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Dodd J.W.,St Georges, University of London | Dodd J.W.,North Bristol Lung Center | Charlton R.A.,St Georges, University of London | Charlton R.A.,University of Illinois at Chicago | And 2 more authors.
Chest | Year: 2013

Background: Cognitive impairment is one of the least well-studied COPD comorbidities. It is known to occur in hypoxemic patients, but its presence during acute exacerbation is not established. Objectives: The purpose of this study was to assess neuropsychological performance in patients with COPD who were awaiting discharge from hospital following acute exacerbation and recovery and to compare them with stable outpatients with COPD and with healthy control subjects. Methods: We recruited 110 participants to the study: 30 inpatients with COPD who were awaiting discharge following an exacerbation, 50 outpatients with stable COPD, and 30 control subjects. Neuropsychological tests measured episodic memory, executive function, visuospatial function, working memory, processing speed, and an estimate of premorbid abilities. Follow-up cognitive assessments for patients who were stable and those with COPD exacerbation were completed at 3 months. Results: Patients with COPD exacerbation were significantly worse (P < .05) than stable patients over a range of measures of cognitive function, independent of hypoxemia, disease severity, cerebrovascular risk, or pack-years smoked. Of the patients with COPD exacerbation, up to 57% were in the impaired range and 20% were considered to have suffered a pathologic loss in processing speed. Impaired cognition was associated with worse St. George's Respiratory Questionnaire score (r = -0.40-0.62, P ≤ .02) and longer length of stay (r = 0.42, P = .02). There was no improvement in any aspect of cognition at recovery 3 months later. Conclusions: In patients hospitalized with an acute COPD exacerbation, impaired cognitive function is associated with worse health status and longer hospital length of stay. A significant proportion of patients are discharged home with unrecognized mild to severe cognitive impairment, which may not improve with recovery. © 2013 American College of Chest Physicians.


Hutchinson S.,St Georges NHS Healthcare Trust
Anaesthesia and Intensive Care Medicine | Year: 2011

Dental anaesthesia developed down a different pathway from the rest of anaesthesia. Techniques such as nasal mask anaesthesia in the sitting position were specific to dental surgery, which took place largely outside hospital in dental clinics. Now dental anaesthesia is confined to locations within the aegis of a hospital and anaesthetic techniques are similar to those in other surgical specialities. Dental surgery consists of extractions and conservation. Short procedures for the extraction of teeth may still be carried out in children using a nasal mask, but more difficult extractions in adults and children, or conservation procedures are best done with a laryngeal mask or endotracheal tube. Close liaison with the dental surgeon is imperative in the planning of the anaesthetic technique. The downward pressure applied to the mandible during the extraction of teeth may cause reduction in airway patency unless intubated, and the anaesthetist may need to support the jaw and head in order to provide counter-pressure, also preventing excessive movement of the neck. Patients needing general anaesthesia include children, those with allergy to local anaesthetics, and adults with special needs, as well as those adults who are likely to need surgical extractions with removal of alveolar bone. During the recovery phase, the airway has to be watched carefully as the potential for obstruction is increased due to stimulation and soiling of the larynx with bleeding. Paracetamol and non-steroidal analgesics are the mainstay of analgesia in combination with local anaesthetic infiltration and specific dental blocks. In addition, stronger analgesics such as tramadol may be required in adults who are having multiple extractions. It should be an aim to provide all dental surgery in a day case setting, and careful choice of the technique should make this possible for all but those with unstable cardiorespiratory disease. © 2011 Elsevier Ltd. All rights reserved.


Oakley C.,Level Inc | Johnson J.,St Georges NHS Healthcare Trust | Ream E.,Kings College London
European Journal of Cancer Care | Year: 2010

Oral chemotherapy is playing a prominent role in the development of new cancer treatments. Research suggests that although oral chemotherapy is viewed as easier to manage and more cost effective than intravenous alternatives, patients do not always find it easier to cope with. The research reported in this paper comprised three phases, a review of the literature, an ethnographic study and a feasibility study. The ethnographic study focused on the experience of patients undergoing oral chemotherapy and demonstrated that patients, carers and family members found managing the treatment challenging. Many highlighted that a patient held diary would assist them with maintaining adherence, recording doses taken and identifying side effects. The authors worked closely with stakeholders, including patients, to corroborate what key elements should be included in such a diary. A generic diary was then introduced into clinical practice and its acceptability explored through a feasibility study. The results of this study showed that patients found the diary effective and useful. Trends emerged showing an association between effective symptom management and increased self-efficacy. The research also highlighted that the diary should be supported by a model of care to enhance education and reiterate information. Use of the diary, and a model of care to support it, could enable concerns highlighted about patient safety and the risks associated with oral chemotherapy to be addressed. © 2010 The Authors. Journal compilation © 2010 Blackwell Publishing Ltd.


