Following up the head injured driver: self versus family assessment.

Driving is an important issue after head injury. This study explores the usefulness of self and family report measures in enhancing our knowledge of head injured peoples' driving. The data was gained from a screening questionnaire given to a head injury clinic cohort and from separate interviews with both head injured drivers and healthy family members. Fifty head injured people who had driven pre-injury participated in the screen and 18 of those who had returned to driving participated in interviews with a close family member. It was predicted changes compared to pre-injury would be perceived in head injured people's driving across the domains of driving skills, behaviours/attitudes and accident rates. It was further predicted issues of insight would be raised from differences between the perceptions of head injured people themselves and family members.Respondents suggested driving was an important issue for head injured people regardless of whether they had returned to driving. Despite this, some had not received information or informed the authorities about their head injuries. Three consistent themes were suggested about post-injury driving. Firstly, there was no evidence of perceived declines in basic driving aspects or increased accident rates. Secondly, specific changes were perceived in: variables similar to the residual psychological difficulties of head injury; head injured drivers' attempts to engage in less risky driving; and the amount of anxiety engendered by driving. Thirdly, although less of an issue than expected, single cases were highlighted where insight may have been a problem.Although interpretation of the results was tempered by methodological considerations, the findings are discussed and the service implications considered. A further longitudinal research programme has been proposed

З історії запровадження метричних книг на українських землях

In article features of introduction of metric books on the Ukrainian earths in XVII-XVIII cent are considered and analyzed

The clinical and cost-effectiveness of rehabilitation of memory in brain injury: the ReMemBrIn RCT

Background People with traumatic brain injuries (TBIs) commonly report memory impairments. These are persistent, debilitating, and reduce quality of life, but patients do not routinely receive memory rehabilitation after discharge from hospital. Objectives To assess the clinical and cost-effectiveness of a group memory rehabilitation programme for people with TBI. Design Multi-centre, pragmatic, cluster randomised controlled trial. Qualitative and health economic evaluations were also undertaken. Setting Community settings in nine sites in England. Participants Participants were aged 18-69 years, with TBI more than 3 months prior to recruitment, reported memory problems, who were able to travel to a site to attend group sessions, communicate in English, and gave informed consent. Randomisation and blinding Clusters of 4 to 6 participants were randomised to intervention or control on a 1:1 ratio. Randomisation was based on a computer generated pseudo-random code using random permuted blocks of randomly varying size, stratified by study site. Participants and therapists were aware of the treatment allocation; outcome assessors were blinded. Interventions Ten weekly sessions of a manualised memory rehabilitation programme were provided in addition to usual care. Participants were taught restitution strategies to retrain impaired memory functions and compensation strategies to enable them to cope with memory problems. The control arm received usual care only. Outcomes Outcomes were assessed at 6 and 12 months after randomisation. Primary: Patient-completed Everyday Memory Questionnaire (EMQ-p) at 6-month follow-up. Secondary: Rivermead Behavioural Memory Test-3, General Health Questionnaire-30, European Brain Injury Questionnaire, Everyday Memory Questionnaire-relative version, individual goal attainment. Costs (based on a UK NHS and PSS perspective) were collected using a service use questionnaire, with the EQ-5D 5L used to derive Quality Adjusted Life Years. A Markov model was developed to explore cost-effectiveness at 5 and 10 years, with 3.5% discount applied. Results We randomised 328 participants (intervention: n=171; control: n=157), with 129 in the intervention arm and 122 in the control arm included in the primary analysis. We found no clinically important difference on the EMQ-p between the two arms at 6-month follow-up (adjusted difference in means -2.1, 95% CI -6.7 to 2.5, p=0.37). For secondary outcomes, differences favouring the intervention arm were observed at 6-month follow-up for RBMT and goal attainment, but remained only for goal attainment at 12-month follow-up. There were no differences between arms in mood or quality of life. Qualitative results suggested positive experiences of participating in the trial and of attending the groups. Participants reported that memory rehabilitation was not routinely accessible in usual care. The primary health economics outcome at 12-months found memory rehabilitation to be £26.89 cheaper than usual care but less effective with an incremental QALY loss of 0.007. Differences in costs and effects were not statistically significant and non-parametric bootstrapping demonstrated considerable uncertainty in these findings. No safety concerns were raised and no deaths reported. Limitations As a pragmatic trial, we had broad inclusion criteria, therefore there was considerable heterogeneity within the sample. The study was not powered to perform further sub-group analyses. Participants and therapists could not be blinded to treatment allocation. Conclusions The group memory rehabilitation delivered in this trial is very unlikely to lead to clinical benefits or to be a cost-effective treatment for people with TBI in the community. Future work Future studies should examine the inclusion and selection of participants who may benefit most from memory rehabilitation. Registration ISRCTN65792154 Funding National Institute for Health Research, Health Technology Assessmen

