Telemedicine for new neurological outpatients: putting a randomized controlled trial in the context of everyday practice

In a retrospective review, the telemedical management of 65 outpatients from a randomized controlled trial (RCT) of telemedicine for non-urgent referrals to a consultant neurologist was compared with the management of 76 patients seen face to face in the same trial, with that of 150 outpatients seen in the neurology clinics of district general hospitals and with that of 102 neurological outpatients seen by general physicians. Outcome measures were the numbers of investigations and of patient reviews. The telemedicine group did not differ significantly from the 150 patients seen face to face by neurologists in hospital clinics in terms of either the number of investigations or the number of reviews they received. Patients from the RCT seen face to face had significantly fewer investigations but a similar number of reviews to the other 150 patients seen face to face by neurologists (the disparity in the number of investigations may explain the negative result for telemedicine in that RCT). Patients with neurological symptoms assessed by general physicians had significantly more investigations and were reviewed significantly more often than all the other groups. Patients from the RCT seen by telemedicine were not managed significantly differently from those seen face to face by neurologists in hospital clinics but had significantly fewer investigations and follow-ups than those patients managed by general physicians. The results suggest that management of new neurological outpatients by neurologists using telemedicine is similar to that by neurologists using a face-to-face consultation, and is more efficient than management by general physicians.

Should we debrief and counsel people who have had psychological shock?

Design: Randomised controlled trial of psychological debriefing. Setting: A British teaching hospital (the Radcliffe Hospital, Oxford). Patients: 66 men and 40 women, aged 17–69 years, admitted to hospital after a motor vehicle accident. Most had been the driver of a car. Median admission duration was four days for the 52 control patients and eight days for the 54 who underwent the intervention. Interventions: A debriefing of about one hour on Day 2 of admission, encouraging patients to describe the accident and express their emotions, followed by a cognitive appraisal which included describing common reactions to traumatic experiences and suggesting a range of people who might be able to assist in the future, including the patient's general practitioner. 91 patients were assessed at four months and 61 were assessed at three years. Control patients had no debriefing or counselling. Main outcome measures: Impact of Event Scale (IES, which focuses on intrusive thoughts and avoidance of similar situations to the event); Brief Symptom Inventory (BSI, a measure of 53 symptoms); and other questions related to physical pain and functional activities. Main results: At four months there was still considerable psychological morbidity among the patients who were followed up. There was a significant difference (P < 0.05) in changes of IES between the 42 who received the intervention, in whom it increased from 15 (standard deviation [SD], 15) to 16 (SD, 15), and the 49 controls, in whom it fell from 15 (SD, 12) to 13 (SD, 14). Similarly, two subscales of the BSI score changed significantly between the intervention group, among whom it deteriorated from 0.5 (SD, 0.5) to 0.6 (SD, 0.8), and the control s, in whom it hardly changed from 0.4 (SD, 0.3) to 0.4 (SD, 0.4). Among the 61 patients followed for three years, the 30 randomised to receive the intervention were significantly worse, by self-report, both psychologically and physically. Their mean IES score deteriorated from a baseline of 15 (SD, 14) to 16 (SD, 18). In comparison, scores for the 31 control patients improved from 16 (SD, 12) to 13 (SD, 17). The difference in change was significant (P < 0.05). Among all patients with high initial scores, these decreased among the controls but not among those receiving the intervention. Conclusion: Psychological counselling should only be used in the context of trials rather than routine care.

Cholesterol-lowering therapy with pravastatin in patients with average cholesterol levels and established ischaemic heart disease: is it cost-effective?

