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Biomedical subjects

D Lowe

Publications and source records attributed to D Lowe.

At least 37 records · Page 2Linked to original sources
PubMed2005

Changing occupational therapy and physiotherapy practice through guidelines and audit in the United Kingdom.

BACKGROUND: The National Clinical Guidelines for Stroke (NCGS) were produced and three rounds of the National Sentinel Audit of Stroke conducted to improve the quality of stroke care in the UK. OBJECTIVE: To compare the results of the occupational therapy and physiotherapy elements of the most recent national sentinel audit with the occupational therapy- and physiotherapy-specific recommendations of the NCGS. METHODS: Retrospective case-note audit. RESULTS: Over 95% of hospitals/sites who manage stroke in England, Wales and Northern Ireland took part in the most recent round of the sentinel audit. The clinical audit took place from 1 April to 30 June 2001 and incorporated 235 hospitals/sites. The organizational audit took place in January 2002 and incorporated 240 hospitals/sites. Data are presented from the 235 with both clinical and organizational data, under the headings of: approaches to rehabilitation; carers/families; rehabilitation interventions; and transfer to the community. Low rates of compliance with national standards were observed for all domains. CONCLUSION: Our findings suggest that occupational therapists and physiotherapists are not fully complying with the national standards for stroke care.

England↗
PubMed2005

Institutionalization after stroke.

BACKGROUND AND PURPOSE: There are widespread regional variations in the institutionalization rate after stroke. This study sought to identify the factors that predict institutionalization after a primary diagnosis of stroke and determine whether institutionalization rate could be used to assess the quality of hospital care. METHODS: A retrospective case note audit of 2778 consecutive admissions with stroke, between 1 September and 31 October 2000 from a randomly selected sample of 79 hospitals in England, Wales and Northern Ireland. Data were collected on demographics, case-mix, clinical outcome, organization of discharge, and place of residence at discharge and at three and six months. The figures from this audit were validated using data from the 1998 National Sentinel Audit of Stroke. RESULTS: Overall 14% of patients previously living at home were discharged to nursing or residential homes. Using logistic regression, Barthel Index score at discharge accounted for 40% of variation. Two-thirds of patients with a discharge Barthel score of < 5 were institutionalized. Age alone explained 14% and when taken together with discharge Barthel and length of stay it accounted for 54% of variation. On admission 22% of the variation in institutionalization rate could be accounted for by total Glasgow Coma Score (15, < 15), age and ability to walk unaided. Regional variations in institutionalization rates are evident and may in part be explained by differences in ease of access to the institutions. CONCLUSIONS: Discharge disability and older age were the dominant factors determining admission to nursing and residential homes. It is not possible to predict sufficiently reliably for an individual patient the likelihood of institutionalization at admission or at 72 h after admission, to justify early resource allocation decisions.

Age Distribution↗
PubMed2004

Stroke unit care and outcome: results from the 2001 National Sentinel Audit of Stroke (England, Wales, and Northern Ireland).

BACKGROUND AND PURPOSE: Stroke unit care is one of the most powerful interventions available to help stroke patients. There are limited data available to assess the impact of stroke units in routine clinical practice outside randomized clinical trials. This article uses data from the 2001 to 2002 National Stroke Audit to assess the effectiveness of stroke unit care in England, Wales, and Northern Ireland in delivering effective processes of care and in reducing case fatality and disability. METHODS: An observational study of the organization, structure, process of care, and outcomes for stroke in 2001. Case fatality after stroke in England was compared using data from the audit and routinely collected data from the Department of Health. 240 hospitals (196 Trusts) from England, Wales, and Northern Ireland took part in the 2001 to 2002 National Stroke Audit, a response rate of >95%. These sites assessed a total of 8200 patients using the Royal College of Physicians Intercollegiate Working Party Stroke Audit Tool. RESULTS: The availability of stroke unit care varies hugely across the country. Case fatality after stroke was higher in Trusts with least availability of stroke unit care. These differences persisted after control for case mix. The process of care was better for patients managed on stroke units compared with other settings. Overall, the risk of death for patients who received stroke unit care was estimated to be approximately 75% that of the risk for those having no stroke unit care (95% CI, 60 to 90). CONCLUSIONS: Stroke unit care as provided in routine clinical practice in England, Wales, and Northern Ireland reduces case fatality by approximately 25%, which is in line with the figures obtained from systematic analysis of stroke unit trial data.

