Elizabeth Robinson

Driver sleepiness and risk of serious injury to car occupants: population based case control study

Abstract Objectives: To estimate the contribution of driver sleepiness to the causes of car crash injuries. Design: Population based case control study. Setting: Auckland region of New Zealand, April 1998 to July 1999. Participants: 571 car drivers involved in crashes where at least one occupant was admitted to hospital or killed (“injury crash”); 588 car drivers recruited while driving on public roads (controls), representative of all time spent driving in the study region during the study period. Main outcome measures: Relative risk for injury crash associated with driver characteristics related to sleep, and the population attributable risk for driver sleepiness. Results: There was a strong association between measures of acute sleepiness and the risk of an injury crash. After adjustment for major confounders significantly increased risk was associated with drivers who identified themselves as sleepy (Stanford sleepiness score 4-7 v 1-3; odds ratio 8.2, 95% confidence interval 3.4 to 19.7); with drivers who reported five hours or less of sleep in the previous 24 hours compared with more than five hours (2.7, 1.4 to 5.4); and with driving between 2 am and 5 am compared with other times of day (5.6, 1.4 to 22.7). No increase in risk was associated with measures of chronic sleepiness. The population attributable risk for driving with one or more of the acute sleepiness risk factors was 19% (15% to 25%). Conclusions: Acute sleepiness in car drivers significantly increases the risk of a crash in which a car occupant is injured or killed. Reductions in road traffic injuries may be achieved if fewer people drive when they are sleepy or have been deprived of sleep or drive between 2 am and 5 am. What is already known on this topic Driver sleepiness is considered a potentially important risk factor for car crashes and related injuries but the association has not been reliably quantified Published estimates of the proportion of car crashes attributable to driver sleepiness vary from about 3% to 30% What this study adds Driving while feeling sleepy, driving after five hours or less of sleep, and driving between 2 am and 5 am were associated with a substantial increase in the risk of a car crash resulting in serious injury or death Reduction in the prevalence of these three behaviours may reduce the incidence of injury crashes by up to 19%

Magnetic resonance imaging of the wrist in early rheumatoid arthritis reveals a high prevalence of erosions at four months after symptom onset

OBJECTIVES To evaluate the role of magnetic resonance imaging (MRI) of the wrist in detecting early joint damage in patients with rheumatoid arthritis (RA). METHODS MRI was performed on 42 patients with early RA (median symptom duration of four months). Scans were scored separately by two musculoskeletal radiologists using a newly devised scoring system, which was validated. MRI findings were compared with plain radiography, clinical measures, and HLA-DRB*01/04 genotyping. RESULTS Interobserver reliability for the overall MRI score was high (r = 0.81) as was intraobserver reliability (r = 0.94 for observer 1 and 0.81 for observer 2). There was more variation in scoring synovitis (interobserver reliability: r = 0.74). Erosions were detected in 45% of scans (19 of 42), compared with 15% of plain radiographs. The most common site for erosions was the capitate (39%), for synovitis the ulnar aspect of the radiocarpal joint, and for tendonitis, the extensor carpi ulnaris tendon. The total MRI score and MRI synovitis score correlated most significantly with C reactive protein (r = 0.40 and 0.42 respectively, p<0.01). The MRI erosion score was highly correlated with MRI bone marrow oedema (r = 0.83) as well as the Ritchie score and disease activity score (r = 0.32, p<0.05). HLA-DRB1*04 or *01 (shared epitope +ve) was found in 76% of patients; 84% of those with MRI erosions and 69% of those without (NS, p = 0.3). CONCLUSIONS A high proportion of RA patients develop MRI erosions very early in their disease, when plain radiography is frequently normal. MRI of the dominant wrist may identify those requiring early aggressive treatment.

