison of non-directive counselling and cognitive behaviour therapy for patients presenting in general practice with an ICD-10 depressive episode: a randomized control trial.

BACKGROUND: Most evidence in the UK on the effectiveness of brief therapy for depression concerns cognitive behaviour therapy (CBT). In a trial published in 2000, we showed that non-directive counselling and CBT were equally effective in general practice for patients with depression and mixed anxiety and depression. Our results were criticized for including patients not meeting diagnostic criteria for a depressive disorder. In this reanalysis we aimed to compare the effectiveness of the two therapies for patients with an ICD-10 depressive episode. METHOD: Patients with an ICD-10 depressive episode or mixed anxiety and depression were randomized to counselling, CBT or usual general practitioner (GP) care. Counsellors provided nondirective, interpersonal counselling following a manual that we developed based on the work of Carl Rogers. Cognitive behaviour therapists provided CBT also guided by a manual. Modelling was carried out using generalized estimating equations with the multiply imputed datasets. Outcomes were mean scores on the Beck Depression Inventory, Brief Symptom Inventory, and Social Adjustment Scale at 4 and 12 months. RESULTS: A total of 134 participants were randomized to CBT, 126 to counselling and 67 to usual GP care. We undertook (1) an interaction analysis using all 316 patients who were assigned a diagnosis and (2) a head-to-head comparison using only those 130 (41%) participants who had an ICD-10 depressive episode at baseline. CBT and counselling were both superior to GP care at 4 months but not at 12 months. There was no difference in the effectiveness of the two psychological therapies. CONCLUSIONS: We recommend that national clinical guidelines take our findings into consideration in recommending effective alternatives to CBT.

Modelling the hierarchical structure in datasets with very small clusters: a simulation study to explore the effect of the proportion of clusters when the outcome is continuous.

In cluster-randomised trials, the problem of non-independence within clusters is well known, and appropriate statistical analysis documented. Clusters typically seen in cluster trials are large in size and few in number, whereas datasets of preterm infants incorporate clusters of size two (twins), size three (triplets) and so on, with the majority of infants being in 'clusters' of size one. In such situations, it is unclear whether adjustment for clustering is needed or even possible. In this paper, we compared analyses allowing for clustering (linear mixed model) with analyses ignoring clustering (linear regression). Through simulations based on two real datasets, we explored estimation bias in predictors of a continuous outcome in different size datasets typical of preterm samples, with varying percentages of twins. Overall, the biases for estimated coefficients were similar for linear regression and mixed models, but the standard errors were consistently much less well estimated when using a linear model. Non-convergence was rare but was observed in approximately 5% of mixed models for samples below 200 and percentage of twins 2% or less. We conclude that in datasets with small clusters, mixed models should be the method of choice irrespective of the percentage of twins. If the mixed model does not converge, a linear regression can be fitted, but standard error will be underestimated, and so type I error may be inflated.

Brief report: impact of applied behaviour analysis (ABA) on carer burden and community participation in challenging behaviour: results from a randomised controlled trial.

BACKGROUND: Applied behaviour analysis (ABA) reduces challenging behaviour in people with intellectual disability. There is interest, however, in whether such interventions reduce carer burden and increase community participation in this group. METHODS: A 6-month randomised controlled trial was followed by a longer-term naturalistic follow-up of participants. We studied the impact of the challenging behaviour on the carers and on the daily activities of the participants measured by the Carer Uplift and Burden Scale and Guernsey Community Participation and Leisure Assessment respectively. RESULTS: Both community participation and carer burden improved at 6 and 24 months. Burden showed significant reduction in family carers compared with paid carers. There was no significant intervention effect on the variables under consideration. CONCLUSIONS: ABA appears to be no more effective than standard care in improving social outcomes in people with intellectual disabilities and challenging behaviour but this requires further examination in a larger trial.

Two-stage method to remove population- and individual-level outliers from longitudinal data in a primary care database.

