The visual and functional impacts of astigmatism and its clinical management

Purpose: To provide a comprehensive overview of research examining the impact of astigmatism on clinical and functional measures of vision, the short and longer term adaptations to astigmatism that occur in the visual system, and the currently available clinical options for the management of patients with astigmatism. Recent findings: The presence of astigmatism can lead to substantial reductions in visual performance in a variety of clinical vision measures and functional visual tasks. Recent evidence demonstrates that astigmatic blur results in short-term adaptations in the visual system that appear to reduce the perceived impact of astigmatism on vision. In the longer term, uncorrected astigmatism in childhood can also significantly impact on visual development, resulting in amblyopia. Astigmatism is also associated with the development of spherical refractive errors. Although the clinical correction of small magnitudes of astigmatism is relatively straightforward, the precise, reliable correction of astigmatism (particularly high astigmatism) can be challenging. A wide variety of refractive corrections are now available for the patient with astigmatism, including spectacle, contact lens and surgical options. Conclusion: Astigmatism is one of the most common refractive errors managed in clinical ophthalmic practice. The significant visual and functional impacts of astigmatism emphasise the importance of its reliable clinical management. With continued improvements in ocular measurement techniques and developments in a range of different refractive correction technologies, the future promises the potential for more precise and comprehensive correction options for astigmatic patients.

The clinical utility of the Cornell Scale for Depression in Dementia as a routine assessment in nursing homes

Objective To examine the clinical utility of the Cornell Scale for Depression in Dementia (CSDD) in nursing homes. Setting 14 nursing homes in Sydney and Brisbane, Australia. Participants 92 residents with a mean age of 85 years. Measurements Consenting residents were assessed by care staff for depression using the CSDD as part of their routine assessment. Specialist clinicians conducted assessment of depression using the Semi-structured Clinical Diagnostic Interview for DSM-IV-TR Axis I Disorders for residents without dementia or the Provisional Diagnostic Criteria for Depression in Alzheimer Disease for residents with dementia to establish expert clinical diagnoses of depression. The diagnostic performance of the staff completed CSDD was analyzed against expert diagnosis using receiver operating characteristic (ROC) curves. Results The CSDD showed low diagnostic accuracy, with areas under the ROC curve being 0.69, 0.68 and 0.70 for the total sample, residents with dementia and residents without dementia, respectively. At the standard CSDD cutoff score, the sensitivity and specificity were 71% and 59% for the total sample, 69% and 57% for residents with dementia, and 75% and 61% for residents without dementia. The Youden index (for optimizing cut-points) suggested different depression cutoff scores for residents with and without dementia. Conclusion When administered by nursing home staff the clinical utility of the CSDD is highly questionable in identifying depression. The complexity of the scale, the time required for collecting relevant information, and staff skills and knowledge of assessing depression in older people must be considered when using the CSDD in nursing homes.

Differential susceptibility to performance degradation across categories of facial emotion - a model confirmation

Patients with a number of psychiatric and neuropathological conditions demonstrate problems in recognising facial expressions of emotion. Research indicating that patients with schizophrenia perform more poorly in the recognition of negative valence facial stimuli than positive valence stimuli has been interpreted as evidence of a negative emotion specific deficit. An alternate explanation rests in the psychometric properties of the stimulus materials. This model suggests that the pattern of impairment observed in schizophrenia may reflect initial discrepancies in task difficulty between stimulus categories, which are not apparent in healthy subjects because of ceiling effects. This hypothesis is tested, by examining the performance of healthy subjects in a facial emotion categorisation task with three levels of stimulus resolution. Results confirm the predictions of the model, showing that performance degrades differentially across emotion categories, with the greatest deterioration to negative valence stimuli. In the light of these results, a possible methodology for detecting emotion specific deficits in clinical samples is discussed.

