Croydon, United Kingdom
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Carr P.,Croydon University Hospital
Nursing standard (Royal College of Nursing (Great Britain) : 1987) | Year: 2015

Stroke units across the UK employ untrained healthcare assistants (HCAs) to assist with nursing care.


Bugge C.,University of Stirling | Hagen S.,Glasgow Caledonian University | Thakar R.,Croydon University Hospital
International Urogynecology Journal and Pelvic Floor Dysfunction | Year: 2013

Introduction and hypothesis: Vaginal pessaries may offer symptomatic improvement for women with pelvic organ prolapse (POP) or urinary incontinence (UI). This study aimed to investigate multidisciplinary perspectives on vaginal pessary use in clinical practice and to understand the service organisation of vaginal pessary care for women with these conditions. Methods: A pretested, anonymous survey was e-mailed to members of the Royal College of Obstetrics and Gynaecology, the Association for Continence Advice and the Association of Chartered Physiotherapists in Women's Health in the UK. Results: A total of 678 respondents, from medical, nursing and physiotherapy professions, consented to survey participation and provided useable data (response rate 20.7 %). Doctors were significantly more likely to report involvement in pessary care than nurses or physiotherapists. Respondents were optimistic about the success of pessary treatment; however, a lower proportion reported using pessaries for UI than for prolapse. The majority of respondents used ring pessaries and shelf pessaries, most recipients were older women, and commonly an indication for fitting a pessary was that the woman was unfit for surgery. More than 15 % of respondents providing pessary care had not received training. Follow-up services for women with pessaries varied considerably. Conclusions: The variation in pessary care delivery and organisation requires further study in order to maximise efficiency and effectiveness. The development of nurse- or physiotherapist-led models of care may be appropriate, but the effectiveness of such models requires testing. Furthermore, to potentially improve outcomes of pessary care, a greater understanding of the availability, content and process of training may be warranted. © 2012 The International Urogynecological Association.


Beggs A.D.,University of Oxford | Beggs A.D.,Croydon University Hospital | Jones A.,University of Oxford | El-Bahwary M.,Imperial College London | And 3 more authors.
Journal of Pathology | Year: 2013

Changes in DNA methylation, whether hypo- or hypermethylation, have been shown to be associated with the progression of colorectal cancer. Methylation changes substantially in the progression from normal mucosa to adenoma and to carcinoma. This phenomenon has not been studied extensively and studies have been restricted to individual CpG islands, rather than taking a whole-genome approach. We aimed to study genome-wide methylation changes in colorectal cancer. We obtained 10 fresh-frozen normal tissue-cancer sample pairs, and five fresh-frozen adenoma samples. These were run on the lllumina HumanMethylation27 whole-genome methylation analysis system. Differential methylation between normal tissue, adenoma and carcinoma was analysed using Bayesian regression modelling, gene set enrichment analysis (GSEA) and hierarchical clustering (HC). The highest-rated individual gene for differential methylation in carcinomas versus normal tissue and adenomas versus normal tissue was GRASP (p adjusted = 1.59 × 10-5, BF = 12.62, p adjusted = 1.68 × 10-6, BF = 14.53). The highest-rated gene when comparing carcinomas versus adenomas was ATM (p adjusted = 2.0 × 10-4, BF = 10.17). Hierarchical clustering demonstrated poor clustering by the CIMP criteria for methylation. GSEA demonstrated methylation changes in the Netrin-DCC and SLIT-ROBO pathways. Widespread changes in DNA methylation are seen in the transition from adenoma to carcinoma. The finding that GRASP, which encodes the general receptor for phosphoinositide 1-associated scaffold protein, was differentially methylated in colorectal cancer is interesting. This may be a potential biomarker for colorectal cancer. Copyright © 2012 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd. Copyright © 2012 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.