Magnetic resonance imaging of the wrist in early rheumatoid arthritis reveals progression of erosions despite clinical improvement

OBJECTIVES To investigate the progression of joint damage in early rheumatoid arthritis (RA) using magnetic resonance imaging (MRI) of the wrist and determine whether this technique can be used to predict prognosis. METHODS An inception cohort of 42 early patients has been followed up prospectively for one year. Gadolinium enhanced MRI scans of the dominant wrist were obtained at baseline and one year and scored for synovitis, tendonitis, bone marrow oedema, and erosions. Plain radiographs were performed concurrently and scored for erosions. Patients were assessed clinically for disease activity and HLA-DRB1 genotyping was performed. RESULTS At one year, MRI erosions were found in 74% of patients (31 of 42) compared with 45% at baseline. Twelve patients (28.6%) had radiographic erosions at one year. The total MRI score and MRI erosion score increased significantly from baseline to one year despite falls in clinical measures of inflammation including erythrocyte sedimentation rate (ESR), C reactive protein (CRP), and swollen joint count (p < 0.01 for all). Baseline findings that predicted carpal MRI erosions at one year included a total MRI score of 6 or greater (sensitivity: 93.3%, specificity 81.8%, positive predictive value 93.3%, p = 0.000007), MRI bone oedema (OR = 6.47, p < 0.001), MRI synovitis (OR = 2.14, p = 0.003), and pain score (p = 0.01). Radiological erosions at one year were predicted by a total MRI score at baseline of greater than 13 (OR = 12.4, p = 0.002), the presence of MRI erosions (OR = 11.6, p = 0.005), and the ESR (p = 0.02). If MRI erosions were absent at baseline and the total MRI score was low, radiological erosions were highly unlikely to develop by one year (negative predictive value 0.91 and 0.92 respectively). No association was found between the shared epitope and erosions on MRI (p = 0.4) or radiography (p = 1.0) at one year. CONCLUSIONS MRI scans of the dominant wrist are useful in predicting MRI and radiological erosions in early RA and may indicate the patients that should be managed aggressively. Discordance has been demonstrated between clinical improvement and progression of MRI erosion scores.

Circumstances of Falls Resulting in Hip Fractures Among Older People

OBJECTIVES: To describe the circumstances of falls resulting in hip fractures among older people and to determine whether the circumstances differ by gender, age, and residential status.

Medications and diagnoses in relation to falls in a long-term care facility

The association between falls, drugs, and diagnoses in elderly residents of a long‐term care facility was explored using case‐control methodology. The odds of being a faller rather than a control were significant (P < .01) for those taking antidepressants, sedatives/hypnotics, or vasodilators, and for those with osteoarthritis or depression.

A Randomized Controlled Trial of Cognitive Behavior Therapy for Multiple Sclerosis Fatigue

Background: The purpose of this study was to assess the efficacy of cognitive behavior therapy (CBT) as a treatment for multiple sclerosis (MS) fatigue. Methods: A randomized controlled design was used where 72 patients with MS fatigue were randomly assigned to eight weekly sessions of CBT or relaxation training (RT). RT was designed to control for therapist time and attention. Participants were assessed before and after treatment, and at 3 and 6 months posttreatment. The primary outcome was the Fatigue Scale. Secondary outcomes included measures of stress, mood, and fatigue-related impairment. Results: Analysis was by intention-to-treat. A group by time interaction showed that the CBT group reported significantly greater reductions in fatigue across the 8 months compared with the RT group (p < .02). Calculated effect sizes for fatigue from baseline to the end of treatment were 3.03 [95% confidence interval, 2.22–3.68] for the CBT group and 1.83 [95% confidence interval, 1.26–2.34] for the RT group. Results also indicted that both groups showed clinically significant decreases in fatigue defined as fatigue levels equivalent or less than those reported by a nonfatigued healthy comparison group. There were no significant interactions between group and any of the secondary outcome variables, with both groups showing improvements over time on all measures. Interpretation: Both CBT and RT appear to be clinically effective treatments for fatigue in MS patients, although the effects for CBT are greater than those for RT. Even 6 months after treatment, both treatment groups reported levels of fatigue equivalent to those of the healthy comparison group. MS = multiple sclerosis; CBT = cognitive behavior therapy; RT = relaxation training; RCT = randomized controlled trial; EDSS = expanded disability status scale; HADS = the hospital anxiety and depression scale.