Trainee-therapists are not all equal: Examination of therapeutic efficiency, effectiveness and early client dropout after 12 months of clinical training

Objective Contemporary research demonstrates the feasibility of assessing therapeutic performance of trainee-therapists through the use of objective measures of client treatment outcome. Further, significant variation between individual therapists based on their client treatment outcomes has been demonstrated. This study sets out to determine whether a reliable composite measure of therapeutic efficiency, effectiveness and early dropout can be developed and used to objectively compare trainee-therapists against each other. Design and methods Treatment outcomes of 611 clients receiving treatment from 58 trainee-therapists enrolled in a professional training programme were tracked with the OQ-45.2 over a 6-year period to assess therapeutic efficiency, therapeutic effectiveness and early client dropout. Results Significant variation between trainee-therapists was observed for each index. Findings of a moderately strong correlation between therapeutic efficiency and effectiveness enabled the ranking of trainee-therapists based upon a composite measure of these indexes. A non-significant correlation was found between early client dropout and measures of therapeutic effectiveness and efficiency. Conclusions The findings stress the importance of utilizing objective measures to track the treatment outcomes. Despite all trainee-therapists being enrolled in the same training programme, significant variation between trainee-therapists' therapeutic efficiency and effectiveness was found to exist. Practitioner points Developing of potential benchmarking tools that enable trainee-therapists, supervisors and educational institutions to quickly assess therapeutic performance can become part of a holistic assessment of a trainee-therapist's clinical development. Despite an inherent optimistic belief that therapists do not cause harm, there appears to be a small and significant proportion of trainee-therapists who consistently evidence little therapeutic change. Considerable variability in trainee-therapists' therapeutic efficiency and effectiveness can exist in the one training programme. Early client dropout may not be associated with therapists' therapeutic effectiveness and efficiency.

Assessing performance in critical care nursing practice using the Benner Novice to expert model: A pilot study

Background It is often believed that by ensuring the ongoing completion of competency documents and life-long learning in nursing practice guarantees quality patient care. This is probably true in most cases where it provides reassurances that the nursing team is maintaining a safe “generalised” level of practice. However, competency does not always promise quality performance. There are a number of studies that have reported differences in what practitioners know and what they actually do despite being deemed competent. Aim The aim of this study was to assess whether our current competency documentation is fit for purpose and to ascertain whether performance assessment needs to be a key component in determining competence. Method 15 nurses within a General ICU who had been on the unit <4 years agreed to participate in this project. Using participant observation and assessing performance against key indicators of the Benner Novice to Expert5 model the participants were supported and assessed over the course of a ‘normal’ nursing shift. Results The results were surprising both positively and negatively. First, the nurses felt more empowered in their clinical decision making skills; second, it identified individual learning needs and milestones in educational development. There were some key challenges identified which included 5 nurses over estimating their level of competence, practice was still very much focused on task acquisition and skill and surprisingly some nurses still felt dominated by the other health professionals within the unit. Conclusion We found that the capacity and capabilities of our nursing workforce needs continual ongoing support especially if we want to move our staff from capable task-doer to competent performers. Using the key novice to expert indicators identified the way forward for us in how we assess performance and competence in practice particularly where promotion to higher grades is based on existing documentation.

Cognitive deficits and the Paced Auditory Serial Addition Test performance among patients with multiple sclerosis

