Patient Perceptions of Surveillance of Small Abdominal Aortic Aneurysms in the Over 85s.

BACKGROUND: Recently instigated local practice for patients with small abdominal aortic aneurysms (AAAs) involves contacting all patients, aged ≥85 years, to discuss with them the advantages and disadvantages of removal from surveillance. However, reasons why patients opt to remain on, or come off, surveillance, are currently unknown. The present study's objective is to explore patient perception of surveillance decision-making. METHODS: A mixed-methods exploratory evaluation was undertaken using patient feedback obtained from a telephone survey. All patients aged ≥85 years, who had a consultation regarding ongoing surveillance of small AAAs (30-49 mm), and consented, were contacted by researchers, who conducted semi-structured interviews concerning factors influencing decision-making. RESULTS: A total of 24 patients (20 male; mean age = 86.9 years) were interviewed; 16 of 24 (66%) had opted to remain on surveillance, with no age difference between those opting in or out. Most felt surveillance was important (91%), and that it made them feel safer (73%). The majority (73%) thought they knew what happened when their AAA reached threshold (5.5 cm), what happened when a threshold AAA is not fixed (64%), and how major AAA surgery is (59%). However, actual knowledge was poor: most (91%) correctly understood surgery was major, but 56% thought that threshold AAA meant certain death or rupture; and 38% thought immediate surgery was required. Thematic analysis expounded patients' beliefs regarding surveillance, which were summarized in 3 distinct subgroups: reliance on professionals' opinions, needing peace of mind, and poor understanding. CONCLUSIONS: While most patients find surveillance reassuring, patient knowledge of AAA management at threshold is poor, potentially impacting surveillance decision-making. Elderly patients, with small AAAs contemplating ongoing surveillance, need to be better informed about AAA management at threshold to support shared decision-making.

Cluster randomised control trial of the effect on attendance and outcomes of multi-disciplinary teams involving psychologists during pelvic floor muscle training for pelvic floor dysfunction.

Pelvic floor muscle training (PFMT) is effective, acceptable to patients, and cost efficient as a treatment for Pelvic Floor Dysfunction (PFD). However, PFMT outcomes are mediated by patient variables, such as depression, anxiety, motivation, and health values. The current study examined whether multi-disciplinary provision of PFMT involving a psychologist would improve attendance and outcomes (Clinical Trial Registration: NCT02549157). 88 consecutively referred patients (age 28 - 85 years), with a variety of PFD, were randomised into two groups: PFMT treatment as usual (n = 47), and PFMT with a psychologist involved (n = 41). Patients received 6-month out-patient physiotherapy. More patients with the psychologist completed the course, and there were significantly greater improvements in subjective symptoms (Queensland scale), quality of life (EQ-5D), and anxiety (HADS), although not in objective measures (Oxford Grading) or depression (HADS). These results suggest that an MDT including a psychologist during PFMT intervention treatment may help some patients.IMPACT STATEMENTWhat is already known on this subject? Pelvic floor muscle training (PFMT) is effective, acceptable to patients, and cost efficient as a treatment for Pelvic Floor Dysfunction (PFD). However, PFMT outcomes are mediated by patient variables, such as depression, anxiety, motivation, and health values. The effectiveness of a multi-disciplinary team delivering both PFMT and psychological support simultaneously to women undergoing PFMT for PFD is unknown.What do the results of this study add? Psychological support delivered alongside PFMT increased patient attendance, improved subjective ratings of pelvic floor functioning, health-related quality of life, and reduced anxiety. This is one of the first demonstrations that this can be achieved through a multi-disciplinary team delivering their support simultaneously to the patients.What are the implications of these findings for clinical practice and/or further research? Improving subjective functioning and reducing attrition rates in PFD patients has cost implications in terms of reduced need for surgery, and making future surgery more effective. The inclusion of brief, easily delivered psychological support, integrated into the PFMT sessions in a multidisciplinary way may represent an extremely cost effective method of improving the service for these patients.

Acceptability and effectiveness of a multidisciplinary team approach involving counselling for mesh-removal patients.