Objective: To measure the cost-effectiveness of cholesterol-lowering therapy with pravastatin in patients with established ischaemic heart disease and average baseline cholesterol levels. Design: Prospective economic evaluation within a double-blind randomised trial (Long-Term Intervention with Pravastatin in Ischaemic Disease [LIPID]), in which patients with a history of unstable angina or previous myocardial infarction were randomised to receive 40 mg of pravastatin daily or matching placebo. Patients and setting: 9014 patients aged 35-75 years from 85 centres in Australia and New Zealand, recruited from June 1990 to December 1992. Main outcome measures: Cost per death averted, cost per life-year gained, and cost per quality-adjusted life-year gained, calculated from measures of hospitalisations, medication use, outpatient visits, and quality of life. Results: The LIPID trial showed a 22% relative reduction in all-cause mortality (P < 0.001). Over a mean follow-up of 6 years, hospital admissions for coronary heart disease and coronary revascularisation were reduced by about 20%. Over this period, pravastatin cost $A4913 per patient, but reduced total hospitalisation costs by $A1385 per patient and other long-term medication costs by $A360 per patient. In a subsample of patients, average quality of life was 0.98 (where 0 = dead and 1 = normal good health); the treatment groups were not significantly different. The absolute reduction in all-cause mortality was 3.0% (95% CI, 1.6%-4.4%), and the incremental cost was $3246 per patient, resulting in a cost per life saved of $107730 (95% Cl, $68626-$209881) within the study period. Extrapolating long-term survival from the placebo group, the undiscounted cost per life-year saved was $7695 (and $10 938 with costs and life-years discounted at an annual rate of 5%). Conclusions: Pravastatin therapy for patients with a history of myocardial infarction or unstable angina and average cholesterol levels reduces all-cause mortality and appears cost effective compared with accepted treatments in high-income countries.

Ross River virus disease in tropical Queensland: evolution of rheumatic manifestations in an inception cohort followed for six months

Objective: To describe the natural history of rheumatic manifestations of Ross River virus (RRV) disease. Design: Prospective longitudinal clinical review. Setting: North Queensland local government areas of Cairns, Douglas, Mareeba and Atherton during January to May 1998. Participants: General practice patients diagnosed with RRV disease on the basis of symptoms and a positive RRV IgM result. Main outcome measures: Rheumatic symptoms and signs assessed as soon as possible after disease onset and on two subsequent occasions (up to 6.5 months after onset). Results: 57 patients were recruited, 47 of whom were reviewed three times (at means of 1.1, 2.4 and 3.6 months after disease onset). Results are reported for these 47: 46 (98%) complained of joint pain at first review, with the ankles, wrists, fingers, knees and metacarpophalangeal joints (II-IV) most commonly involved. Prevalence of joint pain decreased progressively on second and third reviews, both overall (92% and 68% of patients, respectively), and in the five joints most commonly affected. The prevalence of other common rheumatic symptoms and signs, and use of non-steroidal anti-inflammatory drugs, also progressively declined over the three reviews. Conclusions: Earlier studies may have overestimated the prevalence and duration of symptoms in RRV disease. Progressive resolution over 3-6 months appears usual.

Further evidence for the agreement between patients with stroke and their proxies on the Frenchay Activities Index

Objective: To determine item, subscale and total score agreement on the Frenchay Activities Index (FAI) between stroke patients and proxies six months after discharge from rehabilitation. Design: Prospective study design. Setting/subjects: Fifty patient-proxy pairs, interviewed separately, in the patient's residence. Main outcome measures: Modified FAI using 13 items. Individual FAI items, subscales and total score agreement as measured by weighted kappa and intraclass correlation coefficients (ICC). Results: Excellent agreement was found for the total FAI (ICC 0.87, 95% confidence interval (CI) 0.78-0.93), and domestic (ICC 0.85, 95% CI 0.73-0.91) and outdoor (ICC 0.87, 95% CI 0.78-0.95) subscales, with moderate agreement found for the work/leisure subscale (ICC 0.63, 95% CI 0.34-0.78). For the individual FAI items, good, moderate, fair and poor agreement was found for five, three, four and one item, respectively. The best agreement was for objective items of preparing meals, washing-up, washing clothes, shopping and driving. The poorest agreement was for participation in hobbies, social outings and heavy housework. Scoring biases associated with patient or proxy demographic characteristics were found. Female proxies, and those who were spouses, scored patients lower on domestic activities; male patients, and those who were younger, scored themselves higher on outdoor activities and higher patient FIM scores were positively correlated with higher FAI scores. Conclusions: While total and subscale agreement on the FAI was high, individual item agreement varied. Proxy scores should be used with caution due to bias.