Multiple sclerosis (MS) is a chronic, inflammatory disease of the central nervous system, characterized especially by myelin and axon damage. Cognitive impairment in MS is common but difficult to detect without a neuropsychological examination. Valid and reliable methods are needed in clinical practice and research to detect deficits, follow their natural evolution, and verify treatment effects. The Paced Auditory Serial Addition Test (PASAT) is a measure of sustained and divided attention, working memory, and information processing speed, and it is widely used in MS patients neuropsychological evaluation. Additionally, the PASAT is the sole cognitive measure in an assessment tool primarly designed for MS clinical trials, the Multiple Sclerosis Functional Composite (MSFC). The aims of the present study were to determine a) the frequency, characteristics, and evolution of cognitive impairment among relapsing-remitting MS patients, and b) the validity and reliability of the PASAT in measuring cognitive performance in MS patients. The subjects were 45 relapsing-remitting MS patients from Seinäjoki Central Hospital, Department of Neurology and 48 healthy controls. Both groups underwent comprehensive neuropsychological assessments, including the PASAT, twice in a one-year follow-up, and additionally a sample of 10 patients and controls were evaluated with the PASAT in serial assessments five times in one month. The frequency of cognitive dysfunction among relapsing-remitting MS patients in the present study was 42%. Impairments were characterized especially by slowed information processing speed and memory deficits. During the one-year follow-up, the cognitive performance was relatively stable among MS patients on a group level. However, the practice effects in cognitive tests were less pronounced among MS patients than healthy controls. At an individual level the spectrum of MS patients cognitive deficits was wide in regards to their characteristics, severity, and evolution. The PASAT was moderately accurate in detecting MS-associated cognitive impairment, and 69% of patients were correctly classified as cognitively impaired or unimpaired when comprehensive neuropsychological assessment was used as a "gold standard". Self-reported nervousness and poor arithmetical skills seemed to explain misclassifications. MS-related fatigue was objectively demonstrated as fading performance towards the end of the test. Despite the observed practice effect, the reliability of the PASAT was excellent, and it was sensitive to the cognitive decline taking place during the follow-up in a subgroup of patients. The PASAT can be recommended for use in the neuropsychological assessment of MS patients. The test is fairly sensitive, but less specific; consequently, the reasons for low scores have to be carefully identified before interpreting them as clinically significant.

An imagery-based road map to tackle maladaptive motivation in clinical disorders

There is now a widespread recognition of the importance of mental imagery in a range of clinical disorders (1). This provides the potential for a transdiagnostic route to integrate some aspects of these disorders and their treatment within a common framework. This opinion piece argues that we need to understand why imagery is such a central and recurring feature, if we are to progress theories of the origin and maintenance of disorders. This will aid us in identifying therapeutic techniques that are not simply targeting imagery as a symptom, but as a manifestation of an underlying problem. As papers in this issue highlight, imagery is a central feature across many clinical disorders, but has been ascribed varying roles. For example, the involuntary occurrence of traumatic memories is a diagnostic criterion for PTSD (2), and it has been suggested that multisensory imagery of traumatic events normally serves a functional role in allowing the individual to reappraise the situation (3), but that this re-appraisal is disabled by extreme affective responses. In contrast to the disabling flashbacks associated with PTSD, depressed adults who experience suicidal ideation often report “flash forward” imagery related to suicidal acts (4), motivating them to self-harm. Socially anxious individuals who engage in visual imagery about giving a talk in public become more anxious and make more negative predictions about future performance than others who engage in more abstract, semantic processing of the past event (5). People with Obsessive Compulsive Disorder (OCD) frequently report imagery of past adverse events, and imagery seems to be associated with severity (6). The content of intrusive imagery has been related to psychotic symptoms (7), including visual images of the catastrophic fears associated with paranoia and persecution. Imagery has been argued (8) to play a role in the maintenance of psychosis through negative appraisals of imagined voices, misattribution of sensations to external sources, by the induction of negative mood states that trigger voices, and through maintenance of negative schemas. In addiction and substance dependence, Elaborated Intrusion (EI) Theory (9, 10) emphasizes the causal role that imagery plays in substance use, through its role in motivating an individual to pursue goals directed toward achieving the pleasurable outcomes associated with substance use...

Temporomandibular disorders and related psychosocial factors in non-patients : A survey and a clinical follow-up study based on the RDC/TMD

