In-home monitoring of older adults with vision impairment: exploring patients’, caregivers’ and professionals’ views

Objective

To develop a conceptual framework for the design of an in-home monitoring system (IMS) based on the requirements of older adults with vision impairment (VI), informal caregivers and eye-care rehabilitation professionals.

Materials and Methods

Concept mapping, a mixed-methods statistical research tool, was used in the construction of the framework. Overall, 40 participants brainstormed or sorted and rated 83 statements concerning an IMS for older adults with VI. Multidimensional scaling and hierarchical cluster analysis were employed to construct the framework. A questionnaire yielded further insights into the views of a wider sample of older adults with VI (n=78) and caregivers (n=25) regarding IMS.

Results

Concept mapping revealed a nine-cluster model of IMS-related aspects including affordability, awareness of system capabilities, simplicity of installation, operation and maintenance, system integrity and reliability, fall detection and safe movement, user customization, user preferences regarding information delivery, and safety alerts for patients and caregivers. From the questionnaire, independence, safety and fall detection were the most commonly reported reasons for older adults and caregivers to accept an IMS. Concerns included cost, privacy, security of the information obtained through monitoring, system accuracy, and ease of use.

Discussion

Older adults with VI, caregivers and professionals are receptive to in-home monitoring, mainly for fall detection and safety monitoring, but have concerns that must be addressed when developing an IMS.

Conclusion

Our study provides a novel conceptual framework for the design of an IMS that will be maximally acceptable and beneficial to our ageing and vision-impaired population.     

Parkinson’s disease therapy: treatment of early and late disease

Purpose To summarize the current strategies for the treatment of early and late Parkin son’s disease (PD).Data sources The presented guidelines are based on the review of the literature as well as th e author’s extensive experience with the treatment of 7000 patients with PD over the past 25 years.Results An analysis of reported data as well as personal experience suggest that while y oung patients seem to have a slower progression of the disease, they are at a hi gher risk for developing levodopa induced complications, such as motor fluctuati ons and dyskinesias. It is, therefore, prudent practice to delay levodopa thera py, particularly in younger patients, until the PD symptoms become troublesome a nd interfere with social or occupational functioning. Other strategies, such as the use of deprenyl, amantadine, trihexyphenidyl and dopamine agonists, should be employed before instituting levodopa therapy. Entacopone and dopamine agonis ts are useful in smoothing out levodopa related motor fluctuations. Surgical in terventions, such as pallidotomy and pallidal or subthalamic deep brain stimulat ion, are effective therapeutic strategies, but should be reserved only for patie nts in whom optimal medical therapy fails to provide satisfactory control of sym ptoms.Conclusion The medical and surgical treatment of patients with PD must be individualized an d tailored to the needs of the individual patient.     

Systematic Heuristic Evaluation of Computerized Consultation Order Templates: Clinicians’ and Human Factors Engineers’ Perspectives

We assessed the usability of consultation order templates and identified problems to prioritize in design efforts for improving referral communication. With a sample of 26 consultation order templates, three evaluators performed a usability heuristic evaluation. The evaluation used 14 domain-independent heuristics and the following three supplemental references: 1 new domain-specific heuristic, 6 usability goals, and coded clinicians’ statements regarding ease of use for 10 sampled templates. Evaluators found 201 violations, a mean of 7.7 violations per template. Minor violations outnumbered major violations almost twofold, 115 (57%) to 62 (31%). Approximately 68% of violations were linked to 5 heuristics: aesthetic and minimalist design (17%), error prevention (16%), consistency and standards (14%), recognition rather than recall (11%), and meet referrers’ information needs (10%). Severe violations were attributed mostly to meet referrers’ information needs and recognition rather than recall. Recorded violations yielded potential negative consequences for efficiency, effectiveness, safety, learnability, and utility. Evaluators and clinicians demonstrated 80% agreement in usability assessment. Based on frequency and severity of usability heuristic violations, the consultation order templates reviewed may impede clinical efficiency and risk patient safety. Results support the following design considerations: communicate consultants’ requirements, facilitate information seeking, and support communication. While the most frequent heuristic violations involved interaction design and presentation, the most severe violations lacked information desired by referring clinicians. Violations related to templates’ inability to support referring clinicians’ information needs had the greatest potential negative impact on efficiency and safety usability goals. Heuristics should be prioritized in future design efforts.     