Meyer N.P.,Croydon University Hospital
The Ceylon medical journal | Year: 2012

To determine the effect of conservative management of morbidly adherent placentae on maternal morbidity and mortality and to review management options All case notes of patients with placenta accreta and percreta between June 2008 and August 2010 were studied retrospectively. Eight placentae percretae and 4 placentae accretae were identified out of a total of 11,358 deliveries.All 12 patients underwent caesarean section. Placentae percretae were intentionally left in situ. Interventional radiology was used in these cases. There was one emergency hysterectomy for massive obstetric haemorrhage,one case of disseminated intravascular coagulation,one case of early sepsis and 3 cases of delayed sepsis.Average blood loss was 2490 ml with the mean volume transfused being 1425 ml. The mean hospital stay was 7 days and 2 patients were admitted to intensive care. One patient was readmitted with sepsis complicated by a utero-cutaneous fistula (complete placenta praevia).Another patient required re-embolisation 5 months post delivery for persistent haemorrhage. No ureteric or bladder injuries occurred. Conservative management of placenta percreta is an alternative to caesarean hysterectomy. It is associated with lower maternal morbidity rates.However, monitoring for sepsis and secondary postpartum haemorrhage is essential. Rare complications such as utero-cutanus fistulae may occur.


Van Delft K.,Croydon University Hospital | Thakar R.,Croydon University Hospital | Sultan A.H.,Croydon University Hospital
Ultrasound in Obstetrics and Gynecology | Year: 2015

Objectives: A significant reduction in hiatal area and anteroposterior diameter can be induced by pelvic floor muscle contraction, and this has been demonstrated using three-dimensional/four-dimensional (3D/4D) transperineal ultrasound (TPS) in a small group of women. Our objective was to correlate pelvic floor muscle contractility using digital assessment with the change in TPS hiatus measurements during maximum pelvic floor muscle contraction. Methods: Nulliparous pregnant women were recruited from the antenatal clinic. Pelvic floor muscle contractility was assessed by digital palpation using the validated Modified Oxford Scale (MOS). Subsequently, women underwent 3D/4D TPS. Measurements of the hiatal area and anteroposterior diameter were taken from the rendered ultrasound images at rest and at maximum contraction, and differences in measurements were expressed as percentages. Spearman's rank (ρ) was used to assess the correlation. Results: Four hundred and fifty-nine assessments were performed, of which 268 were from women at around 36 weeks' gestation, and 191 were from women following delivery at 3 months postpartum. The overall correlation between MOS and TPS was found to be ρ = 0.47 for hiatal area (P < 0.001) and ρ = 0.51 for hiatal anteroposterior diameter (P < 0.001). Conclusions: Digital palpation using MOS and TPS can both be used as tools to assess pelvic floor muscle contractility. Although MOS is a simple clinical tool without the need for any equipment, TPS can provide good visual biofeedback when training patients in pelvic floor muscle exercises. As TPS is non-intrusive, it may be the method of choice for some women. Copyright ©2014 ISUOG. Published by John Wiley & Sons Ltd.


Moverley R.,Croydon University Hospital | Williams D.,Nuffield Orthopaedic Center | Bardakos N.,South West London Elective Orthopaedic Center | Field R.,University of London
International Orthopaedics | Year: 2014

Purpose: The function of the infrapatella fat pad (IFP) is debated, but it is thought to have a biomechanical and biological role. Removal of the IFP during total knee arthroplasty (TKA) remains a matter of surgeon preference. This study sought to establish if removal of the IFP during TKA affected patient outcome.Methods: Excision of the IFP (not removed, partially excised, or fully excised) and outcome data (Oxford knee Score (OKS) and EQ-5D) were recorded for 1,401 patients (1,417 TKA). There were no differences in the pre-operative scores between the groups.Results: OKS and EQ-5D one-year postoperatively demonstrated significantly (p < 0.05 ANOVA) improved total scores with preservation of the IFP. Patients with the IFP preserved had significantly better OKS associated with rising from a chair, pain, limping, giving way, and pain interfering with work.Conclusions: This study suggests that preservation of the fat pad during TKA is associated with improved outcome. Surgeons routinely undertaking excision of the IFP should reflect whether this is clinically indicated and consider limiting IFP resection, if possible. © 2014, SICOT aisbl.