Temporomandibular disorders (TMD) and psychosocial factors reportedly associate. The underlying factors remain partially obscure, however, and further studies are required to clarify the relationships. The aims of this study were thus to assess in a non-patient working population the prevalence of TMD and related symptoms, and to clinically diagnose and follow the natural courses of TMD over a one-year period. In addition, possible comorbidity of temporomandibular and/or neck muscle pain and perceived stress and their impact on work performance were investigated, as well as how various psychosocial aspects relate to TMD. A questionnaire was mailed to all 30- to 55-year-old employees of the Finnish Broadcasting Company Ltd. whose employment in the Helsinki area had lasted at least five years (n = 1784). Of the 1339 subjects, who returned the questionnaire, 241 were examined according to the RDC/TMD and standard neck muscle palpation methods. Clinical signs of temporomandibular and/or neck muscle pain were found in 118 subjects. One-year follow-up TMD examinations were conducted on 211 subjects. The prevalence of frequent painless TMJ-related symptoms was 10%, orofacial pain 7%, neck pain 38%, and headache 15%. TMD diagnoses were: myofascial pain (13%), disc displacements (16%), and arthralgia, osteoarthritis, osteoarthrosis (4%). Chronic myofascial pain was present in 7% and chronic disc displacement with reduction in 11% of the subjects. Symptoms were significantly associated with almost all the studied psychosocial symptoms. Reduced work performance was significantly positively associated with continuous pain, severity of pain, and health stress perception, and according to logistic regression, somatization with the probability of having chronic myofascial pain. It could be concluded based on the results of this study among a non-patient working population that TMD and related symptoms are common and associated with psychosocial factors. Moreover, myofascial pain and disc displacement with reduction are the most common diagnoses of TMD. In addition, self-reported health related stress, and continuous pain in temporomandibular and/or neck muscles are associated with reduced work performance, and somatization is significantly associated with chronic myofascial pain.

Feedback and clinical practice improvement: A tool to assist workplace supervisors and students

In work integrated learning, students may report difficulties applying theory learned at university to clinical practice. One contributing factor may be students' inability to engage in meaningful reflection and self-correcting behaviours. This paper reports the evaluation of a tool, process and resources developed to assist students to reflect on feedback and engage in self-assessment. Students were assisted to develop self-assessment skills by reflecting on, and engaging with feedback from previous workplace experiences to develop goals, learning outcomes and strategies to improve performance with mostly positive results. A secondary aim was to identify common learning strategies or barriers that impacted on student outcomes. Four themes emerged from the qualitative data: 1) preparing for clinical learning; 2) relationships and engagement levels; 3) shared awareness, and; 4) developing clinical practice. Overall students felt the tool assisted them to narrow their attention on what needed to be improved. While supervisors believed the tool helped them to focus on specific needs of each student. Common barriers to clinical practice improvement related to a lack of opportunity in some settings, and lack of staff willingness to support students to achieve identified goals. Students and supervisors found the use of the tools beneficial and assisted students to demonstrate a greater understanding of how to apply feedback received to support their learning in the clinical environment.

The relationship between forward head posture and cervical muscle performance in healthy individuals

Background Forward head postures (FHP) are proposed to adversely load cervical spine structures. Neck muscles provide support for the neck, and thus an imbalance in neck muscle performance could potentially contribute to the development of FHP. Previous studies have not considered the interaction of multiple muscle groups with regard to postural orientation. Given the interdependence of muscles along the cervical spine for optimal orientation and physical support of the vertebral column, the performance of a single muscle group may not accurately reflect the coordinated ability of the muscles to maintain a neutral neck posture. Purpose The purpose of this study was to investigate the relationship between FHP and the balance between the cervical extensor and flexor muscle groups in healthy individuals. We hypothesised that the magnitude of FHP would be associated with the strength and endurance performance ratios between the cervical extensor and flexor muscle groups. Methods Twenty male and 24 female volunteers were photographed in the sagittal plane wearing surface markers. The FHP of each participant was measured via the tragus-sternum marker distance over two conditions: (1)in relaxed standing and (2)during a sustained sitting task. Maximal strength (Nm) and endurance (s) performance of the extensor and flexor muscle groups were recorded at the upper (craniocervical flexion/extension (CCF/CCE)) and lower (cervicothoracic flexion/extension (CTF/CTE)) cervical regions. Muscle performance measures were expressed as extension:flexion ratios and their relation to FHP evaluated. A stepwise multiple regression analysis using backward elimination was utilised to examine the relationship between the postural measures and the muscle performance ratio measures. Separate models were used for the two different postural conditions (standing, sustained sitting). Gender was included as a constant correction factor in all regression models. Where gender was a significant variable in the model, analyses were repeated separately for males and females. Results Greater FHP in standing was significantly associated with reduced proportional CTE to CCF strength in females (R2 = 0.21, P = 0.03) and greater proportional CTE to CTF strength in males (R2 = 0.23, P = 0.03). A greater drift into FHP during sustained sitting was associated with a relative reduction in CCE endurance proportional to CTF endurance in females only (R2 = 0.27, P = 0.017). Conclusion(s) This initial study indicates that the balance in performance between the cervical flexor and extensor muscle groups may impact FHP in healthy individuals. However, the findings were inconsistent across different muscle performance ratios and gender. Larger scale studies are therefore now needed to further clarify the relationship between FHP and muscle performance. Implications The findings suggest that relative performance of the various cervical muscle groups needs to be accounted for when considering postural correction strategies in the clinical setting, as is often recommended.