Poole R.L.,University of Southampton | Poole R.L.,Wessex Regional Genetics Laboratory | Baple E.,St Georges NHS Healthcare Trust | Crolla J.A.,Wessex Regional Genetics Laboratory | And 4 more authors.
American Journal of Medical Genetics, Part A | Year: 2010

This study was an investigation of 90 patients referred to the Wessex Regional Genetics Laboratory for and negative by molecular cytogenetic analysis using array comparative genomic hybridization. This patient cohort represents typical referrals to a regional genetic centre. Methylation analysis was performed at 13 imprinted loci [PLAGL1, IGF2R, MEST, GRB10, H19, IGF2 DMR2 (IGF2P0), KCNQ1OT1 (KvDMR), MEG3, SNRPN, PEG3, GNAS (GNAS exon 1a and NESP55) and GNASAS]. In total 6/90 (6.67%) were shown to have a methylation defect, 2 of which were associated with known imprinting disorders: 1 patient had isolated hypomethylation at IGF2P0, an atypical epigenotype associated with Russell-Silver syndrome, and 1 showed hypomethylation at KvDMR consistent with a diagnosis of Beckwith-Wiedemann syndrome. A further 4 patients, 3 exhibiting complete hypermethylation, and 1 partial hypomethylation, had aberrations at IGF2R, the clinical significance of which remains unclear. This study demonstrates the potential utility of epigenetic investigation in routine diagnostic testing. © 2010 Wiley-Liss, Inc.


Maughan E.F.,St Georges NHS Healthcare Trust | Lewis J.S.,St Georges NHS Healthcare Trust | Lewis J.S.,St Georges, University of London
European Spine Journal | Year: 2010

The purpose of this prospective, single site cohort quasi-experimental study was to determine the responsiveness of the numerical rating scale (NRS), Roland-Morris disability questionnaire (RMDQ), Oswestry disability index (ODI), pain self-efficacy questionnaire (PSEQ) and the patient-specific functional scale (PSFS) in order to determine which would best measure clinically meaningful change in a chronic low back pain (LBP) population. Several patient-based outcome instruments are currently used to measure treatment effect in the chronic LBP population. However, there is a lack of consensus on what constitutes a "successful" outcome, how an important improvement/deterioration has been defined and which outcome measure(s) best captures the effectiveness of therapeutic interventions for the chronic LBP population. Sixty-three consecutive patients with chronic LBP referred to a back exercise and education class participated in this study; 48 of the 63 patients had complete data. Five questionnaires were administered initially and after the 5-week back class intervention. Also at 5 weeks, patients completed a global impression of change as a reflection of meaningful change in patient status. Score changes in the five different questionnaires were subjected to both distribution- and anchor-based methods: standard error of measurement (SEM) and receiver operating characteristic (ROC) curves to define clinical improvement. From these methods, the minimal clinically important difference (MCID) defined as the smallest difference that patients and clinicians perceive to be worthwhile is presented for each instrument. Based on the SEM, a point score change of 2.4 in the NRS, 5 in the RMDQ, 17 in the ODI, 11 on the PSEQ, and 1.4 on the PSFS corresponded to the MCID. Based on ROC curve analysis, a point score change of 4 points for both the NRS and RMDQ, 8 points for the ODI, 9 points for the PSEQ and 2 points for the PSFS corresponded to the MCID. The ROC analysis demonstrated that both the PSEQ and PSFS are responsive to clinically important change over time. The NRS was found to be least responsive. The exact value of the MCID is not a fixed value and is dependent on the assessment method used to calculate the score change. Based on ROC curve analysis the PSFS and PSEQ were more responsive than the other scales in measuring change in patients with chronic LBP following participation in a back class programme. However, due to the small sample size, the lack of observed worsening of symptoms over time, the single centre and intervention studied these results which need to be interpreted with caution. © 2010 Springer-Verlag.

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