Beggs A.D.,University of Oxford | Beggs A.D.,Croydon University Hospital | Domingo E.,University of Oxford | Abulafi M.,Croydon University Hospital | And 2 more authors.
Oncogene | Year: 2013

It is difficult to explain the differential rates of progression of premalignant colonic lesions and differences in behaviour of morphologically similar lesions. Heterogeneity for microsatellite instability (MSI) and promoter methylation in driving these phenomena forward may explain this; however, no previous analysis has examined this in detail at the gland level, the smallest unit of colorectal premalignant lesions. We aimed to carry out an analysis of gland level genomic instability for MSI and promoter methylation. MSI occurred significantly more frequently (20%) in colonic glands than has previously been observed in whole colorectal polyps. Significant promoter methylation was seen in MLH1, PMS2, MLH3 and MSH3 as well as significant heterogeneity for both MSI and promoter methylation. Methylation and MSI may have a significant role in driving forward colorectal carcinogenesis, although in the case of MSI, this association is less clear as it occurs significantly more frequently than previously thought, and may simply be a passenger in the adenoma-carcinoma sequence. Promoter methylation in MLH1, MLH3, MSH3 and PMS2 was also found to be significantly associated with MSI and should be investigated further. A total of 273 colorectal glands (126 hyperplastic, 147 adenomatous) were isolated via laser capture microdissection (targeted at regions of MLH1 loss) from 93 colonic polyps and tested for MSI, and promoter methylation of the DNA mismatch repair genes MLH1, MSH2, MLH3, MSH6, PMS2, MGMT and MLH3 via methylation specific multiplex ligation-dependent probe amplification. Logistic regression modelling was then used to identify significant associations between promoter methylation and gland histological type and MSI status. © 2013 Macmillan Publishers Limited.


Thakar R.,Croydon University Hospital
Sexual Medicine Reviews | Year: 2015

Introduction: Hysterectomy has been a mainstay of gynecologic therapy for 100 years. It can be postulated that hysterectomy could affect female sexual function due to psychological factors, and also due to disruption of the local nerve and blood supply and the intimate anatomical relationships of the pelvic organs. Aim: To evaluate the effects of hysterectomy performed for benign conditions on female sexual function. Methods: Peer-reviewed publications were identified through a PubMed search using the search terms "hysterectomy," "benign," "sexual function," "dyspareunia," "orgasm," "libido," and "dysfunction." The search was completed through to February 2015 and was limited to articles published in English. Main Outcome Measure: The main outcome measure was sexual function after hysterectomy for benign conditions. As hysterectomy is performed via various routes, abdominal (open and laparoscopic) and vaginal, sexual function in each group was evaluated. Results: Studies were of varying methodology. Majority of women demonstrated either unchanged or improved sexual function after hysterectomy performed by any route in the short term. A significant minority of women reported sexual dysfunction following hysterectomy. Deterioration in sexual function was found on long-term follow-up, which is probably an effect of aging and bilateral salpingo-oophorectomy. There were no proven benefits supracervical compared with total hysterectomy either in the short term (up to 2 years postsurgery) or long term (up to 15 years after hysterectomy). Conclusions: Women can be positively reassured that hysterectomy does not negatively affect sexuality. Health professions should be aware that a minority of women may develop adverse effects after the operation. Preoperative education about the potential negative sexual outcomes after surgery may enhance satisfaction with hysterectomy, independent of whether negative sexual outcomes are experienced. © 2015 International Society for Sexual Medicine.