Patients with complications following mesh removal risk a variety of symptoms, and can view medical intervention negatively. This study explored the patient-acceptability of a Multidisciplinary Team (MDT), and whether the presence of a Counsellor would be accepted and effective. Twenty consecutively referred women, who had undergone mesh-removal but experienced complications were interviewed about their experiences, and completed the Queensland scale for pelvic floor symptoms, McGill Pain Questionnaire, and Hospital Anxiety and Depression Scales, before and after treatment. Patients had high levels of pelvic-floor symptoms, sensory and affective pain, anxiety, and depression. 70% reported a positive MDT experience; predicted by higher anxiety, and lower depression. 60% elected to receive Counselling, which commenced within one week of referral, typically lasted 1-4 sessions, and reduced pelvic-floor symptoms, affective pain, anxiety, and depression. Results suggest that the MDT approach is generally acceptable for this patient group, and that mesh-removal patients accept and benefit from input by a Counsellor.Impact statementWhat is already known on this subject? Concerns have been raised regarding the safety of mesh insertion. Multidisciplinary Teams (MDTs) are suggested to offer a strong approach to managing many women's health conditions, but no studies have examined mesh-removal patients, making generalisation difficult to the current patient group. Furthermore, it is unknown whether an MDT approach, including a Counsellor, would be acceptable to mesh-removal patients.What do the results of this study add? Patients had high levels of pelvic-floor symptoms, pain, anxiety, and depression. 70% reported the MDT experience as positive, predicted by higher anxiety, and lower depression. 60% elected to receive Counselling, which reduced pelvic-floor symptoms, affective pain, anxiety, and depression.What are the implications of these findings for clinical practice and/or further research? The Counselling provided as part of the MDT approach was able to commence quickly, did not require many sessions, and reduced reported pelvic-floor symptoms, affective pain, anxiety, and depression. These findings suggest that an MDT approach involving Counselling is generally acceptable, and that mesh-removal patients accept and benefit from the input of a Counsellor, as part of their treatment.

Randomized Controlled Trial of the Effect of a Brief Telephone Support Intervention on Initial Attendance at Physiotherapy Group Sessions for Pelvic Floor Problems.

OBJECTIVE: To assess the efficacy of a brief telephone call to patients on a waiting list for physiotherapy treatment of pelvic floor dysfunction on initial attendance. DESIGN: Three-armed randomized controlled trial. SETTING: Outpatient physiotherapy clinic at a hospital. PARTICIPANTS: Female patients (N=130; mean age, 51.47±13.33y; range, 26-84y) with various pelvic floor dysfunction problems. INTERVENTIONS: Telephone support call (2-10min) 3 days before or 3 days after receiving an invitation letter to physiotherapy sessions. MAIN OUTCOME MEASURES: Attendance at the initial physiotherapy group session. RESULTS: Groups receiving a telephone call demonstrated 80% attendance at the session, with no significant difference between these groups. The group receiving no call had significantly lower attendance rates (50%) than did the call groups. The telephone support was more effective in those people who were older, came from less economically deprived areas, and had been on the waiting list for less time. CONCLUSIONS: A brief telephone support call may be an effective method to enhance patient attendance at treatment, but it may work best when targeted at certain groups of individuals.

Effect of depression and anxiety on the success of pelvic floor muscle training for pelvic floor dysfunction.

The objective of this study was to determine the impact of the psychiatric symptoms of anxiety and depression, as assessed by validated questionnaires on the success of pelvic floor muscle training (PFMT). A prospective observational study was carried out by the Uro-gynaecological Physiotherapy Department at the Singleton Hospital, Swansea. A total of 108 consecutive women with pelvic floor dysfunction were referred for physiotherapy and admitted to the 6-month physiotherapy programme. They underwent subjective and objective assessments of their pelvic floor and psychological health at the beginning and end of the programme. A strong correlation was noted between the severity of anxiety and depression symptoms and the severity of their pelvic floor dysfunction. Following physiotherapy, apart from sexual function, all domains of pelvic floor dysfunction showed significant improvement. Based on the severity of their anxiety/depression symptoms, the patients were stratified into three groups. The group of patients that benefitted most had either no or only mild anxiety/depression. This study raises the question of whether a targeted approach should be undertaken for managing patients who, in addition to their pelvic floor dysfunction, demonstrate psychiatric symptoms.

