Prognostic value of troponins in acute coronary syndrome depends upon patient age

Peer reviewedPostprin

Does sensory relearning improve tactile function after carpal tunnel decompression? A pragmatic, assessor-blinded, randomized clinical trial

Despite surgery for carpal tunnel syndrome (CTS) being effective in 80-90% of cases, chronic numbness and hand disability can occur. The aim of this study was to investigate whether sensory relearning improves tactile discrimination and hand function after decompression. In a multi-centre, pragmatic, randomized, controlled trial, 104 patients were randomized to sensory relearning (n=52) or control (n=52) group. 93 patients completed 12 week follow-up. Primary outcome was the Shape-Texture Identification (STI) test at 6 weeks. Secondary outcomes were touch threshold, touch localisation, dexterity and self-reported hand function. No significant group differences were seen for the primary outcome (STI) at 6 weeks or 12 weeks. Similarly, no significant group differences were observed on secondary outcomes, with the exception of self-reported hand function. A secondary Complier-Averaged-CausalEffects (CACE) analysis showed no statistically significant treatment effect on the primary outcome. Sensory relearning for tactile sensory and functional deficits after carpal tunnel decompression is not effective

The Bristol ‘OA500 study’: progression and impact of the disease after 8 years

AbstractObjective To study the natural history of peripheral joint osteoarthritis (OA) and assess its impact over eight years in a prospective study of 500 patients.Methods 500 consecutive patients with peripheral joint OA were recruited from a hospital-based rheumatology clinic. All were invited for review 3 and 8 years after entry. Joint sites involved, pain severity, change in index joints, global change in the condition, use of medication, surgery and walking aids were all recorded at each visit, and after eight years disability was assessed by the health assessment questionnaire (HAQ) and anxiety and depression by the Hospital anxiety and depression scale (HAD).Results At eight-year review, 349 patients were seen: 90% of those remaining alive. Outcome was heterogeneous. Sixty patients (17.2%) reported worsening in all three subjective parameters (pain, index joint and global change) compared with 22 (6.3%) who improved in all three parameters. Using this definition of worsening or improvement, strong baseline predictors of clinical outcome did not emerge. For further description, the group was split according to the index joint sites involved at entry to the study, there being 111 with knee OA alone, 87 with hand and knee OA, 72 with hand disease alone, and 29 with hip disease alone. Forty-four percent of those with lone hand disease at entry had acquired significant knee or hip OA 8 years later. The mean HAQ and HAD scores at 8 years were high, especially in those with knee disease, indicating significant disability as a result of the disease. Those with knee or knee and hand disease had the worst outcome in all parameters recorded. The data showed a general decrease in use of NSAIDs over the eight years, but an increase in utilization of analgesics, surgery (especially for hip disease) and walking aids.Conclusions Patients with peripheral joint OA of sufficient severity to lead to hospital referral have a heterogeneous, but generally bad outcome over 8 years, the disease resulting in high levels of physical disability, anxiety and depression, with a high level of utilization of healthcare resources, including joint replacement, drugs and walking aids. The results were consistent with previous suggestions that peripheral joint OA in older people is characterized by the slow acquisition of new joint sites. Progression and outcome may depend on a complex set of psychosocial factors, as well as biological ones

Association of psychological distress, quality of life and costs with carpal tunnel syndrome severity: a crosssectional analysis of the PALMS cohort

Objectives: The PALMS study is designed to identify prognostic factors for outcome from corticosteroid injection and surgical decompression for carpal tunnel syndrome (CTS) and predictors of cost over 2 years. The aim of this paper is to explore the cross-sectional association of baseline patient-reported and clinical severity with anxiety, depression, health-related quality of life and costs of CTS in patients referred to secondary care. Methods: Prospective, multi-centre cohort study initiated in 2013. We collected baseline data on patientreported symptom severity (CTS-6), psychological status (HADS), hand function (Michigan Hand Questionnaire) comorbidities, EQ5D-3L and sociodemographic variables. Nerve conduction tests classified patients into five severity grades (mild to very severe). Data were analysed using a general linear model. Results: 753 patients with CTS provided complete baseline data. Multivariable linear regression adjusting for age, sex, ethnicity, duration of CTS, smoking status, alcohol consumption, employment status, body mass index and comorbidities showed a highly statistically significant relationship between CTS-6 and anxiety, depression and the EQ-5D (p<0.0001 in each case). Likewise, a significant relationship was observed between electrodiagnostic severity and anxiety (p=0.027) but not with depression (p=0.986) or the EQ-5D (p=0.257). NHS and societal costs in the 3 months prior to enrolment were significantly associated with self-reported severity (p<0.0001) but not with electrodiagnostic severity. Conclusions: Patient-reported symptom severity in carpal tunnel syndrome is significantly and positively associated with anxiety, depression, health-related quality of life and NHS and societal costs even when adjusting for age, gender, body mass index, comorbidities, smoking, drinking and occupational status. In contrast there is little or no evidence of any relationship with objectively derived CTS severity. Future research is needed to understand the impact of approaches and treatments that address psychosocial stressors as well as biomedical factors on relief of symptoms from carpal tunnel syndrome.CJH was funded by the National Institute for Health Research (NIHR) through a NIHR Senior Research Fellowship. ECFW is funded by the NIHR Cambridge Biomedical Research Centre