PURPOSE: In the UK, primary care databases include repeated measurements of health indicators at the individual level. As these databases encompass a large population, some individuals have extreme values, but some values may also be recorded incorrectly. The challenge for researchers is to distinguish between records that are due to incorrect recording and those which represent true but extreme values. This study evaluated different methods to identify outliers. METHODS: Ten percent of practices were selected at random to evaluate the recording of 513,367 height measurements. Population-level outliers were identified using boundaries defined using Health Survey for England data. Individual-level outliers were identified by fitting a random-effects model with subject-specific slopes for height measurements adjusted for age and sex. Any height measurements with a patient-level standardised residual more extreme than ±10 were identified as an outlier and excluded. The model was subsequently refitted twice after removing outliers at each stage. This method was compared with existing methods of removing outliers. RESULTS: Most outliers were identified at the population level using the boundaries defined using Health Survey for England (1550 of 1643). Once these were removed from the database, fitting the random-effects model to the remaining data successfully identified only 75 further outliers. This method was more efficient at identifying true outliers compared with existing methods. CONCLUSIONS: We propose a new, two-stage approach in identifying outliers in longitudinal data and show that it can successfully identify outliers at both population and individual level. Copyright © 2011 John Wiley & Sons, Ltd.

Non-invasive brain stimulation techniques for chronic pain. A report of a Cochrane systematic review and meta-analysis.

BACKGROUND: Non-invasive brain stimulation techniques aim to induce an electrical stimulation of the brain in an attempt to reduce chronic pain by directly altering brain activity. They include repetitive transcranial magnetic stimulation (rTMS), cranial electrotherapy stimulation (CES) and transcranial direct current stimulation (tDCS). AIM: To evaluate the efficacy of non-invasive brain stimulation techniques in chronic pain. DESIGN: A Cochrane systematic review with meta-analyses. METHODS: We employed a comprehensive search strategy. Randomised and quasi-randomised studies of rTMS, CES or tDCS were included if they employed a sham stimulation control group, recruited patients over the age of 18 with pain of three months duration or more and measured pain as a primary outcome. Where possible we entered data into meta-analyses. RESULTS: We included 33 trials in the review (19 rTMS, eight CES and six tDCS). Only one study was judged as being at low risk of bias. Studies of rTMS demonstrated significant heterogeneity. Pre-specified subgroup analyses suggest that low-frequency stimulation is ineffective. A short-term effect on pain of active high-frequency stimulation of the motor cortex in single-dose studies was suggested (standardised mean difference (SMD) -0.40, 95% confidence interval (CI) -0.26 to -0.54, P < 0.00001). This equates to a 15% (95% CI 10% to 20%) reduction in pain which does not clearly exceed the pre-established criteria for a minimally clinically important difference (> 15%). For CES (four studies, 133 participants) no statistically significant difference was found between active stimulation and sham. Analysis of tDCS studies (five studies, 83 people) demonstrated significant heterogeneity and did not find a significant difference between active and sham stimulation. Pre-specified subgroup analysis of tDCS applied to the motor cortex suggested superiority of active stimulation over sham (SMD -0.59, 95% CI -1.10 to -0.08). Non-invasive brain stimulation appears to be associated with minor and transient side effects. CONCLUSION: Single doses of high-frequency rTMS of the motor cortex may have small short-term effects on chronic pain. The effects do not clearly exceed the predetermined threshold of minimal clinical significance. Low-frequency rTMS is not effective in the treatment of chronic pain. There is insufficient evidence from which to draw firm conclusions regarding the efficacy of CES or tDCS. The available evidence suggests that tDCS applied to the motor cortex may have short-term effects on chronic pain and that CES may be ineffective. There is a need for further, rigorously designed studies of all types of stimulation.

Randomised trial of high frequency oscillatory ventilation or conventional ventilation in babies of gestational age 28 weeks or less: respiratory and neurological outcomes at 2 years.

