Choosing which ear to implant in adult candidates with functional residual hearing

This study examined whether audiologists consider the potential benefits of contralateral hearing aid use following cochlear implantation when recommending which ear to implant in UK adult candidates with residual hearing. Thirty-four audiologists from providers of adult implantation services completed a decision-choice experiment. Clinicians were willing to consider recommending that the poorer ear be implanted, provided it had been aided continuously, suggesting that their decision making seeks to preserve access to residual hearing in the non-implanted ear where possible. Future approaches to determining candidacy should therefore consider that a sub-set of patients may obtain additional benefit from this residual hearing following implantation

Interpreting the Tinnitus Questionnaire (German version): what individual differences are clinically important?

Objective: Reporting of clinical significance is recommended because findings can be statistically significant without being relevant to patients. For aiding clinical interpretation of the Tinnitus Questionnaire (TQ), many investigators use a 5-point change cut-off as a minimal clinically important difference (MCID). But there are shortcomings in how this value was originally determined. Design: The MCID was evaluated by analysing retrospective clinical data on the TQ (German version). Following recommended standards, multiple estimates were computed using anchor- and distribution-based statistical methods. These took into account not only patients’ experience of clinical improvement, but also measurement reliability. Study sample: Pre- and post-intervention scores were assessed for 202 patients. Results: Our six estimates ranged from 5 to 21 points in TQ change score from pre- to post- intervention. The 5-point TQ change score was obtained using a method that considered change between groups, and did not account for measurement error or bias. The size of the measurement error was considerable, and this comprises interpretation of individual patient change scores. Conclusions: To enhance confidence that a TQ change over time in individual patients is clinically meaningful, we advise at least the median MCID of 12 points

Systematic review of outcome domains and instruments used in clinical trials of tinnitus treatments in adults

BACKGROUND: There is no evidence-based guidance to facilitate design decisions for confirmatory trials or systematic reviews investigating treatment efficacy for adults with tinnitus. This systematic review therefore seeks to ascertain the current status of trial designs by identifying and evaluating the reporting of outcome domains and instruments in the treatment of adults with tinnitus. METHODS: Records were identified by searching PubMed, EMBASE CINAHL, EBSCO, and CENTRAL clinical trial registries (ClinicalTrials.gov, ISRCTN, ICTRP) and the Cochrane Database of Systematic Reviews. Eligible records were those published from 1 July 2006 to 12 March 2015. Included studies were those reporting adults aged 18 years or older who reported tinnitus as a primary complaint, and who were enrolled into a randomised controlled trial, a before and after study, a non-randomised controlled trial, a case-controlled study or a cohort study, and written in English. Studies with fewer than 20 participants were excluded. RESULTS: Two hundred and twenty-eight studies were included. Thirty-five different primary outcome domains were identified spanning seven categories (tinnitus percept, impact of tinnitus, co-occurring complaints, quality of life, body structures and function, treatment-related outcomes and unclear or not specified). Over half the studies (55 %) did not clearly define the complaint of interest. Tinnitus loudness was the domain most often reported (14 %), followed by tinnitus distress (7 %). Seventy-eight different primary outcome instruments were identified. Instruments assessing multiple attributes of the impact of tinnitus were most common (34 %). Overall, 24 different patient-reported tools were used, predominantly the Tinnitus Handicap Inventory (15 %). Loudness was measured in diverse ways including a numerical rating scale (8 %), loudness matching (4 %), minimum masking level (1 %) and loudness discomfort level (1 %). Ten percent of studies did not clearly report the instrument used. CONCLUSIONS: Our findings indicate poor appreciation of the basic principles of good trial design, particularly the importance of specifying what aspect of therapeutic benefit is the main outcome. No single outcome was reported in all studies and there was a broad diversity of outcome instruments. PROSPERO REGISTRATION: The systematic review protocol is registered on PROSPERO (International Prospective Register of Systematic Reviews): CRD42015017525. Registered on 12 March 2015 revised on 15 March 2016. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1186/s13063-016-1399-9) contains supplementary material, which is available to authorized users

Prevalence of peripapillary choroidal neovascular membranes (PPCNV) in an elderly UK population—the Bridlington eye assessment project (BEAP): a cross-sectional study (2002–2006)