Exploratory Study of Parenting Differences for Autism Spectrum Disorder and Attachment Disorder.

The current study explored similarities and differences in parenting stress (PSI) and behaviours in parent reports of autism spectrum disorder (ASD) and attachment disorder (AD). 155 parents whose children had developmental delays and disorders completed the social communication questionnaire, Randolph attachment questionnaire, strengths and difficulties questionnaire, PSI, and parent-child relationship inventory. Parents of children with AD reported greater levels of PSI than parents of children with ASD. Parents of children reaching criteria for both disorders reported the greatest levels of PSI. Limit setting was poorest in parents of children with both classifications, followed by parents of children with AD, and then ASD. Limit setting mediated the relationship between PSI and child behaviour problems for parents of children with ASD < but not for parents of children with AD. These findings suggest different areas of difficulty for parents of children with these conditions, which may be of help in designing interventions.

Longitudinal relationship between problematic internet use with loneliness during and after COVID-19 social restrictions: Short title: Internet use and loneliness.

Two, three-month long longitudinal studies examined the temporal relationships between problematic internet use (PIU), internet usage, and loneliness ratings, during and after lockdown restrictions. Experiment 1 examined 32, 18-51 year old participants, over a three-month period of lockdown restrictions. Experiment 2 studied 41, 18-51 year old participants, over a three-month period following the lifting of lockdown restrictions. Participants completed the internet addiction test, UCLA loneliness scale, and answered questioned about their online usage, at two time points. All cross-sectional analyses revealed a positive relationship between PIU and loneliness. However, there was no association between online use and loneliness. Longitudinal relationships between PIU and loneliness differed during and after lockdown restrictions. During a period of lockdown, there were both positive associations between earlier PIU and subsequent loneliness, and between earlier loneliness and subsequent PIU. However, following the easing of lockdown restrictions, only the temporal relationship between earlier internet addiction and later loneliness was significant.

Change in depression predicts change in bladder symptoms for women with urinary incontinence undergoing pelvic-floor muscle training.

INTRODUCTION: To examine the relationship between depression and bladder symptoms, especially the impact of change in depression on changes in bladder symptoms, for women with urge and stress urinary incontinence undergoing a course of PFMT. METHOD: 106 adult females with pelvic-floor dysfunction (PFD), consecutively referred to an outpatient pelvic-floor muscle training (PFMT) programme for either urge, stress, or mixed incontinence, participated in a prospective observational study. Participants reported subjective views of their pelvic floor problems (Queensland), and their levels of depression (HADS_D), and data relating to age and BMI were collected. The trial was registered on clinicaltrials.gov (NCT02549157). RESULTS: There was a positive relationship between depression and bladder symptoms at intake. Levels of initial depression significantly predicted levels of bladder symptoms at completion of PFMT, and ability to complete the PFMT programme. Change in depression significantly predicted change in bladder symptoms, over and above intake patient characteristics and symptoms. DISCUSSION: These data imply a multidisciplinary focus, including psychological input, for PFD may be a highly effective strategy for its management.

Relationship between depression, anxiety, and attendance at pelvic-floor muscle training sessions.

OBJECTIVES: Psychological comorbidities are associated with non-attendance for pelvic-floor muscle training (PFMT) appointments and non-engagement with ongoing treatment. However, little direct work has examined the precise relationship between these variables. DESIGN: A prospective observational study of consecutively referred women patients with Pelvic-floor Dysfunction. Patients were assessed at intake for age, BMI, pelvic symptoms (measured by the Queensland Pelvic Symptom Scale), and anxiety and depression (measured by the Hospital Anxiety and Depression Scales). SETTING: A women's health physiotherapy outpatient unit of a metropolitan hospital. PARTICIPANTS: 433 consecutively-referred women with pelvic-floor dysfunction (PFD). INTERVENTIONS: Six sessions of PFMT, lasting over a period of 6 months. MAIN OUTCOME MEASURES: Attendance at PFMT sessions was the outcome, and was related to intake patient age, BMI, pelvic symptoms, as well as anxiety and depression. RESULTS: Psychological symptoms of depression and anxiety predicted attendance at PFMT sessions, over and above physical symptoms. Depression was the key predictor of non-attendance, with anxiety having a more complex relationship with attendance. There were few differences between these psychological variables and the different types of PFD, or between type of PFD and PFMT attendance. CONCLUSIONS: The findings add to the literature suggesting that consideration of patients' psychological state is important when designing treatment-regimes. CONTRIBUTION OF THE PAPER.

