Wednesday, 19 December 2012

Patients with advanced Parkinson's disease often have rapid swings between mobility and immobility


Subthalamic nucleus versus globus pallidus bilateral deep brain stimulation for advanced Parkinson's disease (NSTAPS study): a randomised controlled trial


Summary

Background

Patients with advanced Parkinson's disease often have rapid swings between mobility and immobility, and many respond unsatisfactorily to adjustments in pharmacological treatment. We assessed whether globus pallidus pars interna (GPi) deep brain stimulation (DBS) gives greater functional improvement than does subthalamic nucleus (STN) DBS.

Methods

We recruited patients from five centres in the Netherlands who were aged 18 years or older, had idiopathic Parkinson's disease, and had, despite optimum pharmacological treatment, at least one of the following symptoms: severe response fluctuations, dyskinesias, painful dystonias, or bradykinesia. By use of a computer-generated randomisation sequence, we randomly assigned patients to receive either GPi DBS or STN DBS (1:1), applying a minimisation procedure according to drug use (levodopa equivalent dose <1000 i="i" mg="mg" nbsp="nbsp">vs
 ≥1000 mg) and treatment centre. Patients and study assessors (but not those who assessed adverse events) were masked to treatment allocation. We had two primary outcomes: functional health as measured by the weighted Academic Medical Center Linear Disability Scale (ALDS; weighted by time spent in the off phase and on phase) and a composite score for cognitive, mood, and behavioural effects up to 1 year after surgery. Secondary outcomes were symptom scales, activities of daily living scales, a quality-of-life questionnaire, the occurrence of adverse events, and drug use. We used the intention-to-treat principle for all analyses. This trial is registered with www.controlled-trials.com, number ISRCTN85542074.

Findings

Between Feb 1, 2007, and March 29, 2011, we enrolled 128 patients, assigning 65 to GPi DBS and 63 to STN DBS. We found no statistically significant difference in either of our primary outcomes: mean change in weighted ALDS (3·0 [SD 14·5] in the GPi group vs 7·7 [23·2] in the STN group; p=0·28) and the number of patients with cognitive, mood, and behavioural side-effects (36 [58%] of 62 patients in the GPi group vs 35 [56%] of 63 patients in the STN group; p=0·94). Secondary outcomes showed larger improvements in off-drug phase in the STN group compared with the GPi group in the mean change in unified Parkinson's disease rating scale motor examination scores (20·3 [16·3] vs 11·4 [16·1]; p=0·03), the mean change in ALDS scores (20·3 [27·1] vs 11·8 [18·9]; p=0·04), and medication (mean levodopa equivalent drug reduction: 546 [SD 561] vs 208 [521]; p=0·01). We recorded no difference in the occurrence of adverse events between the two groups. Other secondary endpoints showed no difference between the groups.

Interpretation

Although there was no difference in our primary outcomes, our findings suggest that STN could be the preferred target for DBS in patients with advanced Parkinson's disease.

Funding

Stichting Internationaal Parkinson Fonds, Prinses Beatrix Fonds, and Parkinson Vereniging.
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Ambitious about Autism guide