Acupuncture for Bell’s palsy: A systematic review and meta-analysis

<正>Objective:To assess the clinical evidence for and against acupuncture as a treatment for Bell's palsy.Methods:We conducted a literature search of 15 databases from their inception to December 2010 without language restrictions.We included all randomized clinical trials(RCTs) regardless of their controls. Methodological quality was evaluated using the Cochrane risk of bias assessment tool.Results:Of the 3474 articles,only eight RCTs met our inclusion criteria.Four RCTs tested the effects of acupuncture against drug therapy on disease response rate.The meta-analysis of these data showed significant improvements in the acupuncture group[n=463,risk ratio(RR)=1.07,95%CI:1.02 to 1.13;P=0.006,l~2=0%].Six RCTs tested the effects of acupuncture plus drug therapy versus drug therapy alone.The meta-analysis of this set of RCTs also showed the favorable effects of acupuncture on disease response rate(n=512,RR=1.11,95%CI:1.05 to 1.17; P=0.001,l~2=13%).Conclusions:The evidence supporting the effectiveness of acupuncture for treating Bell's palsy is limited.The number and quality of trials are too low to form firm conclusions.Further rigorous RCTs are warranted but need to overcome the many limitations of the current evidence.     

Paget’s disease of the cervical spine: case report and review

Study design

This article presents a case of Paget??s disease of the cervical spine.

Objectives

To report a very rare case of Paget??s disease of the cervical spine and review the literature.

Methods

We report a case of Paget??s disease of the cervical spine in a 51-year-old male presenting with neck pain post RTA. Routine radiographs revealed enlarged sclerotic bodies of C2?CC5 with normal alignment. CT revealed a fracture of the lateral mass of C2 with extensive sclerotic changes in the bodies of C2?CC5 with periosteal apposition, endosteal resorption ??pumice stone?? type focal periosteal apposition consistent with Paget??s disease. Laboratory investigations were consistent with a diagnosis of Paget??s disease. Isotope bone scan revealed isolated uptake in the cervical spine. He was commenced on biosphosphonate therapy. Following 12?weeks of immobilisation his orthosis was removed and rehabilitation commenced.

Results

At 12-month follow-up he is asymptomatic with no radiological change.

Conclusion

This case illustrates the investigation and successful management of a very rare case of Paget??s disease of the cervical spine.     

A case of Poncet’s disease: retroperitoneal tuberculous lymphadenitis and polyarthritis

To the editor： Reactive arthritis （ReA） in tuberculosis （TB） is known as Poncet＇s disease. It is a rare aseptic form of arthritis observed in patients with active TB. It has been suggested that Poncet＇s disease mainly occurs in patients with extrapulrnonary TB. We report here a case of Poncet＇s disease in a patient with retroperitoneal tuberculous lympbadenitis.     

Research and applications: Investigating the link between radiologists’ gaze,diagnostic decision,and image content

Objective

To investigate machine learning for linking image content, human perception, cognition, and error in the diagnostic interpretation of mammograms.

Methods

Gaze data and diagnostic decisions were collected from three breast imaging radiologists and three radiology residents who reviewed 20 screening mammograms while wearing a head-mounted eye-tracker. Image analysis was performed in mammographic regions that attracted radiologists’ attention and in all abnormal regions. Machine learning algorithms were investigated to develop predictive models that link: (i) image content with gaze, (ii) image content and gaze with cognition, and (iii) image content, gaze, and cognition with diagnostic error. Both group-based and individualized models were explored.

Results

By pooling the data from all readers, machine learning produced highly accurate predictive models linking image content, gaze, and cognition. Potential linking of those with diagnostic error was also supported to some extent. Merging readers’ gaze metrics and cognitive opinions with computer-extracted image features identified 59% of the readers’ diagnostic errors while confirming 97.3% of their correct diagnoses. The readers’ individual perceptual and cognitive behaviors could be adequately predicted by modeling the behavior of others. However, personalized tuning was in many cases beneficial for capturing more accurately individual behavior.

Conclusions

There is clearly an interaction between radiologists’ gaze, diagnostic decision, and image content which can be modeled with machine learning algorithms.     

Paternal-Fetal Harm and Men’s Moral Duty to Use Contraception: Applying the Principles of Nonmaleficence and Beneficence to Men’s Reproductive Responsibility

Discussions of reproductive responsibility generally draw heavily upon the principles of nonmaleficence and beneficence. However, these principles are typically only applied to women due to the incorrect belief that only women can cause fetal harm. The cultural perception that women are likely to cause fetal and child harm is reflected in numerous social norms, policies, and laws. Conversely, there is little public discussion of men and fetal and child harm, which implies that men do not (or cannot) cause such harm. My goal in this paper is to begin to fill the void in the academic literature about men’s reproductive responsibility by highlighting the health-related, economic, and social harms men can cause to potential fetuses and children and then examining what it would mean to hold them responsible for preventing these harms. Applying the principles of nonmaleficence and beneficence to men, I conclude that men have a moral duty to use contraception if their behavior—past, current, or future—could harm the potential fetuses and children who result from their unprotected sexual behavior.     