Myocardial Fibrosis and Cardiac Decompensation in Aortic Stenosis

OBJECTIVES: Cardiac magnetic resonance (CMR) was used to investigate the extracellular compartment and myocardial fibrosis in patients with aortic stenosis, as well as their association with other measures of left ventricular decompensation and mortality. BACKGROUND: Progressive myocardial fibrosis drives the transition from hypertrophy to heart failure in aortic stenosis. Diffuse fibrosis is associated with extracellular volume expansion that is detectable by T1 mapping, whereas late gadolinium enhancement (LGE) detects replacement fibrosis. METHODS: In a prospective observational cohort study, 203 subjects (166 with aortic stenosis [69 years; 69% male]; 37 healthy volunteers [68 years; 65% male]) underwent comprehensive phenotypic characterization with clinical imaging and biomarker evaluation. On CMR, we quantified the total extracellular volume of the myocardium indexed to body surface area (iECV). The iECV upper limit of normal from the control group (22.5 ml/m(2)) was used to define extracellular compartment expansion. Areas of replacement mid-wall LGE were also identified. All-cause mortality was determined during 2.9 ± 0.8 years of follow up. RESULTS: iECV demonstrated a good correlation with diffuse histological fibrosis on myocardial biopsies (r = 0.87; p < 0.001; n = 11) and was increased in patients with aortic stenosis (23.6 ± 7.2 ml/m(2) vs. 16.1 ± 3.2 ml/m(2) in control subjects; p < 0.001). iECV was used together with LGE to categorize patients with normal myocardium (iECV <22.5 ml/m(2); 51% of patients), extracellular expansion (iECV ≥22.5 ml/m(2); 22%), and replacement fibrosis (presence of mid-wall LGE, 27%). There was evidence of increasing hypertrophy, myocardial injury, diastolic dysfunction, and longitudinal systolic dysfunction consistent with progressive left ventricular decompensation (all p < 0.05) across these groups. Moreover, this categorization was of prognostic value with stepwise increases in unadjusted all-cause mortality (8 deaths/1,000 patient-years vs. 36 deaths/1,000 patient-years vs. 71 deaths/1,000 patient-years, respectively; p = 0.009). CONCLUSIONS: CMR detects ventricular decompensation in aortic stenosis through the identification of myocardial extracellular expansion and replacement fibrosis. This holds major promise in tracking myocardial health in valve disease and for optimizing the timing of valve replacement. (The Role of Myocardial Fibrosis in Patients With Aortic Stenosis; NCT01755936)

Association between Hypertension and Retinal Vascular Features in Ultra-Widefield Fundus Imaging

Objective: Changes to the retinal vasculature are known to be associated with hypertension independently of traditional risk factors. We investigated whether measurements of retinal vascular calibre from ultra-widefield fundus imaging were associated with hypertensive status.Methods: We retrospectively collected and semiautomatically measured ultra-widefield retinal fundus images from a subset of participants enrolled in an ongoing population study of ageing, categorised as normotensive or hypertensive according to thresholds on systolic/diastolic blood pressure (140/90 mm Hg) measured in a clinical setting. Vascular calibre in the peripheral retina was measured to calculate the nasal-annular arteriole:venule ratio (NA-AVR), a novel combined parameter.Results: Left and right eyes were analysed from 440 participants (aged 50-59 years, mean age of 54.6±2.9 years, 247, 56.1% women), including 151 (34.3%) categorised as hypertensive. Arterioles were thinner and the NA-AVR was smaller in people with hypertension. The area under the receiver operating characteristic curve of NA-AVR for hypertensive status was 0.73 (95% CI 0.68 to 0.78) using measurements from left eyes, while for right eyes, it was 0.64 (95% CI 0.59 to 0.70), representing evidence of a statistically significant difference between the eyes (p=0.020).Conclusions: Semiautomated measurements of NA-AVR in ultra-widefield fundus imaging were associated with hypertension. With further development, this may help screen people attending routine eye health check-ups for high blood pressure. These individuals may then follow a care pathway for suspected hypertension. Our results showed differences between left and right eyes, highlighting the importance of investigating both eyes of a patient.</p