Escalation of Drug Use in Early-Onset Cannabis Users vs Co-twin Controls

Context Previous studies have reported that early initiation of cannabis (marijuana) use is a significant risk factor for other drug use and drug-related problems. Objective To examine whether the association between early cannabis use and subsequent progression to use of other drugs and drug abuse/dependence persists after controlling for genetic and shared environmental influences. Design Cross-sectional survey conducted in 1996-2000 among an Australian national volunteer sample of 311 young adult (median age, 30 years) monozygotic and dizygotic same-sex twin pairs discordant for early cannabis use (before age 17 years). Main Outcome Measures Self-reported subsequent nonmedical use of prescription sedatives, hallucinogens, cocaine/other stimulants, and opioids; abuse or dependence on these drugs (including cannabis abuse/dependence); and alcohol dependence. Results Individuals who used cannabis by age 17 years had odds of other drug use, alcohol dependence, and drug abuse/dependence that were 2.1 to 5.2 times higher than those of their co-twin, who did not use cannabis before age 17 years. Controlling for known risk factors (early-onset alcohol or tobacco use, parental conflict/separation, childhood sexual abuse, conduct disorder, major depression, and social anxiety) had only negligible effects on these results. These associations did not differ significantly between monozygotic and dizygotic twins. Conclusions Associations between early cannabis use and later drug use and abuse/dependence cannot solely be explained by common predisposing genetic or shared environmental factors. The association may arise from the effects of the peer and social context within which cannabis is used and obtained. In particular, early access to and use of cannabis may reduce perceived barriers against the use of other illegal drugs and provide access to these drugs.

Effect of fatigue on torque output and electromyographic measures of trunk muscles during isometric axial rotation

Objectives: To examine the changes in torque output resulting from fatigue, as well as changes in electromyographic measures of trunk muscles during isometric axial rotation and to compare these changes between directions of axial rotation. Design: Subjects performed fatiguing right and left isometric axial rotation of the trunk at 80% of maximum voluntary contraction while standing upright. Setting: A rehabilitation center. Participants: Twenty-three men with no history of back pain. Interventions: Not applicable. Main Outcome Measures: Surface electromyographic Signals were recorded from 6 trunk muscles bilaterally. The primary torque in the transverse plane and the coupling torques in sagittal and coronal planes were also measured. Results: During the fatiguing axial rotation contraction, coupling torques of both sagittal and coronal planes were slightly decreased and no difference was found between directions of axial rotation. Decreasing median frequency and an increase in electromyographic amplitude were also found in trunk muscles with different degrees of changes in individual muscles. There were significant differences (P

Reliability of electromyographic and torque measures during isometric axial rotation exertions of the trunk

Objective: The aim of the present study was to investigate the between-days reliability of electromyographic (EMG) measurement of 6 bilateral trunk muscles and also the torque output in 3 planes during isometric right and left axial rotation at different exertion levels. Methods: Ten healthy subjects performed isometric right and left axial rotation at 100, 70, 50 and 30% maximum voluntary contractions in two testing sessions at least 7 days apart. EMG amplitude and frequency analyses of the recorded surface EMG signals were performed for rectus abdominis, external oblique, internal oblique, latissimus dorsi, iliocostalis lumborum and multifidus bilaterally. The primary torque in the transverse plane and the coupling torques in sagittal and coronal planes were measured. Results: For both EMG amplitude and frequency values, good (intraclass correlation coefficient, ICC = 0.75-0.89) to excellent (ICC greater than or equal to 0.90) reliability was found in the 6 trunk muscles at different exertion levels during axial rotation. The reliability of both maximal isometric axial rotation torque and coupling torques in sagittal and coronal planes were found to be excellent (ICC greater than or equal to 0.93). Conclusions: Good to excellent reliability of EMG measures of trunk muscles and torque measurements during isometric axial rotation was demonstrated. This provides further confidence of using EMG and triaxial torque assessment as outcome measures in rehabilitation and in the evaluation of the human performance in the work place. (C) 2003 International Federation of Clinical Neurophysiology. Published by Elsevier Ireland Ltd. All rights reserved.