Commentary on 'disability outcome measures in multiple sclerosis clinical trials'.

In order to fully understand and explore the effectiveness of any intervention for the management of multiple sclerosis (MS), it is important to have robust, valid, reliable, and universally applied measures. The recent article, 'Disability outcome measures in multiple sclerosis clinical trials' by Cohen, Reingold, Polman and Wolinsky (2012), explores this issue in regards to the effective measurement of MS-related disability, and the utilisation of patient-reported outcome measures, whilst highlighting the need for collaboration between the academic and clinical communities. Although it is important to examine disability measures, it is also equally important to recognise that physical function is only one aspect of a person's experience; for example, quality of life and psychological well-being are also important aspects to assess. The application of e-health technologies and patient registers could be a useful method of gaining additional information, using patient-reported outcomes. This commentary explores these issues in relation to points raised by the Cohen et al. paper.

The feasibility of collecting information from people with Multiple Sclerosis for the UK MS Register via a web portal: characterising a cohort of people with MS.

BACKGROUND: A UK Register of people with Multiple Sclerosis has been developed to address the need for an increased knowledge-base about MS. The Register is being populated via: a web-based portal; NHS neurology clinical systems; and administrative data sources. The data are de-identified and linked at the individual level. At the outset, it was not known whether people with MS would wish to participate in the UK MS Register by personally contributing their data to the Register via a web-based system. Therefore, the research aim of this work was to build an internet-mounted recruitment and consenting technology for people with Multiple Sclerosis, and to assess its feasibility as a questionnaire delivery platform to contribute data to the UK MS Register, by determining whether the information provided could be used to describe a cohort of people with MS. METHODS: The web portal was developed using VB.net and JQuery with a Microsoft SQL 2008 database. UK adults with MS can self-register and enter data about themselves by completing validated questionnaires. Descriptive statistics were used to characterise the respondents. RESULTS: The web portal was launched in May 2011, and in first three months 7,279 individuals registered on the portal. The ratio of men to women was 1:2.4 (n = 5,899), the mean self-reported age at first symptoms was 33.8 (SD 10.5) years, and at diagnosis 39.6 (SD 10.3) years (n = 4,401). The reported types of MS were: 15% primary progressive, 63% relapsing-remitting, 8% secondary progressive, and 14% unknown (n = 5,400). These characteristics are similar to those of the prevalent MS population. Employment rates, sickness/disability rates, ethnicity and educational qualifications were compared with the general UK population. Information about the respondents' experience of early symptoms and the process of diagnosis, plus living arrangements are also reported. CONCLUSIONS: These initial findings from the MS Register portal demonstrate the feasibility of collecting data about people with MS via a web platform, and show that sufficient information can be gathered to characterise a cohort of people with MS. The innovative design of the UK MS register, bringing together three disparate sources of data, is creating a rich resource for research into this condition.

Comparison of fascia iliaca compartment block and 3-in-1 block in adults undergoing knee arthroscopy and meniscal repair.

Peripheral nerve blocks have become a popular method for treatment of pain after lower-extremity surgical procedures. Two peripheral nerve blocks for knee arthroscopy include the 3-in-1 block and the fascia iliaca compartment block (FICB). There is limited research comparing the efficacy of these blocks in adults undergoing knee arthroscopy and meniscal repair who receive both the peripheral nerve block and general anesthesia. This was a randomized controlled trial of 60 adult patients undergoing knee arthroscopy under general anesthesia and with a 3-in-1 block or FICB using the same local anesthetic admixture. Onset of block, time to postoperative analgesic requirements, pain scores, and overall satisfaction scores were measured. No differences in analgesic requirements or pain scores were noted. A faster onset of anesthesia occurred in the 3-in-7 block group, but there was a longer duration of postoperative analgesia in the FICB group. Patient satisfaction scores were similar between groups. Based on this study we recommend that the choice of block can be determined by the clinical scenario. We recommend a 3-in-1 block if speed of onset is the primary goal of anesthesia before induction, and we recommend the FICB block if prolonged postoperative analgesia is the primary goal.