Tips for an autism-friendly Christmas


Emma Tracey Emma Tracey | 15:01 UK time, Friday, 14 December 2012
Dylan and Jake Beadle in the snow with mum Tracy
Most of us see Christmas as a welcome excuse to break from the old routine, do lots of socialising and give and receive presents. But the holidays can prove challenging for children and adults on the autistic spectrum, who find change, crowds and surprises difficult to handle.
That's why Ambitious about Autism and the National Autistic Society have both thought to produce their own online guides to help people with ASD, and their families, to cope with Christmas time.
Tracy Beadle, mother of two children who are on the autistic spectrum, is one of the contributors to the Ambitious about Autism guide which has been crowd-sourced via social media and their Talk about Autism forums.
Her sons, seven-year-old Dylan Beadle and his four-year-old brother Jake both love Christmas but their social difficulties, sensitivities about touch, taste and noise, and untypical reactions to certain situations, have led mum Tracy and dad Glen to approach this part of the year a little differently.
Christmas preparations start for the family in late November to get Dylan and Jake ready for changes at home.
"We give the boys a count down of 'sleeps' before the decorations go up, and then again before they come down," Tracy says.
"A visual calendar is then hung in their bedroom and every night we stand and count the sleeps until Christmas Day."
The calendar is a sheet of paper with a square representing each day. All other squares are blank apart from Christmas Day which has present-bedecked stickers on it.
Both of the online guides appreciate that all children are different, so what works for one may not suit another.
The National Autistic Society suggests that some might benefit from having more events marked on their visual calendar, such as when the school holidays begin and end, when they can expect visitors and so on.
Finding out when preparation will begin at your child's school and then starting your family Christmas at home at the same time is another suggestion.
One Christmas inevitability for children is the annual school performance. Tracy's eldest son Dylan isn't a fan. "He has cried his way through the last three, so he isn't going to take part this year. It upsets him and it isn't an essential life skill."
Younger son Jake hopes to be in his school nativity play but Tracy says this took some work: "He went mad when he saw his shepherd's outfit, and said 'I go to school as a boy, not a shepherd'."
They took the costume in to school and introduced Jake to it slowly. He had learned the songs and was eager to go on stage, so after some encouragement from the teacher, Jake has been convinced to wear the robes during the show.
A fear of people in costume means that visiting Santa is not part of the Beadles' Christmas routine.
"We took Dylan once," Tracy remembers. "He was the only child there who, instead of sitting on Santa's lap, sat on a toy car and started playing with it. He wouldn't speak to Santa at all."
Like many others with autism, Jake and Dylan aren't good at faking delight if they get an unwanted gift. Friends and relatives now always ask mum and dad what the boys would like. For Tracy, this is an easy one to answer.
"They do tend to have an obsession each Christmas," she says. "It is Angry Birds this year. Last year it was Disney's Cars."
Tracy is aware of parents who discourage their autistic child's obsessions but she takes a different approach. "I completely over-indulge the obsessions, buying them every toy they want because I find that if you over-indulge them, it passes more quickly."
Both guides have plenty of tips for managing Christmas Day. Advice includes putting batteries in toys in advance so that they can be played with straight away and making sure that the Christmas meal is ready at a prearranged time.
The consensus, though, is to find a routine that works and stick to it. Through trial and error, Tracy and Glen Beadle have found a pattern of events which the boys like and which they expect to happen. So, what's their pattern?
"On Christmas Eve we go to visit my nan," says Tracy. "On the way home we take them to visit a house with thousands of pounds worth of decorations. On Christmas Day, we open presents and then my immediate family come for dinner."
You can follow Ouch! on Twitter and on Facebook.
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Tuesday, 18 December 2012

Pharmacies caught illegally selling addictive drugs


Nine pharmacists accepted cash for prescription-only medicines

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Pharmacies caught illegally selling addictive drugs to undercover reporters face three separate investigations - including a criminal probe.
Nine west London pharmacies sold drugs including Valium, Viagra, temazepam and morphine to BBC1's Inside Out.
Now both the Metropolitan Police and regulator the General Pharmaceutical Council (GPhC) have requested evidence gathered by the programme.
Selling drugs without prescription has a maximum penalty of two years in jail.
An inspector at the Met's Drugs Directorate told the BBC: "It looks like you have evidence of criminality and obviously we need to look at that very closely.
"We would want to look at that as a matter of urgency."
Council contract suspended
The GPhC also requested the evidence. The organisation has the power to remove pharmacists' right to practise in Great Britain.

