Evaluation of hip precautions following total hip replacement: a before and after study.

PURPOSE: To evaluate the effect of hip precautions following total hip replacement (THR) by comparing outcomes of patients who received hip precautions with those who did not. METHODS: Before (phase 1) and after (phase 2) study with two consecutive cohorts of patients. In phase 1, patients were strictly educated about hip precautions. In phase 2, patients were not advised about precautions but encouraged to move as able. The primary outcome was the Oxford Hip Score (measuring pain and function) at three months. Secondary outcomes included Oxford Hip Score, activities of daily living (ADLs) (Nottingham Extended Activities of Daily Living), sleep (Pittsburgh Sleep Quality Index), mood (Hospital Anxiety and Depression Scale), and quality of life (QoL) (EQ-5 D). RESULTS: A total 237 participants successfully underwent THR surgery, 118 participants in phase 1 and 119 in phase 2. At three months postoperatively, participants had significantly equivalent Oxford Hip Scores (MD= -0.82, 95% CI: -2.64 to 1.00). No significant differences between the groups were observed at six weeks and three months postoperatively for secondary outcomes. CONCLUSIONS: Patients recovered at a similar rate regardless of whether they received hip precautions or not, with no increase in complications observed. The findings lend evidence to support decision-making around the removal of precautions.Implications for rehabilitationThe use of no hip precautions resulted in no additional benefit following primary total hip replacement surgery in terms of functional recovery.Patients who were not prescribed precautions had significantly less pain and greater function during the first week after surgery.Total hip replacement patients had similar outcomes at six weeks and three months postoperatively regardless of whether they received hip precautions or not.The study provides evidence to suggest that hip precautions may not be needed routinely following elective primary total hip replacement.

Hip precautions after total hip replacement and their discontinuation from practice: patient perceptions and experiences.

BACKGROUND: Hip precautions are routinely provided to reduce the risk of dislocation following total hip replacement despite evidence suggesting they provide no additional benefit and may, actually, impede recovery. Our aim was to report the views of patients who had been recruited into a trial comparing outcomes in participants who were prescribed hip precautions with those who were not. METHODS: Semi-structured interviews were conducted. Topics explored included experiences and opinions of the service (either hip precautions or no hip precautions), information offered, and equipment provided. Thematic analysis was used to identify and report themes. RESULTS: Six themes were identified: perceived justification, and advantages and disadvantages for the postoperative recovery regime prescribed, perceived risk, and fear of dislocation, adherence to the postoperative regime prescribed, and experiences of adaptive equipment. CONCLUSIONS: Participants who received hip precautions had mixed views about their use: some felt they were restrictive whilst others believed they provided reassurance. Participants who did not receive hip precautions were less anxious about dislocating their hip but were unsure how to progress their rehabilitation. The discontinuation of precautions may decrease patients' fears about dislocation but more guidance from rehabilitation staff about how to move safely during recovery is required.Implications for rehabilitationHip precautions may unnecessarily exacerbate patients' anxieties and fear about dislocation following total hip replacement.Hip precautions impact on patients' recovery both physically and psychologically.Patients should be advised about moving and returning to activities following total hip replacement, whether they receive hip precautions or not.

OpenMATB: A Multi-Attribute Task Battery promoting task customization, software extensibility and experiment replicability.

OpenMATB is an open-source variant of the Multi-Attribute Task Battery (MATB) and is available under a free software license. MATB consists of a set of tasks representative of those performed in aircraft piloting. It is used, in particular, to study the effect of automation on decision-making, mental workload, and vigilance. Since the publication of MATB 20 years ago, the subject of automation has grown considerably in importance. After introducing the task battery, this article highlights three main requirements for an up-to-date implementation of MATB. First, there is a need for task customization, to make it possible to change the values, appearance or integrated components (such as rating scales) of the tasks. Second, researchers need software extensibility to enable them to integrate specific features, such as synchronization with psychophysiological devices. Third, to achieve experiment replicability, it is necessary that the source code and the scenario files are easily available and auditable. In the present paper, we explain how these aspects are implemented in OpenMATB by presenting the software architecture and features, while placing special emphasis on the crucial role of the plugin system and the simplicity of the format used in the script files. Finally, we present a number of general trends for the future study of automation in human factors research and ergonomics.