Supervised pharmacy student-led medication review in primary care for patients with type 2 diabetes: a randomised controlled pilot study

Objective: To pilot and feasibility-test supervised final year undergraduate pharmacy student-led medication reviews for patients with diabetes to enable definitive trial design. Method: Third year pharmacy students were recruited from one UK School of Pharmacy and trained to review patient's medical records and provide face-to-face consultations under supervision while situated within the patient's medical practice. Patients with type 2 diabetes were recruited by postal invitation letter from their medical practice and randomised via automated system to intervention or usual care. Diabetes-related clinical data, quality of life, patient reported beliefs, adherence and satisfaction with medicines information were collected with validated tools at baseline and 6 months postintervention. The process for collecting resource utilisation data was tested. Stakeholder meetings were held before and after intervention to develop study design and learn from its implementation. Recruitment and attrition rates were determined plus the quality of the outcome data. Power calculations for a definitive trial were performed on the different outcome measures to identify the most appropriate primary outcome measure. Results: 792 patients were identified as eligible from five medical practices. 133 (16.8) were recruited and randomised to control (n=66) or usual care (n=67). 32 students provided the complete intervention to 58 patients. Initial data analysis showed potential for impact in the right direction for some outcomes measured including glycated haemoglobin, quality of life and patient satisfaction with information about medicines. The intervention was found to be feasible and acceptable to patients. The pilot and feasibility study enabled the design of a future full randomised controlled trial. Conclusions: Student and patient recruitment are possible. The intervention was well received and demonstrated some potential benefits. While the intervention was relatively inexpensive and provided an experiential learning opportunity for pharmacy students, its cost-effectiveness remains to be determined. Trial registration number: ISRCTN26445805; Results. © 2015, BMJ Publishing Group. All rights reserved

Clinical assessment of hand oedema: A systematic review

Introduction: Assessment of oedema after trauma or surgery is important to determine whether treatment is effective and to detect change over time. Volumetry is referred to as the ‘gold standard’ method of measuring volume. However, this has practical limitations and other methods are available. The aim of this systematic review was to evaluate the psychometric properties of alternative methods used to assess hand oedema. Methods: A search of electronic bibliographic databases was undertaken for any studies published in English reporting the psychometric evaluation of a method for measuring hand oedema, in an adult population with hand swelling from surgery, trauma or stroke. The Consensus‐based Standards for the Selection of health Measurement Instruments (COSMIN) checklist was used to evaluate the methodological quality. Results: Six studies met the inclusion criteria. Three methods were identified assessing hand oedema: perometry, visual inspection and the figure-of-eight tape measure, all were compared to volumetry. Four different psychometric properties were assessed. Studies scored fair or poor on COSMIN criteria. There is low-quality evidence supporting the use of the figure-of-eight tape measure to assess hand volume. The perometer systematically overestimated volume and visual estimation had poor sensitivity and specificity. Discussion: The figure-of-eight tape measure is the best alternative to volumetry for hand oedema. Benefits include reduced cost and time while having comparable reliability to the ‘gold standard’. Further research is needed to compare methods in patients with greater variability of conditions and with isolated digit oedema. Visual estimation of hand oedema is not recommended

The face validity of an initial sub-typology of people with autism spectrum disorders detained in psychiatric hospitals

