Homocysteine and mild cognitive impairment: Are these the tools for early intervention in the dementia spectrum?

Dementia, being a neurodegenerative disease, has devastating consequences not just for the ailing but also for the carers as it has a tremendous negative impact on the quality of life. The pathophysiology of dementia commences far earlier than its diagnosis. Mild cognitive impairment (MCI) is a stage prior to definite dementia. The progression from MCI to dementia is insidious with no definite demarcation, thus making diagnosis clinically difficult at an early stage. This paper attempts to throw light on the epidemiology, risk factors and the aetiopathogenesis of MCI. It further attempts to elaborate on the rate of conversion of MCI to definite dementia and the factors influencing the same. Many established as well as probable, modifiable as well as non-modifiable risk factors influence the progress of MCI to definite dementia. Homocysteine, a sulphur containing amino-acid has been identified as a probable risk factor for the dementia spectrum. Various existing clinical evidences and biological plausibility towards probable link between homocysteine and dementia are discussed in this paper. B vitamin mediated homocysteine reduction and cognitive outcomes demonstrate mixed results. This review attempts to evaluate hyperhomocysteinaemia and MCI as a brain risk marker and assess their potential for future research with a view to attempt early intervention.     

Performance‐based contracting in home‐care work in The Netherlands: professionalism under pressure?

Our aim was to improve the understanding of the relationships between performance‐based contracting, management supportiveness and professionalism in home care. Using path analysis, this article explores the relationships between home‐care workers' perceptions of management support, implementation of performance‐based contracting (i.e. use of strict time registration rules and cost‐efficiency measures) and autonomy and intrinsic job satisfaction. We hypothesised that: use of strict time registration rules and cost‐efficiency measures relates to lower levels of autonomy and intrinsic job satisfaction (H1); there is an indirect relationship between use of strict time registration rules and use of cost‐efficiency measures and intrinsic job satisfaction via autonomy (H2); higher levels of management support relate to the use of looser time registration rules and less use of cost‐efficiency measures (H3); and higher levels of management support relate to higher levels of autonomy and intrinsic job satisfaction (H4). We used data from a cross‐sectional survey conducted in 2010 of a sample of Dutch home‐care workers (N = 156, response rate = 34%). Overall, our study suggests that the consequences of performance‐based contracting for professionalism are ambiguous. More specifically, using strict time registration rules is related to lower levels of autonomy, whereas using cost‐efficiency measures does not seem to affect autonomy (H1). Performance‐based contracting has no consequences for the level of fulfilment home‐care workers find in their job, as neither of the two contracting dimensions measured was directly or indirectly related to intrinsic job satisfaction (H1, H2). The role of managers must be taken into account when studying performance‐based contracting, because perceived higher management support is related to managers' less frequent use of both strict time registration rules and of cost‐efficiency measures (H3). The insight we gained into the importance of supportive managers for both autonomy and job satisfaction (H4) can help home‐care organisations improve the attractiveness of home‐care work.     

Socio‐economic inequalities in childhood obesity: Can community level interventions help to reduce the gap?

A link between higher rates of childhood obesity and deprivation has been noted in the UK, as well as several other European countries and the US. The drivers of obesity are complex and multi‐factorial, but socially and economically disadvantaged groups may be more vulnerable to many of these. Evidence that rates of obesity are rising faster in low‐income population groups, resulting in widening inequalities indicates that prevention policies must take account of socio‐economic factors. It has been suggested that community‐wide approaches placing less emphasis on individual responsibility or ‘agency’ (i.e. have less emphasis on aspects that require cognitive, psychological and material resources and time) can be more effective and equitable. This paper outlines examples of community approaches that may have contributed to the reported reductions in childhood obesity in some areas, particularly amongst deprived groups including Health, Exercise and Nutrition in the Really Young in Leeds, UK; Ensemble Prévenons l'Obésité Des Enfants and Amsterdam’s citywide Healthy Weight Programme. The policies enacted that improved the nutrition environment and increased opportunities for physical activity in four US sites (the Childhood Obesity Declines project) are also considered. It is clear that there is no silver bullet for tackling childhood obesity. A whole systems approach that takes into account more holistically the reasons why healthy diet and lifestyles may be less available to families on low incomes is needed.     

Potential complications of neonatal cephalhaematoma in the community: when to refer to the paediatric team?

Neonatal cephalhaematoma is commonly seen after a minor birth trauma, e.g. from vacuum-assisted deliveries. It is usually considered benign and resolves spontaneously without any treatment. Considerable parental anxiety may be associated with this condition and thus primary health care professionals play a significant role in providing reassurance to the new parents. Complications, although rare, are known to occur and can be potentially serious. A degree of uncertainty is often seen among primary health care professionals about whether to refer such cases to hospital. Recognition of the complications by primary health care professionals and early involvement of the paediatric services are essential to prevent serious complications such as meningitis and osteomyelitis. A case of bilateral cephalhaematoma is presented which was suspected to be infected and needed in-patient hospital care. The potential complications of a cephalhaematoma are discussed and guidelines provided for expediting early and appropriate referral of complicated cases to the paediatric services.     