Behavioural Activation Therapy for Depression after Stroke (BEADS): a study protocol for a feasibility randomised controlled pilot trial of a psychological intervention for post-stroke depression.

BACKGROUND: There is currently insufficient evidence for the clinical and cost-effectiveness of psychological therapies for treating post-stroke depression. METHODS/DESIGN: BEADS is a parallel group feasibility multicentre randomised controlled trial with nested qualitative research and economic evaluation. The aim is to evaluate the feasibility of undertaking a full trial comparing behavioural activation (BA) to usual stroke care for 4 months for patients with post-stroke depression. We aim to recruit 72 patients with post-stroke depression over 12 months at three centres, with patients identified from the National Health Service (NHS) community and acute services and from the voluntary sector. They will be randomly allocated to receive behavioural activation in addition to usual care or usual care alone. Outcomes will be measured at 6 months after randomisation for both participants and their carers, to determine their effectiveness. The primary clinical outcome measure for the full trial will be the Patient Health Questionnaire-9 (PHQ-9). Rates of consent, recruitment and follow-up by centre and randomised group will be reported. The acceptability of the intervention to patients, their carers and therapists will also be assessed using qualitative interviews. The economic evaluation will be undertaken from the National Health Service and personal social service perspective, with a supplementary analysis from the societal perspective. A value of information analysis will be completed to identify the areas in which future research will be most valuable. DISCUSSION: The feasibility outcomes from this trial will provide the data needed to inform the design of a definitive multicentre randomised controlled trial evaluating the clinical and cost-effectiveness of behavioural activation for treating post-stroke depression. TRIAL REGISTRATION: Current controlled trials ISRCTN12715175.

Occupational Therapy in HomEcare Re-ablement Services (OTHERS): results of a feasibility randomised controlled trial.

OBJECTIVES: The objective of this study was to test the feasibility of conducting a randomised controlled trial (RCT) of an intervention targeted at activities of daily living (ADL), delivered by an occupational therapist, in homecare reablement. DESIGN: Feasibility parallel group RCT. SETTING: Single-site local authority homecare reablement service. PARTICIPANTS: People referred for homecare reablement with ability to consent. Exclusion criteria were as follows: inability to speak English, receiving other community therapy services, needing two or more to assist transfer and receiving end-of-life care. CONTROL: 'Usual care' was 6 weeks of homecare reablement delivered by social care workers (no routine health professional input). INTERVENTION: A targeted ADL programme, delivered by an occupational therapist incorporating goal setting, teaching/practising techniques, equipment/adaptations and provision of advice/support. This was in addition to usual care. OUTCOME MEASURES: Aspects of feasibility including eligibility, recruitment, intervention delivery, attrition and suitability and sensitivity of outcome measures. Participant outcomes were personal and extended ADL, quality of life, falls and use of health and social care services. RESULTS: 30 participants were recruited, 15 to each arm, which was 60% of those eligible. Data from 22 (73%) were analysed at 6 months. Of the 15 participants, 13 (86%) received the intervention and were able to set one or more ADL goals. There were improvements from baseline in both groups, although overall improvements were greater in the occupational therapy (OT) intervention group. The biggest threat to feasibility was a change in service configuration during the trial, involving additional occupational therapy input, affecting usual care and recruitment. CONCLUSIONS: Despite the service reconfiguration, it was feasible to recruit and retain participants, deliver the intervention and collect outcome data that were responsive to change. The choice of primary outcome measure remains unclear. A further powered study is feasible and warranted; however, the design will require careful consideration because of ongoing national changes in service configurations. TRIAL REGISTRATION NUMBER: ISRCTN21710246; Results.

Variability in the diagnostic performance of a bedside rapid diagnostic influenza test over four epidemic seasons in a pediatric emergency department.

We wanted to determine the diagnostic performance of a rapid influenza diagnostic test (RIDT) used bedside in a pediatric emergency department (PED). This was a prospective study over four consecutive winters (2009-2013), comparing the results of a RIDT (QuickVue®) with RT-PCR in children admitted to a PED. Among the 764 children included, we did not observe any significant differences in the diagnostic performance of RIDT except during the H1N1 pandemic. The overall sensitivity of the test was 0.82; the specificity 0.98; the positive and negative likelihood ratios 37.8 and 0.19. The positive and negative post-test probabilities of infection were 98% and 17%. The diagnostic performance was increased for influenza B cases (P = 0.03). RIDTs are suitable for use every winter with few differences in its diagnostic value, except during specific pandemic periods. This test could limit unnecessary complementary exams and guide the prescription of antivirals during influenza epidemic periods in PEDs.