BACKGROUND: The long term outcome of children entered into neonatal trials of high frequency oscillatory ventilation (HFOV) or conventional ventilation (CV) has been rarely studied. OBJECTIVE: To evaluate respiratory and neurodevelopmental outcomes for children entered into the United Kingdom Oscillation Study, which was designed to evaluate these outcomes. METHODS: Surviving infants were followed until 2 years of age corrected for prematurity. Study forms were completed by local paediatricians at routine assessments, and parents were asked to complete a validated neurodevelopmental questionnaire. RESULTS: Paediatricians' forms were returned for 73% of the 585 surviving infants. Respiratory symptoms were common in all infants, and 41% had received inhaled medication. Mode of ventilation had no effect on frequency of any symptoms. At 24 months of age, severe neurodevelopmental disability was present in 9% and other disabilities in 38% of children, but the prevalence of disability was similar in children who received HFOV or CV (relative risk 0.93; 95% confidence interval 0.74 to 1.16). The prevalence of disability did not vary by gestational age, but boys were more likely to have overall disability. Developmental scores were unaffected by mode of ventilation (relative risk 1.13; 95% confidence interval 0.78 to 1.63) and were lower in infants born before 26 weeks gestation compared with babies born at 26-28 weeks. CONCLUSIONS: Initial mode of ventilation in very preterm infants has no impact on respiratory or neurodevelopmental morbidity at 2 years. HFOV and CV appear equally effective for the early treatment of respiratory distress syndrome.

Respiratory function of very prematurely born infants at follow up: influence of sex.

OBJECTIVE: To test the hypothesis that male compared with female prematurely born infants would have worse lung function at follow up. DESIGN: Prospective follow up study. SETTING: Tertiary neonatal intensive care units PATIENTS: Seventy six infants, mean (SD) gestational age 26.4 (1.5) weeks, from the United Kingdom oscillation study. INTERVENTIONS: Lung function measurements at a corrected age of 1 year. MAIN OUTCOME MEASURES: Airways resistance (Raw) and functional residual capacity (FRC(pleth)) measured by whole body plethysmography, specific conductance (sGaw) calculated from Raw and FRC(pleth), and FRC measured by a helium gas dilution technique (FRC(He)). RESULTS: The 42 male infants differed significantly from the 34 female infants in having a lower birth weight for gestation, requiring more days of ventilation, and a greater proportion being oxygen dependent at 36 weeks postmenstrual age and discharge. Furthermore, mean Raw and FRC(pleth) were significantly higher and mean sGaw significantly lower. After adjustment for birth and current size differences, the sex differences in FRC(pleth) and sGaw were 15% and 26% respectively and remained significant. CONCLUSION: Lung function at follow up of prematurely born infants is influenced by sex.

Risk factors for respiratory morbidity in infancy after very premature birth.

OBJECTIVES: To determine the occurrence of respiratory morbidity during infancy after very premature birth and to identify risk factors. DESIGN: Prospective follow up study. SETTING: The United Kingdom oscillation study. PATIENTS: 492 infants, all born before 29 weeks gestation. INTERVENTIONS: Structured questionnaires were completed by local paediatricians when the infants were seen in outpatients at 6 and 12 months of age corrected for prematurity. MAIN OUTCOME MEASURES: Cough, wheeze, and treatment requirements and the composite measure of respiratory morbidity (cough, frequent cough, cough without infection, wheeze, frequent wheeze, wheeze without infection, and use of chest medicine) and their relation to 13 possible explanatory variables. RESULTS: At 6 and 12 months of corrected age, 27% of the infants coughed and 6% had frequent (more than once a week) cough, and 20% and 3% respectively had wheeze or frequent wheeze. At 6 and 12 months, 14% of infants had taken bronchodilators and 8% inhaled steroids. After adjustment for multiple outcome testing, four factors were associated with increased respiratory morbidity: male sex, oxygen dependency at 36 weeks postmenstrual age, having older siblings aged less than 5 years, and living in rented accommodation. CONCLUSIONS: Male infants are particularly vulnerable to respiratory morbidity in infancy after very premature birth. It is important to identify a safe and effective strategy to prevent chronic oxygen dependency.

Outcome of women with inadequate cervical smears followed up for five years.