Foot-to-foot bioelectrical impedance analysis: a valuable tool for the measurement of body composition in children.

OBJECTIVE: To determine the accuracy of foot-to-foot bioelectrical impedance analysis (BIA) and anthropometric indices as measures of body composition in children.DESIGN: Comparison of foot-to-foot BIA and anthropometry to dual-energy X-ray absorptiometry (DEXA)-derived body composition in a multi-ethnic group of children.SUBJECTS: Eighty-two European, NZ Maori and Pacific Island children aged 4.9–10.9 y.MEASUREMENTS: DEXA body composition, foot-to-foot bioelectrical impedance, height, weight, hip and waist measurements.RESULTS: Using a BIA prediction equation derived from our study population we found a high correlation between DEXA and BIA in the estimation of fat-free mass (FFM), fat mass (FM) and percentage body fat (PBF) (r=0.98, 0.98 and 0.94, respectively). BIA-FFM underestimated DEXA-FFM by a mean of 0.75 kg, BIA-FM overestimated DEXA-FM by a mean of 1.02 kg and BIA-PBF overestimated DEXA-PBF by a mean of 2.53%. The correlation between six anthropometric indices (body mass index (BMI), ponderal index, Chinns weight-for-height index, BMI standard deviation score, weight-for-length index and Coles weight-for-height index) and DEXA were also examined. The correlation of these indices with PBF was remarkably similar (r=0.85–0.87), more variable with FM (r=0.77–0.94) and poor with FFM (r=0.41–0.75).CONCLUSIONS: BIA correlated better than anthropometric indices in the estimation of FFM, FM and PBF. Foot-to-foot BIA is an accurate technique in the measurement of body composition.

Risk factors for atopic dermatitis in New Zealand children at 3·5 years of age

Background  The prevalence of atopic dermatitis (AD) is increasing in Western societies. The hygiene hypothesis proposes that this is due to reduced exposure to environmental allergens and infections during early life.

Excess Mortality or Institutionalization After Hip Fracture: Men Are at Greater Risk Than Women

To assess 2‐year excess mortality or institutionalization risk associated with hip fracture in community‐dwelling people aged 60 and over.

Attitudes and behaviour of general practitioners and their prescribing costs: a national cross sectional survey

Background: General practitioner (GP) prescribing accounts for about 10% of NHS expenditure. GPs at the top of the range have annual prescribing costs that are almost twice as much as those at the bottom of the range. This variation cannot be accounted for purely in terms of differences in underlying need for health care. Objectives: To describe the relationship between GPs’ prescribing costs and their attitudes towards prescribing decisions and prescribing information sources, and to identify potentially modifiable attitudinal and behavioural factors associated with high cost prescribing. Design: A postal questionnaire was designed on the basis of hypotheses developed from a literature search and an earlier qualitative survey. This questionnaire was sent to a national sample of GPs with equal numbers of practices in the upper, middle, and lowest quintile of prescribing costs. Setting: GP practices in England. Participants: 1714 GPs in NHS practice. Outcome measures: GPs’ self-reported practices, attitudes and personal characteristics. Results: There was a 64% response rate. Responders were more likely to be from larger practices, in less deprived areas, and with lower prescribing costs than were non-responders. Multivariable analysis showed that GPs with high prescribing costs were significantly more likely to work in dispensing practices, in practices with low income populations, in single handed practices, and in practices without a GP trainer. They were also significantly more likely to see drug company representatives more frequently, to prescribe newly available drugs more freely, to prescribe more readily to patients who expect a prescription, to report high levels of frustration from lack of time in the consultation, to find unsatisfactory those consultations which ended in advice only, and to express dissatisfaction with their review methods for repeat prescribing. They were significantly less likely to find useful criticism of prescribing habits by colleagues, and to check the BNF rather than other sources when uncertain about an aspect of drug treatment. Conclusions: While they cannot be held to have a causal relationship, the pattern of attitudes towards prescribing of GPs in the highest quintile of prescribing costs provide the basis for developing an educational intervention which may be an acceptable method of modifying the attitudes of GPs and consequently reducing their prescribing costs.