Cognitive Rehabilitation for Attention and Memory in people with Multiple Sclerosis: study protocol for a randomised controlled trial (CRAMMS).

BACKGROUND: People with multiple sclerosis have problems with memory and attention. Cognitive rehabilitation is a structured set of therapeutic activities designed to retrain an individual's memory and other cognitive functions. Cognitive rehabilitation may be provided to teach people strategies to cope with these problems, in order to reduce the impact on everyday life. The effectiveness of cognitive rehabilitation for people with multiple sclerosis has not been established. METHODS: This is a multi-centre, randomised controlled trial investigating the clinical and cost-effectiveness of a group-based cognitive rehabilitation programme for attention and memory problems for people with multiple sclerosis. Four hundred people with multiple sclerosis will be randomised from at least four centres. Participants will be eligible if they have memory problems, are 18 to 69 years of age, are able to travel to attend group sessions and give informed consent. Participants will be randomised in a ratio of 6:5 to the group rehabilitation intervention plus usual care or usual care alone. Intervention groups will receive 10 weekly sessions of a manualised cognitive rehabilitation programme. The intervention will include both restitution strategies to retrain impaired attention and memory functions and compensation strategies to enable participants to cope with their cognitive problems. All participants will receive a follow-up questionnaire and an assessment by a research assistant at 6 and 12 months after randomisation. The primary outcome is the Multiple Sclerosis Impact Scale (MSIS) Psychological subscale at 12 months. Secondary outcomes include the Everyday Memory Questionnaire, General Health Questionnaire-30, EQ-5D and a service use questionnaire from participants, and the Everyday Memory Questionnaire-relative version and Carer Strain Index from a relative or friend. The primary analysis will be based on intention to treat. A mixed-model regression analysis of the MSIS Psychological subscale at 12 months will be used to estimate the effect of the group cognitive rehabilitation programme. DISCUSSION: The study will provide evidence regarding the clinical and cost-effectiveness of a group-based cognitive rehabilitation programme for attention and memory problems in people with multiple sclerosis. TRIAL REGISTRATION: ISRCTN09697576 . Registered 14 August 2014.

Interventions to reduce dependency in personal activities of daily living in community dwelling adults who use homecare services: a systematic review.

OBJECTIVES: To identify interventions that aim to reduce dependency in activities of daily living (ADL) in homecare service users. To determine: content; effectiveness in improving ability to perform ADL; and whether delivery by qualified occupational therapists influences effectiveness. DATA SOURCES: The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, AMED, CINAHL, PsycINFO, OTseeker, PEDro, Web of Science, CIRRIE, and ASSIA. REVIEW METHODS: We included: randomised controlled trials, non-randomised controlled trials and controlled before and after studies. Two reviewers independently screened studies for inclusion, assessed risk of bias and extracted data. A narrative synthesis of the findings was conducted. RESULTS: Thirteen studies were included, totalling 4975 participants. Ten (77%) were judged to have risk of bias. Interventions were categorised as those termed 're-ablement' or 'restorative homecare' (n=5/13); and those involving separate components which were not described using this terminology (n=8/13). Content of the intervention and level of health professional input varied within and between studies. Effectiveness on ADL: eight studies included an ADL outcome, five favoured the intervention group, only two with statistical significance, both these were controlled before and after studies judged at high risk of bias. ADL outcome was reported using seven different measures. Occupational therapy: there was insufficient evidence to determine whether involvement of qualified occupational therapists influenced effectiveness. CONCLUSION: There is limited evidence that interventions targeted at personal ADL can reduce homecare service users' dependency with activities, the content of evaluated interventions varies greatly.

Occupational Therapy in HomEcare Re-ablement Services (OTHERS): study protocol for a randomized controlled trial.