Wilms’ tumour in adults: a case report and review of the literature

Background  

Wilms’ tumour is a very rare adult malignancy representing 1% of adult renal tumours. It is however the most common renal tumour of childhood, and adult patients are treated in accordance with paediatric protocols.     

Adoptability and limitation of cancer treatment guidelines: a Chinese oncologist’s perspective

In recent years,great progress has been made in the treatment of cancer;one of the significant reasons is the wide adaptation and implementation of standardized treatment based on high-level clinical evidence.Undoubtedly,the advent of guidelines that represent the achievement of the latest and highest quality clinical studies made a significant contribution to the improvement of cancer treatment and management.Aside from cancer patient care,guidelines have also been widely used as standards or primary references in the diagnosis and treatment of other diseases.Numerous guidelines are being enacted each year by a variety of guideline-makers, including national, regional and intemational academic organizations, medical associations,as well as research institutions and hospitals.     

Gap between evidence and physicians’ knowledge and practice regarding hypertension and its drug treatment: a survey in a Chinese city

Background  Evidence-based medicine has come into its second decade. How prepared clinicians are in practicing it in particular in developing countries remains unclear. Thus we conducted this survey of physicians in urban hospitals in China to determine the size of the gap between research evidence and physicians’ knowledge and practice regarding antihypertensive drugs for primary prevention of cardiovascular diseases in China.

Methods  A cross sectional survey by a face-to-face interview was conducted in 20 tertiary general hospitals in China in 2005. A total of 444 physicians (mostly cardiologists) in internal medicine who had treated at least one hypertensive patient in the past 12 months were invited for the interview on their perception of the cardiovascular risk of hypertension, the magnitude of the benefit of antihypertensive drugs, knowledge on the overall risk approach, first-line drugs used, the risk above which drug treatment is recommended, and knowledge on evidence-based medicine.

Results  A total of 444 of the 468 eligible physicians were successfully interviewed with a response rate of 94.9%. They estimated that a hypertensive man with an actual 5-year cardiovascular risk of 8.4% would have a 5-year cardiovascular risk of 40% (95% CI: 38% to 42%) if not treated, and have an absolute risk reduction and relative risk reduction from drug treatment by 20% (95% CI: 18% to 22%) and 39% (95% CI: 37% to 42%) respectively, as compared to 3.3% and 33% respectively shown in research evidence. On average, the physicians would recommend drug treatment at a number needed to treat (NNT) of 368 or smaller, as compared to the actual NNT of 50 for drug treatment in an average hypertensive Chinese. Fifty-five percent (95% CI: 50% to 59%) of them had never intently used the national hypertension guidelines. The majority still prescribed drugs primarily based on blood pressure alone by ignoring other risk factors or the overall risk and 78% (95 % CI: 76% to 83%) used new expensive drugs such as calcium channel blockers and angiotensin converting enzyme (ACE) inhibitors as first-line treatment. Only 13% (95% CI: 9% to 18%) could correctly interpret the NNT. Forty-three percent (95% CI: 39% to 48%) did not know the randomized controlled trial was scientifically the most rigorous among other study designs for evaluating the effectiveness of anti-hypertensive drugs. Ninety-two percent (95% CI: 90% to 94%) did not know they could start by searching systematic reviews when looking for evidence on the effectiveness of anti-hypertensive drugs as opposed to trials. Ninety-six percent (95% CI: 94% to 98%) did not know the Cochrane Library was an important source of systematic reviews.

Conclusions  The surveyed physicians significantly over-estimated the cardiovascular risk of hypertension and the benefit of drug treatment, and had insufficient knowledge on the overall risk approach. They recommended drug treatment at a cardiovascular risk which was even much lower than the cutoff suggested for western populations, which would make many more people eligible for drug treatment. They also tended to prescribe new expensive drugs although the older cheaper ones may be more appropriate in many patients. They showed inappropriate  knowledge on the basics of evidence-based medicine.

     

Retinal pigment epithelial cells: biological property and application in Parkinson’s disease

Parkinson＇s disease is a neurodegenerative disorder mainly caused by degeneration of the dopaminergic neurons in the substantia nigral pars compacta （SNpc）. The typical motor symptoms of this disease are tremor, akinesia, and rigidity, which are mostly caused by dysfunction of the nigro-striatal pathway. Dopaminergic neurons in the SNpc project long axons to caudate nucleus and the putamen, and secrete dopamine.     