Utilisation of outpatient cardiac rehabilitation in Queensland

Objectives: To determine patient participation rates in outpatient cardiac rehabilitation (OCR) programs; ascertain the barriers to participation; and evaluate the quality of OCR programs. Design and setting: Retrospective cohort study of patient separations from selected public and private Queensland hospitals; questionnaire survey of hospitals and all registered OCR programs. Participants: Patients discharged with cardiac diagnoses between 1 July 1999 and 30 June 2000 from 31 hospitals (24 public; 7 private). Main outcome measures: Rates of referral of hospitalised patients to OCR programs; rates of program attendance and completion; barriers to OCR referral and attendance. Results: 15186 patients were discharged with cardiac diagnoses from participating hospitals, of whom 4346 (29%) were referred to an OCR program after discharge, compared with an estimated 59% (8895/15 186) of patients who were eligible for such a program. Proportionately more patients were referred from secondary (38% [1720/4500]) and private (52% [2116/4031]; P < 0.001) hospitals than from tertiary (25% [2626/10 686]) and public (20% [2230/11 155]) hospitals. Patients undergoing coronary revascularisation procedures comprised 35% of discharges, but accounted for 56% of all program attendances. Fewer than a third of all referred patients completed OCR programs, and only 39% of available OCR program places were fully utilised. Catchment populations of programs with unused places had excess coronary mortality. Conclusion: There is significant underutilisation of facility-based OCR programs in Queensland. Procedures are required for identifying and referring eligible patients to existing programs and improving program compliance. Alternative OCR models are also required.

Impact of bronchopulmonary dysplasia, brain injury, and severe retinopathy on the outcome of extremely low-birth-weight infants at 18 months

CONTEXT: Despite more than 2 decades of outcomes research after very preterm birth, clinicians remain uncertain about the extent to which neonatal morbidities predict poor long-term outcomes of extremely low-birth-weight (ELBW) infants. OBJECTIVE: To determine the individual and combined prognostic effects of bronchopulmonary dysplasia (BPD), ultrasonographic signs of brain injury, and severe retinopathy of prematurity (ROP) on 18-month outcomes of ELBW infants. DESIGN: Inception cohort assembled for the Trial of Indomethacin Prophylaxis in Preterms (TIPP). SETTING AND PARTICIPANTS: A total of 910 infants with birth weights of 500 to 999 g who were admitted to 1 of 32 neonatal intensive care units in Canada, the United States, Australia, New Zealand, and Hong Kong between 1996 and 1998 and who survived to a postmenstrual age of 36 weeks. MAIN OUTCOME MEASURES: Combined end point of death or survival to 18 months with 1 or more of cerebral palsy, cognitive delay, severe hearing loss, and bilateral blindness. RESULTS: Each of the neonatal morbidities was similarly and independently correlated with a poor 18-month outcome. Odds ratios were 2.4 (95% confidence interval [CI], 1.8-3.2) for BPD, 3.7 (95% CI, 2.6-5.3) for brain injury, and 3.1 (95% CI, 1.9-5.0) for severe ROP. In children who were free of BPD, brain injury, and severe ROP the rate of poor long-term outcomes was 18% (95% CI, 14%-22%). Corresponding rates with any 1, any 2, and all 3 neonatal morbidities were 42% (95% CI, 37%-47%), 62% (95% CI, 53%-70%), and 88% (64%-99%), respectively. CONCLUSION: In ELBW infants who survive to a postmenstrual age of 36 weeks, a simple count of 3 common neonatal morbidities strongly predicts the risk of later death or neurosensory impairment.