Psychometric properties of the DCDDaily-Q: A new parental questionnaire on children's performance in activities of daily living

Difficulties in the performance of activities of daily living (ADL) are a key feature of developmental coordination disorder (DCD). The DCDDaily-Q was developed to address children's motor performance in a comprehensive range ADL. The aim of this study was to investigate the psychometric properties of this parental questionnaire. Parents of 218 five to eight year-old children (DCD group: N=25; reference group: N=193) completed the research version of the new DCDDaily-Q and the Movement Assessment Battery for Children-2 (MABC2) Checklist and Developmental Coordination Disorder Questionnaire (DCDQ). Children were assessed with the MABC2 and DCDDaily. Item reduction analyses were performed and reliability (internal consistency and factor structure) and concurrent, discriminant, and incremental validity of the DCDDaily-Q were investigated. The final version of the DCDDaily-Q comprises 23 items that cover three underlying factors and shows good internal consistency (Cronbach's α>.80). Moderate correlations were found between the DCDDaily-Q and the other instruments used (p<.001 for the reference group; p>.05 for the DCD group). Discriminant validity of the DCDDaily-Q was good for DCDDaily-Q total scores (p<.001) and all 23 item scores (p<.01), indicating poorer performance in the DCD group. Sensitivity (88%) and specificity (92%) were good. The DCDDaily-Q better predicted DCD than currently used questionnaires (R2=.88). In conclusion, the DCDDaily-Q is a valid and reliable questionnaire to address children's ADL performance.

Activities of daily living in children with developmental coordination disorder: Performance, learning, and participation

Background Children with developmental coordination disorder (DCD) face evident motor difficulties in daily functioning. Little is known, however, about their difficulties in specific activities of daily living (ADL). Objective The purposes of this study were: (1) to investigate differences between children with DCD and their peers with typical development for ADL performance, learning, and participation, and (2) to explore the predictive values of these aspects. Design. This was a cross-sectional study. Methods In both a clinical sample of children diagnosed with DCD (n=25 [21 male, 4 female], age range=5-8 years) and a group of peers with typical development (25 matched controls), the children’s parents completed the DCDDaily-Q. Differences in scores between the groups were investigated using t tests for performance and participation and Pearson chi-square analysis for learning. Multiple regression analyses were performed to explore the predictive values of performance, learning, and participation. Results Compared with their peers, children with DCD showed poor performance of ADL and less frequent participation in some ADL. Children with DCD demonstrated heterogeneous patterns of performance (poor in 10%-80% of the items) and learning (delayed in 0%-100% of the items). In the DCD group, delays in learning of ADL were a predictor for poor performance of ADL, and poor performance of ADL was a predictor for less frequent participation in ADL compared with the control group. Limitations A limited number of children with DCD were addressed in this study. Conclusions This study highlights the impact of DCD on children’s daily lives and the need for tailored intervention.