BACKGROUND: Homecare re-ablement services have been developed by local authorities in England in response to the government agenda for health and social care. These services aim to optimize users' independence and ability to cope at home, and reduce the need for ongoing health and social care services. However, there is currently limited evidence and guidance regarding the optimum configuration and delivery of re-ablement services. In particular, the impact of occupational therapy input on service user outcomes has been highlighted as a specific research priority. METHODS/DESIGN: This feasibility randomized controlled trial (RCT) will recruit 50 people from one local authority led homecare re-ablement service in England. Those who provide informed consent will be randomized to receive either usual homecare re-ablement (without routine occupational therapy input) or usual homecare re-ablement plus an enhanced program targeted at activities of daily living (ADL), delivered by an occupational therapist. The primary aim of this study is to assess the feasibility of conducting a further, powered study. The participant outcomes assessed will be independence in personal and extended ADL, health and social care-related quality of life, number of care support hours, falls, acute and residential admissions and use of health and social care services. These will be assessed at two weeks, three months and six months post-discharge from the re-ablement service. DISCUSSION: To our knowledge, this is the first RCT of occupational therapy in homecare re-ablement services. The results of this study will lay the foundations for a further powered study. The findings will be relevant to researchers, clinicians, commissioners and users of adult social care services. TRIAL REGISTRATION: Current Controlled Trials registration number: ISRCTN21710246 (registered on 31March 2014).

Behavioural repertoire of working donkeys and consistency of behaviour over time, as a preliminary step towards identifying pain-related behaviours.

BACKGROUND: The donkey has a reputation for stoicism and its behavioural repertoire in clinical contexts is under-reported. Lack of understanding of the norms of donkey behaviour and how it may vary over time can compromise use of behavioural measures as indicators of pain or emotional state. The objective of this study was to find out whether the behaviour of working donkeys was influenced by gender, the time of day or differed between days with a view to assessing how robust these measures are for inclusion in a working donkey ethogram. METHODOLOGY/PRINCIPAL FINDINGS: Frequency and consistency of postural and event behaviours were measured in 21 adult working donkeys (12 females; 9 males). Instantaneous (scan) and focal sampling were used to measure maintenance, lying, ingestive and investigative behaviours at hourly intervals for ten sessions on each of two consecutive days. High head carriage and biting were seen more frequently in male donkeys than females (P<0.001). Level head carriage, licking/chewing and head-shaking were observed more frequently in female donkeys (P<0.001). Tail position, ear orientation, foot stamping, rolling/lying and head-shaking behaviours were affected by time of day (P<0.001). However, only two variations in ear orientation were found to be significantly different over the two days of observations (P<0.001). Tail swishing, head shaking, foot stamping, and ears held sideways and downwards were significantly correlated (P<0.001) and are assumed to be behaviours to discourage flies. CONCLUSIONS/SIGNIFICANCE: All donkeys expressed an extensive behavioural repertoire, although some differences in behaviour were evident between genders. While most behaviours were consistent over time, some behaviours were influenced by time of day. Few behaviours differed between the two test days. The findings can be used to inform the development of a robust, evidence-based ethogram for working donkeys.

Thermal nociceptive threshold testing detects altered sensory processing in broiler chickens with spontaneous lameness.

Lameness is common in commercially reared broiler chickens but relationships between lameness and pain (and thus bird welfare) have proved complex, partly because lameness is often partially confounded with factors such as bodyweight, sex and pathology. Thermal nociceptive threshold (TNT) testing explores the neural processing of noxious stimuli, and so can contribute to our understanding of pain. Using an acute model of experimentally induced articular pain, we recently demonstrated that TNT was reduced in lame broiler chickens, and was subsequently attenuated by administration of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs). This study extended these findings to a large sample of commercial broilers. It examined factors affecting thermal threshold (Part 1) and the effect of an NSAID drug (meloxicam, 5 mg/kg) and of an opioid (butorphanol; 4 mg/kg) (Part 2). Spontaneously lame and matched non-lame birds (n=167) from commercial farms were exposed to ramped thermal stimulations via a probe attached to the lateral aspect of the tarsometatarsus. Baseline skin temperature and temperature at which a behavioural avoidance response occurred (threshold) were recorded. In Part 1 bird characteristics influencing threshold were modelled; In Part 2 the effect of subcutaneous administration of meloxicam or butorphanol was investigated. Unexpectedly, after accounting for other influences, lameness increased threshold significantly (Part 1). In Part 2, meloxicam affected threshold differentially: it increased further in lame birds and decreased in non-lame birds. No effect of butorphanol was detected. Baseline skin temperature was also consistently a significant predictor of threshold. Overall, lameness significantly influenced threshold after other bird characteristics were taken into account. This, and a differential effect of meloxicam on lame birds, suggests that nociceptive processing may be altered in lame birds, though mechanisms for this require further investigation.