Pectus Excavatum postsurgical outcome based on preoperative soft body dynamics simulation

Pectus excavatum is the most common congenital deformity of the anterior chest wall, in which an abnormal formation of the rib cage gives the chest a caved-in or sunken appearance. Today, the surgical correction of this deformity is carried out in children and adults through Nuss technic, which consists in the placement of a prosthetic bar under the sternum and over the ribs. Although this technique has been shown to be safe and reliable, not all patients have achieved adequate cosmetic outcome. This often leads to psychological problems and social stress, before and after the surgical correction. This paper targets this particular problem by presenting a method to predict the patient surgical outcome based on pre-surgical imagiologic information and chest skin dynamic modulation. The proposed approach uses the patient pre-surgical thoracic CT scan and anatomical-surgical references to perform a 3D segmentation of the left ribs, right ribs, sternum and skin. The technique encompasses three steps: a) approximation of the cartilages, between the ribs and the sternum, trough b-spline interpolation; b) a volumetric mass spring model that connects two layers - inner skin layer based on the outer pleura contour and the outer surface skin; and c) displacement of the sternum according to the prosthetic bar position. A dynamic model of the skin around the chest wall region was generated, capable of simulating the effect of the movement of the prosthetic bar along the sternum. The results were compared and validated with patient postsurgical skin surface acquired with Polhemus FastSCAN system

Estudo sobre a influência da rotatividade de postos de trabalho na prevalência de sintomatologia músculo-esquelética auto-referida

Objectivo: O objectivo deste estudo foi avaliar a eficácia de um plano de rotatividade de postos de trabalho, específico, na prevalência de sintomatologia músculo-esquelética auto-referida, de operadoras de costura. Metodologia: Realizou-se um estudo quantitativo, observacional e analítico longitudinal, onde se avaliou o efeito de uma intervenção, em 25 operadoras que se voluntariaram para o estudo, de acordo com o interesse da empresa. Foram utilizados como instrumentos de avaliação o Risk Filter, o Questionário Nórdico Músculo-Esquelético e o Rapid Upper Limbs Assessment (RULA). O projecto englobou uma análise de factores de risco e classificação dos respectivos postos de trabalho de modo a estruturar uma (re)organização do trabalho (Plano de rotatividade de postos de trabalho). Resultados: A implementação do projecto reduziu significativamente (p<0,05) a sintomatologia músculo-esquelética auto-referida, sobretudo ao nível da cervical, tornozelos e pés, punhos e mãos, tendo sido estas últimas as áreas de maior prevalência referida. Verificou-se também uma diminuição da média da intensidade de dor reportada, pelas operadoras. Conclusões: O resultado deste estudo reforça a recomendação e implementação da variação do gesto (variação biomecânica da exposição), através da implementação de um plano de rotatividade de postos de trabalho, específico, tornando-se eficaz como intervenção preventiva e promotora de saúde, no que refere às lesões musculesqueléticas relacionadas com o trabalho.

Phonological and articulation treatment approaches in Portuguese children with speech and language impairments: a randomized controlled intervention study

Background: In Portugal, the routine clinical practice of speech and language therapists (SLTs) in treating children with all types of speech sound disorder (SSD) continues to be articulation therapy (AT). There is limited use of phonological therapy (PT) or phonological awareness training in Portugal. Additionally, at an international level there is a focus on collecting information on and differentiating between the effectiveness of PT and AT for children with different types of phonologically based SSD, as well as on the role of phonological awareness in remediating SSD. It is important to collect more evidence for the most effective and efficient type of intervention approach for different SSDs and for these data to be collected from diverse linguistic and cultural perspectives. Aims: To evaluate the effectiveness of a PT and AT approach for treatment of 14 Portuguese children, aged 4.0–6.7 years, with a phonologically based SSD. Methods & Procedures: The children were randomly assigned to one of the two treatment approaches (seven children in each group). All children were treated by the same SLT, blind to the aims of the study, over three blocks of a total of 25 weekly sessions of intervention. Outcome measures of phonological ability (percentage of consonants correct (PCC), percentage occurrence of different phonological processes and phonetic inventory) were taken before and after intervention. A qualitative assessment of intervention effectiveness from the perspective of the parents of participants was included. Outcomes & Results: Both treatments were effective in improving the participants’ speech, with the children receiving PT showing a more significant improvement in PCC score than those receiving the AT. Children in the PT group also showed greater generalization to untreated words than those receiving AT. Parents reported both intervention approaches to be as effective in improving their children’s speech. Conclusions & Implications: The PT (combination of expressive phonological tasks, phonological awareness, listening and discrimination activities) proved to be an effective integrated method of improving phonological SSD in children. These findings provide some evidence for Portuguese SLTs to employ PT with children with phonologically based SSD