BACKGROUND: The clinical and prognostic significance of "inadequate" cervical smear is unknown, even though women with repeated inadequate smears are referred for colposcopy in the National Health Service (NHS) Cervical Screening Programme. AIM: To follow up a cohort of women with inadequate cervical smears over the following five years to examine outcomes, including detection of high grade cervical intraepithelial neoplasia (CIN). METHODS: The study comprised 1972 women with an inadequate cervical smear reported at Walsall Hospitals NHS Trust between 1 April 1995 and 31 March 1996. Results of cervical smears and biopsies taken over the following five years were reviewed to confirm the outcome. FINDINGS: Within five years, 2.2% of women with an inadequate cervical smear developed histologically confirmed high grade CIN, which was higher than the 1.3% seen among all women with cervical smear tests reported at the same laboratory over the same period, although the difference was not significant at the 95% level of confidence. Where inadequacy resulted from or was contributed to by "polymorphs obscuring", the risk of subsequent development/detection of high grade CIN was 2.6%. CONCLUSIONS: Women with inadequate cervical smears had an increased risk of detection of high grade CIN in the following five years compared with "all women". This increased risk was not significant, although if a larger number of women had been studied significance may have been reached, so that further studies are needed. The increased risk appeared to be at least partially dependent on the reason for inadequacy.

Particulate air pollution and hospital admissions for cardiorespiratory diseases: are the elderly at greater risk?

A systematic literature review suggests that particulate air pollution is associated with daily admissions for both respiratory and cardiac diseases in people aged > 65 yrs. A model of acute effects is proposed which shows how admissions can be brought forward by a relatively short period of time as well as events being added that would not have happened at all except for air pollution. A model of the effects of air pollution on chronic disease is proposed that provides the background of long-term vulnerability upon which the increased short-term vulnerability is superimposed. A study of daily hospital admissions in London shows that for respiratory disease the relative risks of admission associated with particles reduce with increasing age, while for cardiac disease, there is no trend. When the attributable risk is estimated using baseline admission rates for respiratory disease, it is children who have the highest attributable risk, followed by the elderly. For cardiac disease there is a steep increase in attributable risk with age, reflecting the dominant influence of baseline risks. The attributable risk for cardiovascular disease in the elderly is considerably greater than for respiratory disease, due to higher baseline admission rates.

Molecular epidemiology of tuberculosis in London 1995-7 showing low rate of active transmission.

BACKGROUND: Tuberculosis notification rates for London have risen dramatically in recent years. Molecular typing of Mycobacterium tuberculosis has contributed to our understanding of the epidemiology of tuberculosis throughout the world. This study aimed to assess the degree of recent transmission of M tuberculosis in London and subpopulations of the community with high rates of recent transmission. METHODS: M tuberculosis isolates from all persons from Greater London diagnosed with culture positive tuberculosis between 1 July 1995 and 31 December 1997 were genetically fingerprinted using IS6110 restriction fragment length polymorphism (RFLP) typing. A structured proforma was used during record review of cases of culture confirmed tuberculosis. Cluster analysis was performed and risk factors for clustering were examined in a univariate analysis followed by a logistic regression analysis with membership of a cluster as the outcome variable. RESULTS: RFLP patterns were obtained for 2042 isolates with more than four copies of IS6110; 463 (22.7%) belonged to 169 molecular clusters, which ranged in size from two (65% of clusters) to 12 persons. The estimated rate of recent transmission was 14.4%. Young age (0-19 years) (odds ratio (OR) 2.65, 95% confidence interval (CI) 1.59 to 4.44), birth in the UK (OR 1.55, 95% CI 1.04 to 2.03), black Caribbean ethnic group (OR 2.19, 95% CI 1.15 to 4.16), alcohol dependence (OR 2.33, 95% CI 1.46 to 3.72), and streptomycin resistance (OR 1.82, 95% CI 1.15 to 2.88) were independently associated with an increased risk of clustering. CONCLUSIONS: Tuberculosis in London is largely caused by reactivation or importation of infection by recent immigrants. Newly acquired infection is also common among people with recognised risk factors. Preventative interventions and early diagnosis of immigrants from areas with a high incidence of tuberculosis, together with thorough contact tracing and monitoring of treatment outcome among all cases of tuberculosis (especially in groups at higher risk of recent infection), remains most important.