Thermal nociception as a measure of non-steroidal anti-inflammatory drug effectiveness in broiler chickens with articular pain.

Pain associated with poultry lameness is poorly understood. The anti-nociceptive properties of two non-steroidal anti-inflammatory drugs (NSAIDs) were evaluated using threshold testing in combination with an acute inflammatory arthropathy model. Broilers were tested in six groups (n=8 per group). Each group underwent a treatment (saline, meloxicam (3 or 5mg/kg) or carprofen (15 or 25mg/kg)) and a procedure (Induced (arthropathy-induction) or sham (sham-handling)) prior to testing. Induced groups had Freund's complete adjuvant injected intra-articularly into the left intertarsal joint (hock). A ramped thermal stimulus (1°C/s) was applied to the skin of the left metatarsal. Data were analysed using random-intercept multi-level models. Saline-induced birds had a significantly higher skin temperature (± SD) than saline-sham birds (37.6 ± 0.8°C vs. 36.5 ± 0.5°C; Z=-3.47, P<0.001), consistent with an inflammatory response. Saline was associated with significantly lower thermal thresholds (TT) than analgesic treatment (meloxicam: Z=2.72, P=0.007; carprofen: Z=2.58, P=0.010) in induced birds. Saline-induced birds also had significantly lower TT than saline-sham birds (Z=-2.17, P=0.030). This study found direct evidence of an association between inflammatory arthropathies and thermal hyperalgesia, and showed that NSAID treatment maintained baseline thermal sensitivity (via anti-nociception). Quantification of nociceptive responsiveness in a predictable broiler pain model identified thermal anti-hyperalgesic properties of two NSAIDs, which suggested that therapeutically effective treatment was provided at the doses administered. Such validation of analgesic strategies will increase the understanding of pain associated with specific natural broiler lameness types.

Cost-effectiveness of an adjustment group for people with multiple sclerosis and low mood: a randomized trial.

OBJECTIVE: To evaluate the cost effectiveness of a psychological adjustment group shown to be clinically effective in comparison with usual care for people with multiple sclerosis. DESIGN: Randomized controlled trial with comparison of costs and calculation of incremental cost effectiveness ratio. SETTING: Community. PARTICIPANTS: People with multiple sclerosis were screened on the General Health Questionnaire 12 and Hospital Anxiety and Depression Scale, and those with low mood were recruited. INTERVENTIONS: Participants randomly allocated to the adjustment group received six group treatment sessions. The control group received usual care, which did not include psychological interventions. MAIN MEASURES: Outcomes were assessed four and eight months after randomization, blind to group allocation. The costs were assessed from a service use questionnaire and information provided on medication. Quality of life was assessed using the EQ-5D. RESULTS: Of the 311 patients identified, 221 (71%) met the criteria for having low mood. Of these, 72 were randomly allocated to receive treatment and 79 to usual care. Over eight months follow-up there was a decrease in the combined average costs of £378 per intervention respondent and an increase in the costs of £297 per patient in the control group, which was a significant difference (p=0.03). The incremental cost-effectiveness ratio indicated that the cost per point reduction on the Beck depression inventory-II was £118. CONCLUSION: In the short term, the adjustment group programme was cost effective when compared with usual care, for people with multiple sclerosis presenting with low mood. The longer-term costs need to be assessed.

Interventions to reduce dependency in personal activities of daily living in community-dwelling adults who use homecare services: protocol for a systematic review.