WHAT THE BBC BOUGHT AND WHERE

  • Al Farabi, Paddington: Oramorph, Diazepam, Viagra, amoxicillin
  • Curie Pharmacy, Maida Vale: Temazepam, Diazepam, Viagra, amoxicillin
  • Bin Seena, Paddington: Valium, Tramadol (offered), amoxicillin
  • R and C Pharmacy, Willesden: Amoxicillin
  • Safeer, Paddington: Valium, Viagra, amoxicillin
  • Craig Thomson, Willesden: Amoxicillin
  • Al Razi, Paddington: Viagra, amoxicillin
It admitted that prior to the BBC investigation it had only taken one pharmacist in England to a fitness to practise hearing for selling drugs without a prescription in 2012.
Meanwhile a third investigation is being launched jointly by Westminster Council and Inner North West London Primary Care Trust.
Westminster Council has said it is suspending its contract with one of the pharmacies involved.
The council had used Curie Pharmacy in Maida Vale to provide supervised methadone doses to drug addicts.
Undercover reporters were sold temazepam, Diazepam, Viagra and amoxicillin at the business - all without a prescription.
'Extremely disturbing'
Councillor Rachael Robathan, Westminster City Council's Cabinet Member for Adults, said: "The council has suspended its contract with Curie for services, such as controlled consumption by people on recovery programmes.
"We have launched an immediate investigation with Inner North West London Primary Care Trust of these extremely disturbing revelations."
ChemistThis chemist advised the researcher to take whatever dose of morphine he wanted
Councillor Robathan continued: "The council expect that all pharmacies operate at all times within the law and the regulations governing them.
"The fitness to practise of this pharmacist and others identified will be a matter for our Primary Care Contracts Team."
A Westminster Council spokesman said its officers were also checking training standards were being met at the dozen pharmacies in its area which deliver local authority services.
He added: "This is in direct response to the revelations made by your report."
A spokeswoman for the trust said: "Clearly the accusations are very serious. We will follow our normal procedures and respond to any formal evidence or complaint that is forwarded to us."

“Start Quote

This is the antithesis of what we'd like pharmacists to be doing”
Neal PatelRoyal Pharmaceutical Society
Contacted on Tuesday about the latest developments, all the pharmacies involved declined to comment.
Several London pharmacies sold the reporters from the BBC's Inside Out programme diazepam or its trade name drug Valium - a strong and addictive sedative in the benzodiazepine family - for up to £85.
The BBC was acting on specific intelligence about the pharmacies.
Latest figures show 293 people died in the UK in 2011 from misuse of benzodiazepines, more than double the 125 killed by cocaine and ecstasy combined.
And for £200, Al Farabi Pharmacy in Paddington dispensed a bottle of Oramorph - containing morphine.
A standard NHS prescription would cost about £7.65.
'Shocked and appalled'
Over a few weeks, researchers bought 288 Valium tablets, 21 temazepam tablets, 294 amoxicillin tablets, 24 Viagra tablets and one bottle of Oramorph without prescriptions.
Neal Patel, spokesman for the Royal Pharmaceutical Society, said: "I have been speaking to pharmacists and colleagues are absolutely shocked and appalled at the behaviour we've seen.
"The allegations are the most serious ones I can imagine - pharmacists I know pride themselves on patient safety and this is the antithesis of what we'd like pharmacists to be doing.
"I'm a pharmacist myself and watching this is very difficult for me."
The Labour Party continues to call for a fourth inquiry - into whether the pharmaceutical regulatory system is robust enough.
Shadow Health secretary Andy Burnham said: "The government should review again how pharmacy is regulated. For instance, there is a clear case for unannounced spot-checks to change the regulatory culture."
The Department of Health insists it takes abuse of prescription drugs seriously
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Winter bug cases '83% up on 2011'


Winter bug cases '83% up on 2011'