Methotrexate and angiographic embolization for conservative treatment of cervical pregnancy.

Cervical pregnancy has traditionally been treated by hysterectomy. Recent reports of the use of methotrexate have been encouraging as a potential conservative approach. We present a case of a cervical pregnancy diagnosed at 8 weeks' gestation in a woman who greatly desired fertility. She was treated successfully with a combination of multidose intramuscular methotrexate (1 mg/kg/day) and citrovorum rescue. When profuse bleeding developed on day 8, angiographic embolization was used to obviate surgery. The beta-hCG titer peaked at 58,362 IU/mL and was undetectable by postchemotherapy day 30. No blood transfusion was required, and reproductive capacity was spared. Four months after the cervical pregnancy, the patient became pregnant and had a healthy infant. Medical management of cervical pregnancy is an option when reproductive capacity is desired in selected patients with appropriate counseling.

Maps and keys--world involuntary migration.

PIP: This article charts world involuntary migration movements from 1500-1900 and from 1900-1980, using maps. The African slave trade to North and South America, the Caribbean, Europe, the Middle East, and the Persian Gulf dominated international involuntary migration from 1500 until 1900 when it was both legally abolished and largely although not entirely suppressed. An estimated 9-10 million Africans were taken as slaves to the Americas and Europe during this period and an estimated 1.4 million to the Middle East and the Persian Gulf. The extent and duration of this migration was far greater than the many involuntary migrations within and between societies on any single continent. The 2nd map refers to all forms of involuntary migration across national boundaries from 1900-1980, primarily refugees. The tentative and approximate total for the 1st 4 decades of the 20th century 15 nearly 70 million persons who have involuntarily left one country for another whether during times of war or lesser conflicts. The total number of international refugees since 1900 probably exceeds the total number of involuntary international migrants in all previous recorded human history.^ieng

Effect of cigarette smoking on tympanic membrane admittance characteristics.

The effect of cigarette smoking on the admittance characteristics at the plane of the tympanic membrane was investigated using 40 young adults evenly divided into two groups, smokers and nonsmokers. Otoadmittance measurements, which included conductance, susceptance, admittance and phase angle, were administered for all subjects. Otoadmittance values, expressed in mmhos, were computed for both 220 and 660 Hz probe tone frequencies. Statistical analysis revealed no significant difference and no significant interaction between smokers and nonsmokers for measures of susceptance, conductance admittance, or phase angle. These findings indicate that the condition of smoking has no significant effect on the admittance characteristics at the plane of the tympanic membrane. As expected, a significant frequency difference was found between 220 and 660 Hz probe tones in measurements of conductance, admittance, and phase angle.

Changes in number and type of errors on repetition of acoustically distorted sentences as a function of age in normal children.

The intelligibility of recorded sentences, distorted by binaural switching, interruption, and low-pass filtering, was investigated in 53 children ranging in age from five to eleven and in adults. All had normal hearing. The sentence vocabulary was pretested for comprehension, articulation errors were evaluated in a way so as not to influence test results, and length and structure of the sentences were controlled. The results indicated that although the performance of children increased with age, the 11-year-old group had not attained adult performance. Error analyses showed that most errors for all age groups were acoustically unrelated to the distorted message, although adults made more acoustically related errors than did children. When children made errors in sentences, other errors (e.g., substitutions) were made to preserve the syntax or semantic integrity of the message.

Anticipatory middle-ear reflex activity from noisy toys.

Middle-ear reflex activity was measured in 14 listeners in response to visual and acoustic exposure to each of seven noisy toys (such as a cap gun, party horn, cow bell, and so forth). Anticipatory middle-ear reflex (AMER) activity was a common occurrence. Normal middle-ear reflex generally occurred after the sound exposure. AMERs generally occurred in the two seconds prior to sound exposure but as early as 10 seconds before sound exposure. Loudness ratings and exposure SPLs were obtained. The presence of acoustically evoked middle-ear (ME) reflex activity and AMERs to the toys was generally unrelated to SPL or reflex threshold. Many reflex responses occurred in response to exposure SPLs below reflex threshold and with low anticipated loudness rating.