Late onset Alzheimer’s disease and apolipoprotein association in the Irish population: Relative risk and attributable fraction

Background Familial and sporadic late onset Alzheimer’s disease (LOAD) shows a consistent genetic association with APOE ε4. Aims To examine the role of APOE in the AD Irish population. Methods One hundred and ten Irish LOAD patients and 217 ethnically-matched controls were genotyped for APOE marker as described by Crook et al.¹ Chi square test was used to compare allelic and genotypic frequencies between patients and controls samples. Attributable fractions were calculated as described by Levin.² Results A highly significant association between AD and APOE ε4 was observed (X²=37.9, p=0.0000000, RR=2.18). Further, the influence of APOEε4 seems to follow a dose-dependent manner whereby individuals with the genotype APOEε4/4 have a higher relative risk than those heterozygous for the ε4 allele (RR=4.03 and 1.76 respectively). The relative risk and the attributable fraction calculated for APOE ε4 are consistent with those reported for other €pean populations. This places the influence of this locus on AD development in the Irish population between those of the Spanish and New York white populations. Conclusion These findings provide further evidence for the importance of APOE in the development of AD.     

Cultural and personal behavioralfactors and women’s reproductive tract infections

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A case of ‘blue skin’ and ‘dark urine’

A 60-year-old female presented with a 20-year history of progressive dark bluish discoloration of skin and passage of dark colored urine, painful arthritis and a recent history of invasive ductal carcinoma of right breast. Skin biopsy revealed hyaline material which was Periodic-Acid-Schiff stain positive and Congo-red stain negative, urine analysis revealed dark urine with presence reducing substance and radio-imaging showed intervertebral ossification and joint ankyloses. The patient was managed symptomatically with physiotherapy and acetaminophen on as required basis. This image is reported as a classic case of Alkaptonuria with clinical, histopathological and radio-imaging findings and the presence of invasive ductal breast carcinoma in the same patient.     

Concomitant Graves’ disease and primary hyperparathyroidism: the first case re port in mainland of China and literature review

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Relationship between peptic ulcer patients’ compliance and doctors’ order in China

Objective To get the knowledge about between patients’ compliance and doctors’ order in China, and to observe the influence on the reactivity of peptic ulcers due to the variation between patients’ compliance and doctors’ orders. Methods This is a prospective, randomized, multicenter, controlled trial of the efficacy in various instructional programs upon patients’ compliance with doctors’ orders. Patients with active peptic ulcers diagnosed through gastroscopic and pathologic examinations and followed up at the selected 100 hospitals of ten districts in Zhejiang Province of China between January 1 to December 31, 1997 were eligib le for this study. All patients were given the same medications (proton pump inhibitor and amoxycillin) and were divided into four groups (A, B, C, D) by randomly selected envelopes as follows. Group A: simple patient education, namely simple instruction about the use and the course of the medications, and the follow-up time. Group B: stressed patient education, namely detailed instruction about the use, the course, the curative and side effects, the necessity of following up as well as making appointments of being checked. Group C: supervised education, meaning that the patients were managed as Group A while their family members/friends as Group B. The family members/friends were also asked to supervise the patients in taking the medications, in following-up and giving their phone numbers to doctors. Group D: stressed patient education plus supervised education, meaning that the patients and their family members/friends were treated as both Group B and C.Results The compliance rate was 47.1% in all 11 983 patients. From high to low the compliance rates in the four groups were D (52.8%), C (46.8%), B (46.3%) and A (46.2%), but statistically there were no significant differences between them. The most compliant age was under 20 years with 51.7% as the rate of compliance , and the occupation was of medical workers (57.0%), and persons graduated from secondary specialized schools also had the highest compliance (55.4%). On the contrary, the most noncompliants were young people (20-29 years old, 44.6%), illiterate persons (43.9%) and self-employed laborers (43.9%). Mountain areas were the lowest (40.8%) compliant areas. The main reasons for the failure of compliance included drug cost (34.9%), inconvenience to see doctor (31.8%), forgetfulness of patients (24.2%). The reactivity of each group was shown as D (91.1%), C (90.3%), B (89.4%) and A (89.2%), with also no significant difference in statistics. But a big difference and be found between compliant group with the noncompliant one because the reactivity in the compliant group was 97.4% while in the noncompliant group was only 58.8% (x=1449.2, P&lt;0.005). Conclusion Compliance with doctors’ orders exerts a significant influence on the reactivity. The main reasons of noncompliance (drug costs, inconvenience to see doctor) are corresponding to the economic and social conditions in China.