There have been just over 3,000 lab-confirmed cases.NorovirusLatest figures show there has been an increase in cases of norovirus - often known as the winter vomiting bug.
The Health Protection Agency estimates there have been about 880,000 cases in England and Wales since the summer, 83% more than in the same period last year.
But the HPA says these reported cases are the tip of the iceberg and for each one, there will be around 288 that go unreported.
Health Protection Scotland has also reported a rise in cases.
Early increase
The figures also show there were 61 outbreaks of norovirus in hospitals in the fortnight up to December 16 - almost double the number in the same period last year when there were 35.
Norovirus is highly contagious and can be transmitted by contact with an infected person, contaminated surfaces or objects or through consuming contaminated food or water.
It spreads rapidly in closed environments such as hospitals, schools and care homes.
The norovirus "year" - the date from which experts start to count cases - begins in July and runs to the following June.
The increase in norovirus cases is occurring earlier than normal - but experts are unsure why this is happening.
And these figures are a small fraction of the number of confirmed cases seen during the usual peak period of January to March.
However the HPA stresses norovirus is unpredictable, and no two years are the same.
Laboratory confirmed reports represent a small proportion of the actual number of cases because most people do not see a doctor - and therefore their case is not recorded.
'Short-lived'
John Harris, an expert in norovirus at the HPA said: "The number of laboratory confirmed cases has risen again, following the drop in the number we reported last week.
"This is typical of the norovirus season where the number of laboratory reports fluctuates between October and April with the bulk of cases usually occurring between January and March.
"Norovirus is very contagious so we would urge anyone who thinks they may be unwell with norovirus to stay at home and stay away from hospitals and care homes.
"The infection is short-lived although it is very unpleasant while you are unwell.
"Most people will not need to go to see their doctor and will recover in a couple of days. It is important to take plenty of fluids to avoid dehydration."
A Department of Health spokesman said: "The NHS is well prepared for the increase in winter related health problems which are typical at this time of year.
"Our weekly published figures show the number of beds closed across the NHS due to norovirus symptoms is around 2%.
"This compares to 2.9% of beds that were closed during the peak of norovirus cases last winter."
The latest Scottish figures, published on 5 December, showed 2,016 laboratory reports so far this season - up 46% on 2011 figures.
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Saturday, 15 December 2012

guilty of killing baby


Grace Adeleye guilty of killing baby in botched circumcision

Grace AdeleyeGrace Adeleye denied causing Goodluck Caubergs' death

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A nurse has been found guilty of manslaughter after causing a baby's death by botching his circumcision.
Grace Adeleye, 67, carried out the procedure on four-week-old Goodluck Caubergs at an address in Chadderton, Oldham, in April 2010.
The boy bled to death before he could reach hospital the following day.
Adeleye was found guilty of manslaughter by gross negligence at Manchester Crown Court.
The nurse, who denied the charge, had told the jury she had done "more than 1,000" circumcision operations without incident.
The court heard that Adeleye and Goodluck's parents were from Nigeria, where the circumcision of newborns is the tradition for Christian families.
Adeleye, of Sarnia Court, Salford, was paid £100 to do the operation.
The jury was told that she carried out the procedure using a pair of scissors, forceps and olive oil and without anaesthetic.
She had claimed there had been "no problem" when she left the infant and that his parents had been pleased with the operation.

“Start Quote

Goodluck Caubergs was a healthy little boy whose tragic death was wholly unnecessary”
Jane WraggCrown Prosecution Service
However, the court heard that when Goodluck's parents had changed his nappy several hours later, they had found a large amount of blood and phoned Adeleye, who had told them to redress the wound.
Goodluck's parents called an ambulance the following morning and he was taken to the Royal Oldham Hospital, where he died a short time later.
A spokesman for NHS Oldham said had the family gone to the hospital and asked for a circumcision, "they would have been advised to go to an approved practitioner who would have charged £100, the same as Grace Adeleye".
Following the guilty verdict, Adeleye was bailed while pre-sentencing reports are prepared.
The Crown Prosecution Service's Jane Wragg said the case "was not about the rights or wrongs of circumcision, but the grossly negligent way in which the procedure was undertaken".
"Goodluck Caubergs was a healthy little boy whose tragic death was wholly unnecessary," she said.
"Goodluck died because the standard of care taken by Grace Adeleye in carrying out the circumcision fell far below the standard that should be applied.
"She also failed to inform his parents of the risks and possible complications, which ultimately led to his tragic death."