A group memory rehabilitation programme for people with traumatic brain injuries: the ReMemBrIn RCT

Main outcome measures: Outcomes were assessed at 6 and 12 months after randomisation. Primary outcome: patient-completed Everyday Memory Questionnaire – patient version (EMQ-p) at 6 months’ follow-up. Secondary outcomes: Rivermead Behavioural Memory Test – third edition (RBMT-3), General Health Questionnaire 30-item version, European Brain Injury Questionnaire, Everyday Memory Questionnaire – relative version and individual goal attainment. Costs (based on a UK NHS and Personal Social Services perspective) were collected using a service use questionnaire, with the EuroQol-5 Dimensions, five-level version, used to derive quality-adjusted life-years (QALYs). A Markov model was developed to explore cost-effectiveness at 5 and 10 years, with a 3.5% discount applied.Results: We randomised 328 participants (memory rehabilitation, n = 171; usual care, n = 157), with 129 in the memory rehabilitation arm and 122 in the usual-care arm included in the primary analysis. We found no clinically important difference on the EMQ-p between the two arms at 6 months’ follow-up (adjusted difference in mean scores –2.1, 95% confidence interval –6.7 to 2.5; p = 0.37). For secondary outcomes, differences favouring the memory rehabilitation arm were observed at 6 months’ follow-up for the RBMT-3 and goal attainment, but remained only for goal attainment at 12 months’ follow-up. There were no differences between arms in mood or quality of life. The qualitative results suggested positive experiences of participating in the trial and of attending the groups. Participants reported that memory rehabilitation was not routinely accessible in usual care. The primary health economics outcome at 12 months found memoryrehabilitation to be £26.89 cheaper than usual care but less effective, with an incremental QALY loss of 0.007. Differences in costs and effects were not statistically significant and non-parametric bootstrapping demonstrated considerable uncertainty in these findings. No safety concerns were raised and no deaths were reported.Limitations: As a pragmatic trial, we had broad inclusion criteria and, therefore, there was considerable heterogeneity within the sample. The study was not powered to perform further subgroup analyses.Participants and therapists could not be blinded to treatment allocation.Conclusions: The group memory rehabilitation delivered in this trial is very unlikely to lead to clinical benefits or to be a cost-effective treatment for people with TBI in the community. Future studies should examine the selection of participants who may benefit most from memory rehabilitation

Evaluation of a whole system approach to diet and healthy weight in the east of Scotland: Study protocol

Obesity is a global epidemic affecting all age groups, populations and income levels across continents. The causes of obesity are complex and are routed in health behaviours, environmental factors, government policy and the cultural and built environment. Consequently, a Whole System Approach (WSA) which considers the many causes of obesity and shifts the focus away from individuals as points of intervention and puts an emphasis on understanding and improving the system in which people live in is required. This protocol describes a programme of research that will: critically evaluate the evidence for WSAs; assess longitudinally the implementation of a WSA to diet and healthy weight to explore the range of levers (drivers) and opportunities to influence relevant partnerships and interventions to target obesity in East Scotland. The programme consists of four workstreams within a mixed methods framework: 1) Systematic review of reviews of WSAs to diet and healthy weight; 2) Longitudinal qualitative process evaluation of implementing two WSAs in Scotland; 3) Quantitative and Qualitative momentary analysis evaluation of a WSA; and 4) the application of System Dynamics Modelling (SDM) methodology to two council areas in Scotland. A Public Involvement in Research group (PIRg) have informed each stage of the research process. The research programme’s breadth and its novel nature, mean that it will provide valuable findings for the increasing numbers who commission, deliver, support and evaluate WSAs to diet and healthy weight nationally and internationally