Patient and economic benefits of psychological support for noncompliant patients.

The current paper provides an overview of treatment noncompliance at various points in the treatment pathway, especially with respect to treatment for Pelvic-floor Dysfunction (PFD). The effects of noncompliance on healthcare are considered, and examples of supporting patients psychologically to increase compliance are discussed. An outline of a method to identify costs of non-compliance, and where such costs most intensely impact the healthcare system, is provided. It is suggested that psychological support is effective in terms of increased compliance and improved healthcare economics. The model is presented for PFD, but the principles developed can be generalised to many aspects of healthcare.

Patient Expectations of Assigned Treatments Impact Strength of Randomised Control Trials.

Patient engagement with treatments potentially poses problems for interpreting the results and meaning of Randomised Control Trials (RCTs). If patients are assigned to treatments that do, or do not, match their expectations, and this impacts their motivation to engage with that treatment, it will affect the distribution of outcomes. In turn, this will impact the obtained power and error rates of RCTs. Simple Monto Carlo simulations demonstrate that these patient variables affect sample variance, and sample kurtosis. These effects reduce the power of RCTs, and may lead to false negatives, even when the randomisation process works, and equally distributes those with positive and negative views about a treatment to a trial arm.

Intensive behavioural interventions based on applied behaviour analysis for young children with autism: An international collaborative individual participant data meta-analysis.

LAY ABSTRACT: Early intensive applied behaviour analysis-based interventions are designed to support young autistic children's learning and development. Unfortunately, the available evidence about the effectiveness of these interventions remains unclear. Several reviews have focused on the published findings rather than contacting the authors to collect and analyse data about the individual participants in the original studies. Also, most of the studies were carried out by groups involved in delivering the interventions leading to the potential bias in interpreting the results. Our research team (supported by an international advisory group) carried out an independent individual patient data review by collecting the original participant data from the authors of the studies, to examine the effectiveness of these interventions. The results suggested that early intensive applied behaviour analysis-based interventions might lead to some changes in children's cognitive ability (intelligence quotient) and everyday life skills after 2 years, compared with standard treatments. However, all the studies had problems with the way they were designed. Also, few of the studies looked at outcomes that have been described as most important to autistic people or followed children beyond 2 years. We think that further systematic reviews of the existing evidence are unlikely to add to the findings of our review. Furthermore, we recommend that future research should investigate which types of supports and interventions are most effective for children and families, prioritising outcomes measures that are meaningful for the autism community and include, wherever possible, longer-term follow-up.

Impact of Strength and Nature of Patient Health Values on Compliance and Outcomes for Physiotherapy Treatment for Pelvic Floor Dysfunction.

OBJECTIVE: To determine whether patient values impact on compliance and outcome for physiotherapy treatment for pelvic floor dysfunction. Although studies have related "health values" to behaviors in the laboratory, or to behaviors such as exercise, there have been no studies of the impact of patient values on actual medical treatments. METHODS: A prospective observational study of the impact of patient values on compliance and outcomes for physiotherapy treatment for pelvic floor dysfunction was conducted in a physiotherapy clinic in the urogynaecological outpatients unit of a hospital. Two hundred eighteen patients were approached and agreed to participate. Prior to treatment, pelvic floor functioning was assessed using the Oxford Grading System, and Queensland Pelvic Floor Questionnaire, and values were assessed using the Personal Values Questionnaire (PVQ-II). Following a 6-month physiotherapy treatment programme, pelvic floor function was reassessed. RESULTS: The strength of patient health-related values measured by the PVQ-II significantly predicted compliance with the intervention, but the nature of health value (intrinsically-valued, as opposed to externally-controlled) predicted objective outcome. CONCLUSION: Patient values impact on physiotherapy adherence and outcomes, and could be considered as part of future assessment/screening procedures.

Correlating an 11-point verbal numeric rating scale to a 4-point verbal rating scale in the measurement of pruritus.