Autistic adults who have a history of committing crimes present a major problem for providers of services in terms of legal disposal options and possible interventions, and greater understanding of this group and their associated needs is required. For this reason, we aimed to investigate the face validity of a proposed sub-typology of autistic adults detained in secure psychiatric hospitals in the United Kingdom. Initially, a focus group was completed with psychiatrists, clinical psychologists, healthcare workers, family members, and autistic adults who had been detained in hospital, leading to revisions of the sub-typology. Following this, a consensus rating exercise of ten clinical vignettes based upon this subtypology with three rounds was completed with fifteen psychiatrists and clinical psychologists; revisions to the vignettes to improve clarity were made following each round. The findings indicated these subtypes possess face validity and raters were able to classify all ten clinical case vignettes into the sub-typology and percentage of agreement ranged from 96% to 100% for overall subtype classification. This study suggests that the further validity of the sub-typology should be investigated within a larger study, as these sub-types have the potential to directly inform the hospital care-pathway such that length of stay can be minimised

Contamination in trials of educational interventions

Objectives: To consider the effects of contamination on the magnitude and statistical significance (or precision) of the estimated effect of an educational intervention, to investigate the mechanisms of contamination, and to consider how contamination can be avoided. Data sources: Major electronic databases were searched up to May 2005. Methods: An exploratory literature search was conducted. The results of trials included in previous relevant systematic reviews were then analysed to see whether studies that avoided contamination resulted in larger effect estimates than those that did not. Experts’ opinions were elicited about factors more or less likely to lead to contamination. We simulated contamination processes to compare contamination biases between cluster and individually randomised trials. Statistical adjustment was made for contamination using Complier Average Causal Effect analytic methods, using published and simulated data. The bias and power of cluster and individually randomised trials were compared, as were Complier Average Causal Effect, intention-to-treat and per protocol methods of analysis. Results: Few relevant studies quantified contamination. Experts largely agreed on where contamination was more or less likely. Simulation of contamination processes showed that, with various combinations of timing, intensity and baseline dependence of contamination, cluster randomised trials might produce biases greater than or similar to those of individually randomised trials. Complier Average Causal Effect analyses produced results that were less biased than intention-to-treat or per protocol analyses. They also showed that individually randomised trials would in most situations be more powerful than cluster randomised trials despite contamination. Conclusions: The probability, nature and process of contamination should be considered when designing and analysing controlled trials of educational interventions in health. Cluster randomisation may or may not be appropriate and should not be uncritically assumed always to be a solution. Complier Average Causal Effect models are an appropriate way to adjust for contamination if it can be measured. When conducting such trials in future, it is a priority to report the extent, nature and effects of contamination.We are grateful to the National Health Service Research and Development National Coordinating Centre for Research Methodology for funding this research

Evaluating Palin Stammering Therapy for School Children (Palin STSC 8–14): protocol for a feasibility randomised controlled trial comparing Palin STSC(8–14) with usual treatment

Background: Having a stammer can have a significant effect on a child’s social, emotional and educational development. With approximately 66,000 children in the UK having a stammer, there is a need to establish an adequate evidence base to inform clinical practice. We describe a feasibility trial to explore the effectiveness of a new therapy programme for children aged 8–14: Palin Stammering Therapy for School Children (Palin STSC(8–14)). Preliminary data from the Michael Palin Centre, where the programme was developed, indicate that Palin STSC(8–14) is effective in reducing stammering frequency and impact for children, with beneficial effects for parents too. We will investigate the feasibility of the methods required for a definitive randomised controlled trial to investigate the application of this therapy by NHS speech and language therapists (SLTs), compared with ‘treatment as usual’ (TAU), beyond the specialist context in which it was developed. Methods: This is a two-arm feasibility cluster-randomised controlled trial of Palin STSC(8–14) with TAU control arm, and randomisation at the level of the SLT. Quantitative and qualitative data will be collected to examine the following: the recruitment and retention of therapists and families, the acceptability of the research processes and the therapeutic intervention and the appropriateness of the therapy outcome measures. Assessments will be completed by children and parents at baseline and 6 months later, including measures of stammering severity; the impact of child’s stammering on both children and parents; child temperament, behaviour and peer relations, anxiety; quality of life; and economic outcomes. There will also be a qualitative process evaluation, including interviews with parents, children, SLTs and SLT managers to explore the acceptability of both the research and therapy methods. Treatment fidelity will be examined through analysis of therapy session records and recordings. Discussion: The findings of this feasibility trial will inform the decision as to whether to progress to a full-scale randomised controlled trial to explore the effectiveness of Palin STSC(8–14) when compared to Treatment as Usual in NHS SLT services. There is a strong need for an evidence-based intervention for school age children who stammer. Trial registration: ISRCTN. ISRCTN17058884. Registered on 18 December 2019