BACKGROUND: There is a growing demand for services whereby individuals receive assistance from care workers for personal care within the home. This has led to the development of re-ablement or restorative homecare services that provide time-limited input aimed at reducing dependency in personal activities of daily living, and preventing or delaying the need for further homecare support. However, little is currently known about how such interventions are configured, or how they may affect individuals' ability to carry out personal care independently. METHODS/DESIGN: We will seek to identify studies that compare an intervention designed to reduce dependency in personal activities of daily living with routine input or usual care as the control. We will include randomised controlled trials, nonrandomised controlled trials, and controlled before and after studies. We will also include interrupted time series studies. We shall search electronic databases in addition to searching for ongoing and unpublished studies, and where appropriate will contact key authors. Two reviewers will independently screen articles for inclusion; will assess risk of bias using quality assessment tools; and will carry out data extraction using pre-prepared forms. Any disagreements, at any stage, will be resolved by discussion and the involvement of a third reviewer if needed. We will produce a narrative summary of the results. A meta-analysis will be conducted if sufficient data are available of appropriate quality and comparability. DISCUSSION: The findings from this review will inform future practice within homecare re-ablement services; will inform policy decisions about the structure, organisation and content of such services; and will identify areas where further research is warranted. TRIAL REGISTRATION: This review protocol has been registered on the PROSPERO database (CRD42013004163).

Kinematic analysis quantifies gait abnormalities associated with lameness in broiler chickens and identifies evolutionary gait differences.

This is the first time that gait characteristics of broiler (meat) chickens have been compared with their progenitor, jungle fowl, and the first kinematic study to report a link between broiler gait parameters and defined lameness scores. A commercial motion-capturing system recorded three-dimensional temporospatial information during walking. The hypothesis was that the gait characteristics of non-lame broilers (n = 10) would be intermediate to those of lame broilers (n = 12) and jungle fowl (n = 10, tested at two ages: immature and adult). Data analysed using multi-level models, to define an extensive range of baseline gait parameters, revealed inter-group similarities and differences. Natural selection is likely to have made jungle fowl walking gait highly efficient. Modern broiler chickens possess an unbalanced body conformation due to intense genetic selection for additional breast muscle (pectoral hypertrophy) and whole body mass. Together with rapid growth, this promotes compensatory gait adaptations to minimise energy expenditure and triggers high lameness prevalence within commercial flocks; lameness creating further disruption to the gait cycle and being an important welfare issue. Clear differences were observed between the two lines (short stance phase, little double-support, low leg lift, and little back displacement in adult jungle fowl; much double-support, high leg lift, and substantial vertical back movement in sound broilers) presumably related to mass and body conformation. Similarities included stride length and duration. Additional modifications were also identified in lame broilers (short stride length and duration, substantial lateral back movement, reduced velocity) presumably linked to musculo-skeletal abnormalities. Reduced walking velocity suggests an attempt to minimise skeletal stress and/or discomfort, while a shorter stride length and time, together with longer stance and double-support phases, are associated with instability. We envisage a key future role for this highly quantitative methodology in pain assessment (associated with broiler lameness) including experimental examination of therapeutic agent efficacy.

Attendance at a psychological support group for people with multiple sclerosis and low mood.

PURPOSE: A cognitive behavioural group promoting psychological adjustment for people with multiple sclerosis (MS) was found to reduce psychological distress. Not all those offered treatment attended the group sessions. The aims were to examine the rates of attendance and to evaluate feedback from participants. METHOD: Participants with MS and low mood were recruited to a randomized trial comparing attendance at a psychological support group with a usual care control group. The attendance at each session was determined and those who attended were compared with those who failed to attend using a Mann-Whitney U-test or chi-squared. A sample of participants completed a telephone feedback questionnaire to determine their views of the group. RESULTS: The 44 participants who attended four or more sessions were not significantly different from the 28 who attended fewer than four sessions on demographic variables, disability, self-efficacy or quality of life, but significantly fewer men attended than women (p = 0.03). Participants' feedback from the group was mainly positive, and no factors were identified associated with non-attendance. CONCLUSIONS: Men were less likely to attend group treatment sessions than women, but no other variables were associated with non-attendance. Attendance rates influence the effectiveness of interventions and reasons for non-attendance need to be determined.

Evaluation of an adjustment group for people with multiple sclerosis and low mood: a randomized controlled trial.