Pruritus, the subjective sensation of itch, can be a difficult symptom to assess and treat. Evaluating levels of patient discomfort across populations has proven to be challenging because of a lack of a standardized measurement tool to quantify levels of itch. The most widely used tool is the 4-point verbal rating scale (VRS-4), but others use an 11-point verbal numeric rating scale (VNRS-11). Therefore, the purpose of our study was to correlate a VNRS-11 to a VRS-4 for the assessment of pruritus. Fifty parturients were enrolled in this correlational study. Each subject's level of pruritus was measured at five specific intervals after administration of intrathecal opioids. The scales were administered one minute apart in random order. Data analysis demonstrated a strong correlation between these two scales, (r=.910 to .853) indicating that each verbal descriptor on the VRS-4 could readily be substituted with a quantifiable range on the VNRS-11.

Effect of timing of fluid bolus on reduction of spinal-induced hypotension in patients undergoing elective cesarean delivery.

Spinal-induced hypotension remains the most common complication associated with spinal anesthesia for cesarean delivery. Recent evidence indicates that a 20-mL/kg bolus via pressurized infusion system administered at the time of subarachnoid block (SAB) (coload) may provide better prophylaxis than the traditional administration of a 20-mL/kg crystalloid infusion (preload) approximately 20 minutes before SAB; however, this method raises some concerns. We hypothesized that administering half of the fluid bolus (10 mL/kg) before and half immediately following injection of the SAB would provide benefit. Variables included demographics, spinal anesthetic dermatome level obtained, additional intravenous (IV) fluid bolus and vasopressor requirements, and maternal vital signs. We enrolled 87 subjects in this prospective, randomized investigation, 43 preload (control) and 44 preload/coload (experimental). There were no demographic differences between groups. The increased supplemental vasopressors required to treat maternal hypotension in the preload group were not statistically significant. Total IV fluids and supplemental IV bolus requirements were significantly higher in the preload group. No differences in neonatal outcomes were noted between groups. Maternal vital signs were not significantly different between groups; hypotension was treated as it occurred. We recommend replacing standardized prophylactic crystalloid fluid administration with the preload/coload method described herein.

A Review of Hypnotherapy for Overactive Bladder.

This review examines the effectiveness of hypnotherapy for the relief of overactive bladder (OAB) symptoms. Ten studies examining outcomes of hypnotherapy for OAB were located from searches of electronic databases. Most reports were case studies or observational, but there were two randomized, controlled trials. Hypnotherapeutic treatment regimens were idiosyncratic and tailored to individual patients. All studies suggested benefits from hypnotherapy as an adjunct treatment for OAB, especially in terms of subjective reports of symptoms and increasing self-efficacy. These benefits suggest hypnotherapy increases patients' abilities to engage in relaxation, reduces condition-associated anxiety, and improves patients' perceptions of their symptom-coping abilities. Although strong objective evidence of improvement in OAB symptoms is lacking, these subjective improvements, combined with increasing use and acceptance of hypnotherapy in obstetric and gynecological settings, suggest the utility of hypnotherapy as a psychological adjunctive procedure in the treatment of OAB.

Reaction to diagnosis and subsequent health in mothers of children with autism spectrum disorder.

The current study assessed whether reactions to diagnosis are associated with health status for mothers of children with autism spectrum disorder at the time of diagnosis, and whether such diagnostic-reaction resolution status is associated with changes in health status over time. A total of 84 mothers of children newly diagnosed with autism spectrum disorder, with stable reactions to diagnosis over a year, participated. Their perceptions of their physical and psychological functioning, and quality of life, were taken at the time of diagnosis and 1 year later. The mothers were also given the Reaction to Diagnosis Interview. Mothers who had an unresolved reaction to diagnosis had a worse health status in terms of their perception of the physical symptoms at the time of the diagnosis, and showed worsening levels of health over the period of a year, relative to mothers who had a resolved diagnostic status. These relationships were independent of other potential predictors of ill health in this sample. The findings point to the potential of the diagnostic process to negatively impact parental health. Given that this can have negative consequences for child prognosis, as well as parental health, there is a need to develop better understanding of the impacts of diagnostic practices.