Aged↗
PubMed2004

Differential sensitivity of three marine invertebrates to copper assessed using multiple biomarkers.

Understanding how biomarkers relate to each other on exposure to particular contaminants in different species is key to their widespread application in environmental management. However, few studies have systematically used multiple biomarkers in more than a single species to determine the variability of sublethal effects of a particular contaminant. In this study, three marine invertebrates, the shore crab Carcinus maenas, the common limpet Patella vulgata and the blue mussel Mytilus edulis, were exposed over 7 days in the laboratory to environmentally realistic concentrations of the priority pollutant copper. A combination of molecular, cellular and physiological biomarkers was measured in each organism to detect the toxic effects of copper. Biomarkers included lysosomal stability (neutral red retention), neurotoxicity (acetylcholinesterase activity), metabolic impairment (total haemolymph protein), physiological status (heart rate) and induction of protective metallothionein proteins. P. vulgata was the most sensitive to copper with significant effects measured in all biomarkers at concentrations of 6.1 microg Cu l(-1). In C. maenas, cellular and neurotoxic endpoints were affected significantly only at 68.1 microg Cu l(-1). Exposure to copper also induced metallothionein production in crabs. Over a 7-day exposure period, M. edulis was the most tolerant species to copper with significant effects being observed at the cellular level only at 68.1 microg Cu l(-1) . In all three species, cellular and neurotoxic pathways were more sensitive to disruption than physiological processes (protein and heart rate). Results illustrate how a suite of biomarkers applied to different sentinel species can provide a 'diagnosis of stress', whereby, effects at the molecular level can be used to interpret the level of physiological impairment of the organism.

Acetylcholinesterase↗
PubMed2004

A UK multi-centre pilot study of speech and swallowing outcomes following head and neck cancer.

Speech and swallowing are important components of health-related quality of life following head and neck cancer treatment. The aim of this study was to demonstrate the value of prospective multi-centre evaluation by Speech and Language Therapists and to compare health-related quality of life with speech and swallowing impairments. The University of Washington Head and Neck questionnaire version 4 (UW-QOL) and Therapy Outcome Measures (TOM) were rated before and 6 months after cancer treatment in 95 patients from 12 centres. There was deterioration in TOM scores at 6 months. Pretreatment UW-QOL swallowing was ranked equal first, with speech fourth. At 6 months speech was first and swallowing second. There were positive correlations between UW-QOL swallowing and TOM dysphagia and between UW-QOL speech and TOM laryngectomy, voice, phonology and dysarthria disorders. Both outcome measures are suitable for routine practice. Adaptation of TOM scales for use with head and neck cancer patients may improve sensitivity, validity and therapist compliance.

Aged↗
PubMed2004

National clinical sentinel audit of evidence-based prescribing for older people.

OBJECTIVES: To audit the performance of hospitals in evidence-based prescribing. SETTING: All hospitals in England were invited to participate. The audit was completed in 62 hospitals. SUBJECTS: Prescribing and clinical data were collected on 100 consecutive medical inpatients aged >/= 65 years at each site, enabling evaluation of eight prescribing indicators before and after intervention. The data were collected using a specifically designed database. INTERVENTIONS: The results of the first audit were available immediately from the software and a national report with locally identifiable information was returned to hospitals. Hospitals were encouraged to design and deliver their own intervention strategy. A questionnaire was sent to all hospitals to document prioritization of indicators. RESULTS: Generic names were used for 36 061 (82.6%) in 1999 and 39 188 (86.4)% in 2000. In 1999, 50% (3074) of patients had documentation of allergy status. This increased to 60% (3684) in 2000. For 21.2% of patients prescribed paracetamol in 1999 and 18.1% in 2000, the prescription was written such that it was possible to exceed the maximum recommended dose of 4 g in 24 hours. Long-acting hypoglycaemic drugs were prescribed to 29 patients in 1999 and 20 patients in 2000. Anti-thrombotics were used appropriately for 54% (520/966) of patients in atrial fibrillation in the first audit and 57% (579/1019) in the second audit. The appropriate use of aspirin increased from 91% (595/651) to 94% (725/772) and the appropriate use of benzodiazepines dropped from 49% (537/1088) to 47% (460/966) between the audits. For three indicators, the allocating of a high priority translated into a bigger improvement between the audits. CONCLUSIONS: Local ownership of data and the quality improvement process, and provision of national benchmarking data did not result in a significant improvement in prescribing in the second audit.