The ‘expert’ in problem‐based and case‐based learning: necessary or not?

BACKGROUND: Problem-based learning (PBL) and other small-group teaching methods which incorporate principles of adult learning, are exciting innovations in medical education. In the application of these methods to medical curricula many schools have introduced non-expert tutors. However, research evaluating the effectiveness of non-expert lead teaching has been inconclusive. AIM: The present study aim was to compare the outcome of teaching in small groups facilitated by either an 'expert' or a 'non-expert' tutor, in a single topic area. METHOD: Fourth-year medical students were allocated randomly to teaching of eating disorders either by a non-expert or an expert tutor. Outcomes were evaluated by (i) a knowledge test, and (ii) self-report ratings by tutors and students of their learning methods and other qualities. RESULTS: The study found that while the non-expert tutor was rated more highly for her group management skills, and she also rated her students more highly in the area of oral communication, students who were taught by the expert scored higher in the end-of-course test in the topic area. CONCLUSION: The findings suggest that caution should be exercised, and the need for more research before widespread adoption of teaching by non-expert tutors.     

What are the components of complex interventions in healthcare? Theorizing approaches to parts,powers and the whole intervention

The components of complex interventions are frequently discussed, invoked and examined in theory and research but seldom defined. This leads to theoretical and ontological ambiguities, lack of methodological transparency, and potentially, resistance to the wider movement towards complex intervention. This paper is the first to compare and contrast the different approaches that can be taken to the components of complex interventions. Most basically, complex interventions are defined as being composed of parts that make the whole intervention and, in isolation or combination, can generate the power of the intervention. Examples from the field of cardiac rehabilitation are used to illustrate key points. In relation to complex interventions past approaches variously: downplay complexity, focus on the complicatedness of complex interventions, or emphasize the complexity of complex interventions. Thus, approaches can be categorized as viewing components variously as: (1) Non existent parts and powers; (2) Irrelevant parts and powers; (3) Undifferentiated powerful parts; (4) Higher order parts and non-existent lower parts; (5) Higher order parts with non-powerful lower order parts; (6) Higher and lower order parts with powers; and (7) Components as the parts and the whole with powers. Based on this overview, complex interventions should be defined as being formed of parts, which can be material, human, theoretical, social, or procedural in nature, possibly stratified into higher and lower realms, that exercise power individually, in combination, or as emergent properties.     

Reduce dimension or reduce weights? Comparing two approaches to multi‐arm studies in network meta‐analysis

Network meta‐analysis is a statistical method combining information from randomised trials that compare two or more treatments for a given medical condition. Consistent treatment effects are estimated for all possible treatment comparisons. For estimation, weighted least squares regression that in a natural way generalises standard pairwise meta‐analysis can be used. Typically, as part of the network, multi‐arm studies are found. In a multi‐arm study, observed pairwise comparisons are correlated, which must be accounted for. To this aim, two methods have been proposed, a standard regression approach and a new approach coming from graph theory and based on contrast‐based data (Rücker 2012). In the standard approach, the dimension of the design matrix is appropriately reduced until it is invertible (‘reduce dimension’). In the alternative approach, the weights of comparisons coming from multi‐arm studies are appropriately reduced (‘reduce weights’). As it was unclear, to date, how these approaches are related to each other, we give a mathematical proof that both approaches lead to identical estimates. The ‘reduce weights’ approach can be interpreted as the construction of a network of independent two‐arm studies, which is basically equivalent to the given network with multi‐arm studies. Thus, a simple random‐effects model is obtained, with one additional parameter for a common heterogeneity variance. This is applied to a systematic review in depression. Copyright © 2014 John Wiley & Sons, Ltd.     

Cost‐effectiveness analysis based on the number‐needed‐to‐treat: common sense or non‐sense?

This paper explores and critically discusses some of the methodological limitations of using the number-needed-to-treat (NNT) in economic evaluation. We argue that NNT may be a straightforward measure of benefit when the effect of an intervention is immediate, but that serious problems arise when the effect is delay rather than avoidance of an adverse event. In this case, NNT is not a robust or accurate measure of effect, but will vary considerably and inconsistently over time. This weakness will naturally spill over onto any CEA based on NNT. A literature review demonstrated that CEAs based on NNT were all published within the last five years, and that all studies suffered from important limitations. A major weakness of using NNT is the imposed restrictions on the outcome measure, which can only be strictly uni-dimensional and non-generic. Using NNT in economic evaluations is obtained at a cost in terms of both methodological shortcomings, and a reduced ability for such evaluations to serve as a useful tool in decision making processes. The use of NNT in economic evaluations might be better avoided.To every complicated question, there is a simple, straightforward, easy--and probably wrong answer (Occam's Sledgehammer).