Development and psychometric properties of the DCDDaily: a new test for clinical assessment of capacity in activities of daily living in children with developmental coordination disorder

Objective To develop the DCDDaily, an instrument for objective and standardized clinical assessment of capacity in activities of daily living (ADL) in children with developmental coordination disorder (DCD), and to investigate its usability, reliability, and validity. Subjects Five to eight-year-old children with and without DCD. Main measures The DCDDaily was developed based on thorough review of the literature and extensive expert involvement. To investigate the usability (assessment time and feasibility), reliability (internal consistency and repeatability), and validity (concurrent and discriminant validity) of the DCDDaily, children were assessed with the DCDDaily and the Movement Assessment Battery for Children-2 Test, and their parents filled in the Movement Assessment Battery for Children-2 Checklist and Developmental Coordination Disorder Questionnaire. Results 459 children were assessed (DCD group, n = 55; normative reference group, n = 404). Assessment was possible within 30 minutes and in any clinical setting. For internal consistency, Cronbach’s α = 0.83. Intraclass correlation = 0.87 for test–retest reliability and 0.89 for inter-rater reliability. Concurrent correlations with Movement Assessment Battery for Children-2 Test and questionnaires were ρ = −0.494, 0.239, and −0.284, p < 0.001. Discriminant validity measures showed significantly worse performance in the DCD group than in the control group (mean (SD) score 33 (5.6) versus 26 (4.3), p < 0.001). The area under curve characteristic = 0.872, sensitivity and specificity were 80%. Conclusions The DCDDaily is a valid and reliable instrument for clinical assessment of capacity in ADL, that is feasible for use in clinical practice.

Randomised Evaluation of New Technologies within the Population‐Based Cervical Cancer Screening Programme in Finland: Cross‐Sectional Performance and Validity

A randomised and population-based screening design with new technologies has been applied to the organised cervical cancer screening programme in Finland. In this experiment the women invited to routine five-yearly screening are individually randomised to be screened with automation-assisted cytology, human papillomavirus (HPV) test or conventional cytology. By using the randomised design, the ultimate aim is to assess and compare the long-term outcomes of the different screening regimens. The primary aim of the current study was to evaluate, based on the material collected during the implementation phase of the Finnish randomised screening experiment, the cross-sectional performance and validity of automation-assisted cytology (Papnet system) and primary HPV DNA testing (Hybrid Capture II assay for 13 oncogenic HPV types) within service screening, in comparison to conventional cytology. The parameters of interest were test positivity rate, histological detection rate, relative sensitivity, relative specificity and positive predictive value. Also, the effect of variation in performance by screening laboratory on age-adjusted cervical cancer incidence was assessed. Based on the cross-sectional results, almost no differences were observed in the performance of conventional and automation-assisted screening. Instead, primary HPV screening found 58% (95% confidence interval 19-109%) more cervical lesions than conventional screening. However, this was mainly due to overrepresentation of mild- and moderate-grade lesions and, thus, is likely to result in overtreatment since a great deal of these lesions would never progress to invasive cancer. Primary screening with an HPV DNA test alone caused substantial loss in specificity in comparison to cytological screening. With the use of cytology triage test, the specificity of HPV screening improved close to the level of conventional cytology. The specificity of primary HPV screening was also increased by increasing the test positivity cutoff from the level recommended for clinical use, but the increase was more modest than the one gained with the use of cytology triage. The performance of the cervical cancer screening programme varied widely between the screening laboratories, but the variation in overall programme effectiveness between respective populations was more marginal from the very beginning of the organised screening activity. Thus, conclusive interpretations on the quality or success of screening should not be based on performance parameters only. In the evaluation of cervical cancer screening the outcome should be selected as closely as possible to the true measure of programme effectiveness, which is the number of invasive cervical cancers and subsequent deaths prevented in the target population. The evaluation of benefits and adverse effects of each new suggested screening technology should be performed before the technology becomes an accepted routine in the existing screening programme. At best, the evaluation is performed randomised, within the population and screening programme in question, which makes the results directly applicable to routine use.