Use of accelerometry to measure physical activity in adults and the elderly

OBJECTIVE: To review the use of accelerometry as an objective measure of physical activity in adults and elderly people. METHODS: A systematic review of studies on the use of accelerometty as an objective measure to assess physical activity in adults were examined in PubMed Central, Web of Knowledge, EBSCO and Medline databases from March 29 to April 15, 2010. The following keywords were used: "accelerometry," "accelerometer," "physical activity," "PA," "patterns," "levels," "adults," "older adults," and "elderly," either alone or in combination using "AND" or "OR." The reference lists of the articles retrieved were examined to capture any other potentially relevant article. Of 899 studies initially identified, only 18 were fully reviewed, and their outcome measures abstracted and analyzed. RESULTS: Eleven studies were conducted in North America (United States), five in Europe, one in Africa (Cameroon) and one in Australia. Very few enrolled older people, and only one study reported the season or time of year when data was collected. The articles selected had different methods, analyses, and results, which prevented comparison between studies. CONCLUSIONS: There is a need to standardize study methods for data reporting to allow comparisons of results across studies and monitor changes in populations. These data can help design more adequate strategies for monitoring and promotion of physical activity.

TERT Promoter Mutations Are a Major Indicator of Poor Outcome in Differentiated Thyroid Carcinomas

Context: Telomerase promoter mutations (TERT) were recently described in follicular cell-derived thyroid carcinomas (FCDTC) and seem to be more prevalent in aggressive cancers. Objectives: We aimed to evaluate the frequency of TERT promoter mutations in thyroid lesions and to investigate the prognostic significance of such mutations in a large cohort of patients with differentiated thyroid carcinomas (DTCs). Design: This was a retrospective observational study. Setting and Patients: We studied 647 tumors and tumor-like lesions. A total of 469 patients with FCDTC treated and followed in five university hospitals were included. Mean follow-up (±SD) was 7.8 ± 5.8 years. Main Outcome Measures: Predictive value of TERT promoter mutations for distant metastasization, disease persistence at the end of follow-up, and disease-specific mortality. Results: TERT promoter mutations were found in 7.5% of papillary carcinomas (PTCs), 17.1% of follicular carcinomas, 29.0% of poorly differentiated carcinomas, and 33.3% of anaplastic thyroid carcinomas. Patients with TERT-mutated tumors were older (P < .001) and had larger tumors (P = .002). In DTCs, TERT promoter mutations were significantly associated with distant metastases (P < .001) and higher stage (P < .001). Patients with DTC harboring TERT promoter mutations were submitted to more radioiodine treatments (P = .009) with higher cumulative dose (P = .004) and to more treatment modalities (P = .001). At the end of follow-up, patients with TERT-mutated DTCs were more prone to have persistent disease (P = .001). TERT promoter mutations were significantly associated with disease-specific mortality [in the whole FCDTC (P < .001)] in DTCs (P < .001), PTCs (P = .001), and follicular carcinomas (P < .001). After adjusting for age at diagnosis and gender, the hazard ratio was 10.35 (95% confidence interval 2.01–53.24; P = .005) in DTC and 23.81 (95% confidence interval 1.36–415.76; P = .03) in PTCs. Conclusions: TERT promoter mutations are an indicator of clinically aggressive tumors, being correlated with worse outcome and disease-specific mortality in DTC. TERT promoter mutations have an independent prognostic value in DTC and, notably, in PTC.