Van Delft K.,Croydon University Hospital | Sultan A.H.,Croydon University Hospital | Thakar R.,Croydon University Hospital | Schwertner-Tiepelmann N.,Croydon University Hospital | Kluivers K.,Radboud University Nijmegen
BJOG: An International Journal of Obstetrics and Gynaecology | Year: 2014

Objective To establish the relationship between postpartum levator ani muscle (LAM) avulsion and signs and/or symptoms of pelvic floor dysfunction (PFD). Design Observational longitudinal cohort study. Setting District General University Hospital, UK. Population or sample Primigravida at 36 weeks' gestation and 3 months postpartum. Methods Pelvic floor muscle strength (PFMS) and pelvic organ prolapse were assessed clinically using validated methods. Transperineal ultrasound was performed to identify LAM avulsion and measure hiatus dimensions. Validated questionnaires evaluated sexual function, urinary and faecal incontinence. Main outcome measures PFD signs and symptoms related to LAM avulsion. Results Two hundred and sixty nine primigravida without LAM avulsion participated and 71% (n = 191) returned postpartum. LAM avulsion was found in 21% of vaginal deliveries (n = 30, 95%CI 15.1-28.4%). Women with minor and major avulsion had worse PFMS (P < 0.038) and more anterior compartment prolapse (maximum stage 2; P < 0.024). Antenatal hiatus antero-posterior diameter on ultrasound was significantly smaller in women sustaining avulsion (P = 0.011). Postnatal measurements were significantly increased following avulsion. Women with major avulsion were less sexually active at both antenatal and postnatal periods (P < 0.030). These women had more postnatal urinary incontinence and symptoms such as reduced vaginal sensation and 'too loose vagina'. No postnatal differences were found for faecal incontinence, prolapse symptoms or quality of life. The correlation of differences in variables was only slight-fair with avulsion severity. Conclusions Twenty one percent of women sustain LAM avulsion during their first vaginal delivery with significant impact on signs and symptoms of PFD. As avulsion has been described as the missing link in the development of prolapse; longer term follow-up is vital. © 2014 Royal College of Obstetricians and Gynaecologists.


Van Delft K.,Croydon University Hospital | Thakar R.,Croydon University Hospital | Sultan A.H.,Croydon University Hospital | Schwertner-Tiepelmann N.,Croydon University Hospital | Kluivers K.,Radboud University Nijmegen
BJOG: An International Journal of Obstetrics and Gynaecology | Year: 2014

Objective To establish the incidence of levator ani muscle (LAM) avulsion in primiparous women and to develop a clinically applicable risk prediction model. Design Observational longitudinal cohort study. Setting District General University Hospital, United Kingdom. Sample Nulliparous women at 36 weeks of gestation and 3 months postpartum. Methods Four-dimensional transperineal ultrasound was performed during both visits. Tomographic ultrasound imaging at maximum contraction was used to diagnose no, minor or major LAM avulsion. A risk model was developed using multivariable ordinal logistic regression. Main outcome measures Incidence of LAM avulsion and its risk factors. Results Of 269 women with no antenatal LAM avulsion 71% (n = 191) returned postpartum. No LAM avulsion was found after caesarean section (n = 48). Following vaginal delivery the overall incidence of LAM avulsion was 21.0% (n = 30, 95% confidence interval [95% CI] 15.1-28.4). Minor and major LAM avulsion were diagnosed in 4.9% (n = 7, 95% CI 2.2-9.9) and 16.1% (n = 23, 95% CI 10.9-23.0), respectively. Risk factors were obstetric anal sphincter injuries (odds ratio [OR] 4.4, 95% CI 1.6-12.1), prolonged active second stage of labour per hour (OR 2.2, 95% CI 1.4-3.3) and forceps delivery (OR 6.6, 95% CI 2.5-17.2). A risk model and nomogram were developed to estimate a woman's individual risk: three risk factors combined revealed a 75% chance of LAM avulsion. Conclusions Twenty-one percent of women sustain LAM avulsion during their first vaginal delivery. Our risk model and nomogram are novel tools to estimate individual chances of LAM avulsion. We can now target postnatal women at risk of sustaining a LAM avulsion. © 2014 Royal College of Obstetricians and Gynaecologists.

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