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Friday, 7 December 2012

'Never mind the patient, tick the box'


'Never mind the patient, tick the box'

By Prof Sue BaileyPresident, Royal College of Psychiatrists
PaperworkRegulation and inspection are often increased after a crisis

Scrubbing Up

Scandals lead to inquiries and to recommendations - leading to a focus on filling in forms and ticking the right boxes.
But in this week's Scrubbing Up Sue Bailey, president of the Royal College of Psychiatrists, says it's time to listen to those receiving the care.
Why do care standards break down? We've all read heartbreaking stories of elderly people with dementia or patients with learning difficulties being neglected, mistreated and abused.
When things go wrong, inquiries are set up, reports are published and lessons learnt.
Think Winterbourne View; Mid-Staffordshire; childcare in Rochdale, or the Carlisle Report.
At heart, the recommendations boil down to improving communication, listening, learning and acting. It means taking notice of what patients and service users have to say.
Blame culture
But when trying to deliver the right kind of care, the health service often addresses regulation, standard setting, inspection and monitoring.
This approach aims to improve scrutiny and accountability, which most people would agree is a "good thing".

“Start Quote

The present blame culture doesn't help anyone.”
But there is a risk that a constant focus on targets, procedures and performance can lead to a tick box approach to healthcare.
This usually ends up placing more controls on healthcare workers, greater monitoring and prescriptive procedures.
Unfortunately, this is often at the expense of professional judgement, leading to dissatisfied and demoralised staff - with the all important relationship between the patient and healthcare worker forgotten.
I'm not saying that people shouldn't be held to account for their actions, but the present blame culture doesn't help anyone.
Healthcare is, or should be, a moral as well as a practical undertaking.
It deals with uncertainty in which mistakes are inevitable - but this isn't a message anyone wants to hear. Positive change won't happen if we continue to exist in a risk-averse bubble.
As Professor Eileen Munro of the London School of Economics put it recently, defensive care practice doesn't avoid risk, it simply displaces it - usually onto those using the services.
Time sensitive
What is needed is something in very short supply in the health service - time.
It takes time to develop expertise and build relationships based on intelligent kindness, not just technical skills.
It takes time to build critical reasoning skills and provide effective supervision.
It takes time to allow staff doing a difficult and stressful job to reflect, offload and be mentored by those with more experience.
In an era of unprecedented NHS reform, how can we find the time?
I believe we need a greater focus on helping the workforce develop the skills, knowledge and personal qualities required to meet care needs, support new staff more and improve opportunities for career progression
Workforce development takes time and money, but it is an investment that could support safer and better care, and mutual respect between patient and carer or doctor.
Old fashioned?
Don't get me wrong; improved processes can help, too.
We need data in healthcare but what we want and need are useful, practical tools that help learning and improve care.

“Start Quote

Policy makers will have to be brave to think and act in the long term”
This learning should involve ongoing feedback from patients, which is acted on by people like me.
What's the bottom line? A health service in which the treatment and care of people - not systems and processes - are at the heart of what we do.
Does that seem terribly old fashioned?
It sounds an awful lot like what I came into medicine for 40-odd years ago, but which I have seen start to drift away.
I will be accused of being simple minded, but a just culture should replace a blame culture.
This will require a major shift in approach towards positive risk taking and being open and honest with ourselves and with our patients that not everything can be "cured".
It's not too late, but policy makers will have to be brave to think and act in the long term. But is anybody listening?
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Monday, 3 December 2012

westof mengele: Seasonal Affective Disorder

westof mengele: Seasonal Affective Disorder
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westof mengele: autumn equinox

westof mengele: autumn equinox
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