Aged↗
PubMed2004

A prospective study of the practical issues of local involvement in national audit of COPD.

RATIONALE, AIMS AND OBJECTIVES: Variation in quality of local services is of great concern to the government and public. National audit is an important means of providing data of comparative performance but is hampered at local level by poor methodology including audit design, standard setting and data collection tools. A pilot audit of the hospital care of patients admitted with acute chronic obstructive pulmonary disease (COPD) was performed in preparation for a national audit programme and was designed and supported by experts. It was hoped to overcome these barriers. We report a prospective evaluation of the practical issues involved in local participation of hospital audit of COPD care within a national framework. METHODS: Hospitals were recruited to the study by random selection and voluntary participation. A clinical audit study was completed over an 8-week period immediately followed by a survey of clinicians and audit staff to identify positive and negative issues of participation and the process required to achieve a successful outcome. RESULTS: Forty-one hospitals were invited to participate, 26 (63%) accepted, and four others volunteered to meet the target of 30 enrolled centres. Reasons cited for non-participation were of inadequate resources amongst either clinicians or audit departments or prior engagement in other national or local audit schemes. Following completion of the audit most (81%) participating units reported it was a useful exercise and were willing to be involved in future audits. Negative aspects of involvement included the lack of dedicated time and manpower for audit, poor information technology and inadequate systems for identifying patient diagnoses either at admission or at discharge and incomplete case note entries. Methodological issues such as study design and data collection tools were not cited as important barriers to participation. CONCLUSION: There is local willingness to be involved in national audit of hospital care of COPD and central provision of expert design of methods and tools may reduce some audit barriers. Nevertheless, priority must be given to improving resources identified to support audit and in improving methods and systems for data capture. These issues appear to be important in most units and represent a potentially serious barrier to achieving widespread local involvement in a national audit programme of COPD care and may also apply to other national audits designed to provide comparative assessment of National Health Service services.

Humans↗
PubMed2004

The Liverpool Oral Rehabilitation Questionnaire: a pilot study.

There are several validated health-related quality of life (HRQOL) questionnaires designed to record patient-derived outcomes in head and neck cancer. None deals specifically with oral rehabilitation. The aim of this study was to pilot a new questionnaire, the Liverpool Oral Rehabilitation Questionnaire (LORQ). The questionnaire consists of 25 items about oral function and denture satisfaction. A four-point Likert scale is used. Sixty-one consecutive patients attending oral rehabilitation clinics completed the LORQ in combination with the University of Washington Head and Neck questionnaire version 3 (UW-QOL) and European Organisation for Research and Treatment of Cancer H and N quality of life questionnaire (EORTC H and N 35). Forty-two patients received questionnaires at baseline, whereas the rest were provided with the questionnaires at various stages of oral rehabilitation. For each item on the questionnaire, a full range of possible responses were given by patients. Kappa coefficients of agreement for test-retest data indicated moderate to very good agreement between repeat questionnaires. There were significant correlations (P < 0.001) between items in the LORQ and those in the UW-QOL and EORTC HN questionnaires. The LORQ also identified differences in responses between non-cancer and cancer groups of patients undergoing oral rehabilitation. This study of the LORQ is encouraging, although data on its responsiveness over time and to intervention is awaited.

Atrophy↗
PubMed2003

Cervical lymph node metastasis in oral cancer: the importance of even microscopic extracapsular spread.

The prognostic significance of extracapsular spread of cervical metastases in oral cancer is still controversial. To investigate the importance of extent of extracapsular spread; the relationship between extracapsular spread and both traditional measures of metastatic disease and clinical/histological features of the primary tumour, and to determine their relative prognostic significance. The survival of 173 patients undergoing radical surgery and simultaneous neck dissection for oral/oropharyngeal squamous cell carcinoma with histologically confirmed nodal metastasis and followed for 2.2-12.3 years is reported and related to pathological features. The most predictive clinical/histopathological features were determined by Cox regression modelling. The 3-year survival probability was similar for patients with macroscopic and only microscopic extracapsular spread (33 and 36%, respectively, compared with 72% for patients with intranodal metastasis). The Cox model showed the most predictive factor was extracapsular spread followed by status of resection margins. Extracapsular spread should be incorporated into pathological staging systems. Even microscopic extracapsular spread is of critical importance and must be sought especially in small-volume metastatic disease.