© 2018, The Royal College of Ophthalmologists. Purpose: There is paucity of data on the epidemiology of peripapillary choroidal neovascularisartion (PPCNV). Our aim was to determine prevalence of PPCNV in the elderly UK population of Bridlington residents aged ≥65 years. Methods: Eyes with PPCNV in the Bridlington eye assessment project (BEAP) database of 3475 participants were analysed. PPCNV outline was drawn, its area measured, and clock-hour involvement of disc circumference recorded. Location and shortest distance from the lesion edge to fovea were recorded. Masked grading for age-related maculopathy (ARM)/reticular pseudodrusen (RPD) within the ETDRS grid was assigned for each eye using a modified Rotterdam scale. Peripapillary retinal pigment epithelial (RPE) changes/drusen were recorded. Visual acuity (VA) and demographic details analysed separately were merged with grading data. Results: PPCNV were identified in ten subjects, and were bilateral in two (20%), a population prevalence of 0.29%, and 0.06% bilaterality. Gender-specific prevalence were 0.36% and 0.19% for females and males, respectively. Age ranged from 66 to 85 years [mean 76.3 (SD 6.4)]. PPCNV were located nasal to disc in 41.7%, measuring 0.46–7.93 mm 2 [mean 2.81 mm 2 (SD 2.82)]. All PPCNV eyes had peripapillary RPE changes. One subject had no ARM, 1 angioid streaks, and 30% RPD. No direct foveal involvement, or reduced VA attributable to PPCNV was observed. Conclusion: PPCNV were infrequent in this population, more common in females, and often located nasal to the disc, without foveal extension. Peripapillary degenerative changes were universal, and strong association with ARM was observed in eyes with PPCNV. Typically, PPCNV were asymptomatic with VA preservation

Cost effectiveness of support for people starting a new medication for a long term condition through community pharmacies: an economic evaluation of the New Medicine Service (NMS) compared with normal practice

Background: The English community pharmacy New Medicine Service (NMS) significantly increases patient adherence to medicines, compared with normal practice. We examined the cost-effectiveness of NMS compared with normal practice by combining adherence improvement and intervention costs with the effect of increased adherence on patient outcomes and healthcare costs. Methods: We developed Markov models for diseases targeted by the NMS (hypertension, type 2 diabetes, chronic obstructive pulmonary disease, asthma and antiplatelet regimens) to assess the impact of patients’ non-adherence. Clinical event probability, treatment pathway, resource-use and costs were extracted from literature and costing tariffs. Incremental costs and outcomes associated with each disease were incorporated additively into a composite probabilistic model and combined with adherence rates and intervention costs from the trial. Costs per extra quality-adjusted-life-year(QALY) were calculated from the perspective of NHS England, using a lifetime horizon. Results: NMS generated a mean of 0.05 (95%CI: 0.00, 0.13) more QALYs per patient, at a mean reduced cost of -£144 (95%CI: -769, 73). The NMS dominates normal practice with probability of 0.78 (ICER: - £3166 per QALY). NMS has a 96.7% probability of cost-effectiveness compared with normal practice at a willingness-to-pay of £20000 per QALY. Sensitivity analysis demonstrated that targeting each disease with NMS has a probability over 0.90 of cost-effectiveness compared with normal practice at a willingness-to-pay of £20000 per QALY. Conclusions: Our study suggests that the New Medicine Service increased patient medicine adherence compared with normal practice, which translated into increased health gain at reduced overall cost

Tuotantoprosessin kehittäminen Case Vähälä Logistics Oy

Opinnäytetyön tarkoituksena oli tutkia voiteluaineiden noutojakeluprosessia Vähälä Logistics Oy:ssä. Vähälä Logistics Oy on osa valtakunnallista Kiitolinjaketjua, jossa se vastaa Oulun ja Lapin läänin sekä Keski-Suomen kappaletavaraliikenteestä. Työssä tutkittiin mahdollisuuksia tuotantoprosessin läpimenoajan lyhentämiseksi ja voiteluaineiden lajitteluun liittyvää resursointia. Tutkimus rajattiin koskemaan Oulun terminaalissa tapahtuvaa lajittelua. Teoriaosuudessa käytiin yleisesti läpi prosessi ja prosessien kehittämisen vaiheet. Teoriaosuuden tiedot kerättiin kirjallisuudesta ja internetistä. Tutkimusosuudessa prosessi kuvattiin sanallisesti ja prosessikaaviota hyväksi käyttäen. Tietoa kerättiin edelleen kirjallisuudesta, internetistä ja haastattelemalla prosessissa työskenteleviä ja siitä tietoisia henkilöitä. Kuvauksessa kiinnitettiin huomioita prosessin kriittisiin tekijöihin. Prosessikuvauksen analysoinnilla pyrittiin löytämään päällekäisiä vastuita ja kiinnittämään huomiota poikkeamiin. Prosessikuvauksesta kävi ilmi, että voiteluaineiden lajittelu viivästyy ruuhkautuneen lajittelupaikan vuoksi. Tähän johtavia syitä pohditiin ja pyrittiin antamaan toimenpide-ehdotuksia viivästysten välttämiseen.The purpose of this thesis was to examine the lubricant pick up and distribution process in Vähälä Logistics Oy. Vähälä Logistics is part of the nationwide Kiitolinja chain, in which it is responsible for Oulu and Lapland County and Central Finland parcelled goods traffic. The study examined the possibilities of the production lead time reduction and lubricants' sorting resourcing. The study focused on sorting in the terminal of Oulu. The theoretical part describes the process and the process development stages. The theory part's information was gathered from literature and the Internet. The research section described the process in words and by using a process diagram. Information was gathered from literature, the Internet and by interviewing the people aware of the process. The process description aimed at finding the critical points of the process and the duplication in responsibilities and paying attention to the deviations. The process description revealed that sorting of lubricants is delayed due to congested sorting place. Causes for this were discussed, and proposals for measures to avoid delays were make

