Background: Home-based computerised cognitive training (CCT) is ineffective at enhancing global cognition, a key marker of cognitive ageing. Objectives: To test the effectiveness of supervised, group-based, multidomain CCT on global cognition in older adults and to characterise the dose-response relationship during and after training. Design: A randomised, double-blind, longitudinal, active-controlled trial. Setting: Community-based training centre in Sydney, Australia Participants: Eighty nondemented community-dwelling older adults (mean age = 72.1, 68.8% females) with multiple dementia risk factors but no major neuropsychiatric or sensory disorder. Of the 80 participants admitted to the study, 65 completed post-training assessment and 55 were followed up one year after training cessation. Interventions: Thirty-six group-based sessions over three months of either CCT targeting memory, speed, attention, language and reasoning tasks, or active control training comprising audiovisual educational exercises. Measurements: Primary outcome was change from baseline in global cognition as defined by a composite score of memory, speed and executive function. Secondary outcome was 15-month change in Bayer Activities of Daily Living from baseline to one year post-training. Results: Intention-to-treat analyses revealed significant effects on global cognition in the cognitive training group compared to active control after three weeks of training (ES = 0.33, P=.039) that increased after 3 months of training (ES = 0.49, P=.003) and persisted three months after training cessation (ES = 0.30, P=0.023). Significant and durable improvements were also noted in memory and processing speed. Dose-response characteristics differed among cognitive domains. Training effects waned gradually but residual gains were noted twelve months post-training. No significant effects on activities of daily living were noted and there were no adverse effects. Conclusions: In older adults with multiple dementia risk factors, group-based CCT is a safe and effective intervention for enhancing overall cognition, memory and processing speed. Dose-response relationships vary for each cognitive domain, vital information for clinical and community implementation and further trial design.
The accurate prediction of malignancy for a pelvic mass detected on ultrasound allows for appropriate referral to specialised care. IOTA simple rules are one of the best methods but are inconclusive in 25% of cases, where subjective assessment by an expert sonographer is recommended but may not always be available. In the present paper, we evaluate the methods for assessing the nature of a pelvic mass, including IOTA with subjective assessment by expert ultrasound, RMI and ROMA. In particular, we investigate whether ROMA can replace expert ultrasound when IOTA is inconclusive. This prospective study involves one cancer centre and three general units. Women scheduled for an operation for a pelvic mass underwent a pelvic ultrasound pre-operatively. The final histology was obtained from the operative sample. The sensitivity, specificity and accuracy for each method were compared with the McNemar test. Of the 690 women included in the study, 171 (25%) had an inconclusive IOTA. In this group, expert ultrasound was more sensitive in diagnosing a malignant mass compared to ROMA (81% vs. 63%, p = 0.009) with no significant difference in the specificity or accuracy. All assessment methods involving IOTA had similar accuracies and were more accurate than RMI or ROMA alone. In conclusion, when IOTA was inconclusive, assessment by expert ultrasound was more sensitive than ROMA, with similar specificity.
Objective To determine the effectiveness of nurse‐led consultations in patients with stable rheumatoid arthritis (RA) in Hong Kong. Methods The present work was a single‐center, randomized, open‐label, noninferiority trial. Patients who had rheumatoid arthritis (RA) with low disease activity (LDA) were randomized at a 1:1 ratio to attend a nurse‐led consultation or rheumatologist follow‐up visit for 2 years. The primary end point was the proportion of patients whose RA remained at LDA. Secondary end points included the proportion of patients with RA in disease remission and the scores recorded on the Leeds Satisfaction Questionnaire at 2 years, changes from baseline on the Disease Activity Score in 28 joints using the C‐reactive protein level (DAS28‐CRP), modified Sharp/van der Heijde score (SHS), Health Assessment Questionnaire disability index (HAQ DI), Short Form 36 (SF‐36) physical component score, and 19‐item Compliance Questionnaire for Rheumatology (CQR‐19) score. Results Among 280 patients who were randomized equally to either attend nurse‐led consultations or rheumatologist follow‐up visits, 267 patients completed the study. In the nurse‐led consultation and rheumatologist follow‐up groups, 92.1% and 91.4% patients, respectively, remained at LDA at 2 years. The 95% confidence intervals (95% CIs) of the adjusted treatment difference were within the predefined noninferiority margin in both the intention‐to‐treat analysis (95% CI 5.75, 7.15) and the per‐protocol analysis (95% CI 1.67, 7.47). Although the changes in DAS28‐CRP score over 2 years were significantly different between the 2 treatment groups (P < 0.001), there were no significant changes from baseline in SHS, HAQ DI, SF‐36 physical component scores, and CQR‐19 scores. At the end of the study, more patients expressed satisfaction with nurse‐led consultations. Conclusion Nurse‐led consultations were not inferior to rheumatologist follow‐up visits in patients with stable RA.