BACKGROUND: Mood problems affect many people with multiple sclerosis (MS). The aim was to evaluate the effectiveness of a group treatment based on cognitive behavioural principles. METHODS: People with MS were screened on the General Health Questionnaire 12 (GHQ-12) and Hospital Anxiety and Depression Scale (HAD). Those identified with low mood were invited to take part in a randomized trial comparing the effect of attending an adjustment group with a waiting list control. Patients allocated to the adjustment group received six 2 h group treatment sessions. Outcomes were assessed 4 and 8 months after randomization, blind to group allocation. RESULTS: Of the 311 patients identified, 221 (71%) met the criteria for low mood and 151 (68%) agreed to take part. Hierarchical regression analyses were conducted to compare the two groups, correcting for baseline mood and disability. At 4 months, group allocation alone was a significant predictor of the primary outcome measure, the GHQ-12. At 8 months, group allocation alone was no longer a significant predictor for GHQ-12 scores, but it was when baseline GHQ-12 and Guy's Neurological Disability Scale scores were controlled for. Comparison of the area under the curve revealed significant differences between the groups for GHQ-12 (p = 0.003), HAD Anxiety (p = 0.013), HAD Depression (p = 0.004), Beck Depression Inventory (p = 0.001), MS Self-efficacy (p = 0.037) and MS Impact Scale Psychological (p = 0.012). CONCLUSION: Patients receiving treatment were less distressed and had less depression and anxiety. There was some evidence of improved self-efficacy and a reduction of the impact of MS on people's lives.

Environmental assessment and modification to prevent falls in older people.

UNLABELLED: To assess the effectiveness of an environmental falls prevention intervention delivered by qualified occupational therapists or unqualified trained assessors. DESIGN: A pilot three-armed randomized controlled trial. SETTING: Airedale National Health Service Trust catchment, North and West Yorkshire, England. PARTICIPANTS: Two hundred thirty-eight community-dwelling adults aged 70 and older with a history of falls in the previous year. INTERVENTION: Assessment and modification of the home environment of people at greater risk of falls. MEASUREMENTS: Fear of falling was the primary outcome measure, and an analysis of covariance was conducted on the area under the curve at 12 months. As a secondary outcome, falls were analysed using negative binomial regression. Quality of life and independence in activities of daily living (ADLs) were also measured. RESULTS: The intervention had no effect on fear of falling (P=.63). The occupational therapy group had significantly fewer falls than controls 12 months after the assessment (incidence rate ratio (IRR)=0.54, 95% confidence interval (CI)=0.36-0.83, P=.005). There was no significant effect on falls in the trained assessor group (IRR=0.78, 95% CI=0.51-1.21, P=.34). CONCLUSION: Environmental assessment had no effect on fear of falling. Environmental assessment prescribed by an occupational therapist significantly reduced the number of falls in high-risk individuals whereas that prescribed by a trained assessor did not. Further research in other settings is needed to confirm this, to explore the mechanisms, and to estimate cost-effectiveness.

Late onset Leigh syndrome and ataxia due to a T to C mutation at bp 9,185 of mitochondrial DNA.

A T-to-C missense mutation at nucleotide position 9,185 in the protein-coding ATP6 gene of the mitochondrial genome was present at high heteroplasmy in members of a Canadian family with Leigh syndrome with predominant ataxia and peripheral neuropathy. This mutation results in the substitution of a proline residue for an evolutionary-conserved leucine at position of amino acid 220 near the carboxyl terminus of the mitochondrial protein. The index patient and brother, who had an identical clinical presentation, had >90% mutant mtDNA in cultured skin fibroblasts, lymphocytes, and whole blood. Their mother and a maternal uncle, symptomatic with a peripheral neuropathy alone, had 86% and 85% heteroplasmy, respectively. Symptomatic maternal cousins with early onset revealed 90% and 91% mutant mtDNA in all tissues analyzed. Studies of lymphoblasts from the asymptomatic maternal grandmother and eldest brother of the proband were heteroplasmic for mutant mtDNA with 56% and 17%, respectively. Biochemical analysis demonstrated normal respiratory chain enzyme activity in muscle and fibroblasts, normal ATP synthesis, but reduced oligomycin-sensitive H(+)ATPase in cultured lymphoblast mitochondria. We propose that the 9,185T > C mtDNA mutation is pathogenic even though the initial phenotype is mild and the biochemical phenotype not easily detectable.