Predicting the outcome of Legg-Calve-Perthes' disease in children under six years old

Purpose In this study, we investigated the outcome of Legg-Calve-Perthes disease in children presenting under 6 years old. Firstly, we wished to know the outcome in terms of femoral head deformity in this age group. Secondly, we investigated the potential for improvement in femoral head deformity with growth and remodelling after the Perthes lesion had healed. Thirdly, we assessed the ability of Herring's lateral pillar classification to predict femoral head deformity in this age group. Methods The outcome in this group was assessed using Stulberg's classification of femoral head deformity and compared to that for older children with Perthes seen at our institution over the same period. To investigate the potential for improvement of Stulberg grade with growth we assessed the hips at the stage of final healing (Waldenstrom IV) and again at skeletal maturity. To assess whether Herring's classification of lateral column collapse is predictive of deformity at this age we recorded the Herring class A, B or C at the time of maximum fragmentation and compared this to Stulberg grade. Results Out of a total of 127 children (131 hips) seen at our institution, 67 children (69 hips) presented before the age of 6 years. The number of Stulberg III and IV hips was 14 (20%) and 10 (15%), respectively. Chi-squared test of age against outcome confirmed that the younger children overall had a better outcome (P < 0.001). Stulberg grade did not improve predictably after the stage of final healing. Twenty-three hips graded as Stulberg III and IV at Waldenstrom IV were reassessed at skeletal maturity. Three changed from Stulberg III to IV and five changed from Stulberg IV to III, but none had improved to Stulberg I/II. Herring's classification was predictive of outcome, with 96% of Herring A hips having Stulberg I or II outcome, 61% of Herring B hips having Stulberg I or II outcome, while 60% of Herring C hips (18 hips) had significant femoral head deformity, and 10 hips Stulberg III and 6 hips Stulberg IV. Conclusions Perthes in children presenting before 6 years of age can result in significant femoral head deformity which does not predictably improve with time. The risk of a poor outcome can be predicted by Herring's classification of lateral pillar collapse

Echocardiography-based score to predict outcome after renal transplantation

Background: Given the high cardiac mortality of renal transplant recipients, identification of high-risk patients is important to offer appropriate treatment before transplantation.Aim: To determine patients with high mortality after renal transplantation despite selection according to current criteria.Methods: Preoperative parameters were collected from 203 renal transplant recipients over a follow-up time of 3.6 (1.9) years. The primary end point was all-cause mortality.Results: 22 deaths (11%) and 12 cardiac failures (6%) were observed. Non-survivors were older (p0.001), had larger left ventricular end-systolic diameter (LVSD) (p0.001) and end-diastolic diameter (p = 0.002), and lower ejection fraction (p0.001). Left ventricular mass index (p = 0.001), maximal wall thickness (p = 0.006) and the proportion with mitral annular calcification (p = 0.001) were significantly higher in the non-survivors. The risk factors for ischaemic heart disease and exercise test data were not significantly different between the two groups. Four independent predictors of mortality after renal transplantation were identified: age 50 years (p = 0.002), LVESD 3.5 cm (p = 0.002), maximal wall thickness 1.4 cm (p = 0.014) and mitral annular calcification (p = 0.036). The 5-year survival estimates for 0, 1, 2 and 3 prognostic factors were 96%, 86%, 69% and 38%, respectively. No patient had four prognostic factors. In patients 50 years, the 5-year survival estimates for 0, 1 and 2 additional prognostic factors were 73%, 45% and 18%, respectively.Conclusion: In addition to selection according to current guidelines, age and three conventional echocardiography parameters may further improve risk stratification before renal transplantation.Abbreviations: LVEF, left ventricular ejection fraction; LVESD, left ventricular end-systolic diamete