Lymph node status is important in predicting the prognosis and guiding adjuvant treatment in endometrial cancer. However, previous studies showed that systematic lymphadenectomy conferred no therapeutic values in clinically early-stage endometrial cancer but might lead to substantial morbidity and impact on the quality of life of the patients. The sentinel lymph node is the first lymph node that tumor cells drain to, and sentinel lymph node biopsy has emerged as an acceptable alternative to full lymphadenectomy in both low-risk and high-risk endometrial cancer. Evidence has demonstrated a high detection rate, sensitivity and negative predictive value of sentinel lymph node biopsy. It can also reduce surgical morbidity and improve the detection of lymph node metastases compared with systematic lymphadenectomy. This review summarizes the current techniques of sentinel lymph node mapping, the applications and oncological outcomes of sentinel lymph node biopsy in low-risk and high-risk endometrial cancer, and the management of isolated tumor cells in sentinel lymph nodes. We also illustrate a revised sentinel lymph node biopsy algorithm and advocate to repeat the tracer injection and explore the presacral and paraaortic areas if sentinel lymph nodes are not found in the hemipelvis.
Background Fear of childbirth causes significant distress and impact on women’s wellbeing. It also contributes to the rising trend of non-medically indicated Caesarean sections worldwide. The Wijma Delivery Expectancy/Experience Questionnaire (Version A) (W-DEQ-A) is a comprehensive instrument for the assessment of fear of childbirth among antenatal women. Methods Hong Kong Chinese women at the antenatal booking clinic completed the translated questionnaire, Edinburgh Postpartum Depression Scale, State-trait Anxiety Inventory and indicated their preferred mode of delivery. The validity and reliability of the translated questionnaire were analysed using Cronbach’s alpha coefficient and intraclass correlation coefficient respectively. The subscales of the questionnaire were determined using exploratory factor analysis. The relationship between demographic data, preferred mode of delivery and the W-DEQ-A score were analysed using student’s t test, Mann-Whitney test or Pearson’s correlation. Results One hundred and fifty women completed the study. The Cronbach’s alpha coefficient and test-retest reliability of the Chinese version were 0.907 and 0.867 respectively. Convergent validity was demonstrated with other psychological measures at expected levels. The mean W-DEQ-A score among the Hong Kong Chinese population is 65 out of 165, which is negatively correlated with gravidity, parity and partner support. Using a standard cut-off of 85, 11.3% women were found to suffer from fear of childbirth and it is associated with a history of psychiatric history. 72% and 22.7% women preferred vaginal delivery and Caesarean section respectively. Nulliparous women who preferred a vaginal delivery have a significantly lower score than those who preferred a Caesarean section, with mean (SD) W-DEQ-A scores of 67.1 (14.8) compared to 75.9 (15.9) (p = 0.036). Conclusion The Chinese version of Wijma Delivery Expectancy/Experience Questionnaire (Version A) is a reliable and valid instrument to measure antenatal fear of childbirth among Chinese women. Clinicians can use this measure to assess the severity of women’s fear over the course of their pregnancy, and to monitor the success of any medical or psychological interventions for women with fear of childbirth in the future.
BackgroundThe waiting time for newly referred patients to the rheumatology clinic is approximately 24 months. The Rheumatology Nurse Rapid Access Triage Clinic aims to shorten the waiting time of patients suspected to have rheumatoid arthritis (RA). It is hoped that patients with active RA can be fast-tracked to commence earlier treatment for better disease control.ObjectivesTo validate if Rheumatology Nurses (RhN) can screen out patients with active RA for earlier treatment and to evaluate the level of agreement in RA diagnosis between RhN and rheumatologists.MethodsNewly referred patients suspected to have RA were assessed by RhN from March 2012 to September 2015. Based on a protocol modelled upon the 2010 European League Against Rheumatism (EULAR)/American College of Rheumatologists (ACR) criteria for the classification of RA, RhN performed history taking, physical examination of joints, and ordered relevant blood and X-ray investigations. RhN then reviewed all results to discriminate between RA and non-RA. Paired t-tests and logistic regression were used to compare variables between RA and non-RA patients diagnosed by RhN. Correlation coefficient (CC) was used to compare the level of agreement between RhN's and rheumatologists' assessment.ResultsRhN assessed 102 patients (mean age =53.46 ± 12.59 years, 84.3% women). The group diagnosed to have RA by RhN had shortened waiting time for the rheumatology clinic when compared to the non-RA group. (11.5 vs 3.6 months; p<0.001) Agreement between RhN diagnosed RA and rheumatologist diagnosed RA was excellent (CC 90%; P<0.001). Comparing with the non-RA group, RhN diagnosed RA group also had greater chance of receiving disease modifying anti-rheumatic drugs (DMARDs) early (OR 43.08, p<0.001). The mean duration between onset of joint symptom and DMARDs commencement was 8.26 ± 11.52 months ranging from 3 to 52 months.ConclusionsThe Rheumatology Nurse Rapid Access Triage Clinic provides accurate diagnosis and shortens RA patient's waiting time. It also helps to screen out active patients to receive earlier treatment.ReferencesGormley GJ, Steele WK, Gilliland A, Leggett P, Wright GD, Bell AL, Matthew C, Meenagh G, Wylie E, Mulligan R, Stevenson M, Reilly DO and Taggart AJ (2003) Can diagnostic triage by general practitioners or rheumatology nurses improve the positive predictive value of referrals to early arthritis clinics? Rheumatology 42:763–768.Disclosure of InterestNone declared
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