Adult↗
PubMed2003

Nitrous oxide/oxygen mixture and the prevention of pain during injection of propofol.

BACKGROUND AND OBJECTIVE: The incidence of pain associated with the injection of propofol still remains a problem. This study sought to examine the analgesic effects of inhaled nitrous oxide in oxygen on the prevention of propofol injection pain. METHODS: Nitrous oxide in oxygen was compared with a lidocaine (20 mg)-propofol mixture and with propofol alone (control) in a prospective, randomized, observer-blinded study. ASA I and II patients (n = 135) scheduled for elective surgical procedures were studied. A standard propofol injection technique and scoring system to measure the pain on injection was used. RESULTS: Demographic variables were similar between the study groups. Without analgesia (control) 26 of 45 patients (58%) reported pain on injection compared with 11 of 45 patients (24%) in both the nitrous oxide (95% CI: 14-52%, P = 0.001) and lidocaine groups (95% CI: 14-52%, P = 0.001). CONCLUSIONS: The inhalation of a nitrous oxide/oxygen mixture significantly reduces the incidence of pain during propofol injection. This therapeutic stratagem was as effective as a lidocaine-propofol mixture.

Adolescent↗
PubMed2003

Evidence for a link between mortality in acute COPD and hospital type and resources.

BACKGROUND: The 1997 BTS/RCP national audit of acute care of chronic obstructive pulmonary disease (COPD) found wide variations in mortality between hospitals which were only partially explained by known audit indicators of outcome. It was hypothesised that some of the unexplained variation may result from differences in hospital type, organisation and resources. This pilot study examined the hypothesis as a factor to be included in a future national audit programme. METHODS: Thirty hospitals in England and Wales were randomly selected by geographical region and hospital type (teaching, large district general hospital (DGH), small DGH). Data on process and outcome of care (death and length of stay) were collected retrospectively at 90 days on all prospectively identified COPD admissions over an 8 week period. Each centre completed a questionnaire relating to organisation and resources available for the care of COPD patients. RESULTS: Eleven teaching hospitals, nine large DGHs, and 10 small DGHs provided data on 1274 cases. Mortality was high (14%) with wide variation between centres (IQR 9-19%). Small DGHs had a higher mortality (17.5%) than teaching hospitals (11.9%) and large DGHs (11.2%). When corrected for confounding factors, an excess of deaths in small DGHs was still observed (OR 1.56 (CI 1.04 to 2.35)) v teaching hospitals. Analysis of resource and organisational factors suggested higher mortality was associated with fewer doctors (OR 1.5) and with fewer patients being under the care of a specialist physician (OR 1.8). Small DGHs had fewest resources. CONCLUSION: Significant differences in mortality may exist between hospital types. The findings justify further study in a proposed national audit.

Aged↗
PubMed2002

Factors that influence the method of mandibular resection in the management of oral squamous cell carcinoma.

The method of conservative (rim) resection of the mandible is now well established and provides good control of disease in the primary site. There are few audits of this technique in terms of margins of resection for both rim and segmental resection of the mandible. Consecutive previously untreated patients managed with resection of the mandible as part of their treatment for oral and oropharyngeal squamous cell carcinoma were recruited for the study. The presence and extent of tumour invasion of the mandible was recorded and a retrospective analysis made to establish the incidence of unnecessary segmental resections. The invasion rate was 33% (8/35) for rims and 83% (54/65) in segmental resections of the mandible, which compares favourably with previous studies and indicates a reasonable accuracy of resection. In between 6 and 11 of the 62 cases (10-17%) a rim resection could have achieved a satisfactory resection margin and retained a functioning lower border of the mandible. The accuracy of resection in terms of margins was greater for mandibular resections (94% clear margins) than soft tissues (62% clear margins). The number of compromised margins was significantly greater in the invaded rim resection group (P=0.018). This study indicates that a more conservative mandibular resection was possible in a few cases. This is unlikely to have an adverse effect on the close or involved margin rate, which depends mainly on the accuracy of the soft tissue resection. Angling the horizontal rim resection to take into account tumour entry at the point of contact will help to ensure a clear bone margin if a conservative approach to mandibular resection is an option.

Adult↗
PubMed2002

National sentinel clinical audit of evidence-based prescribing for older people: methodology and development.

RATIONALE, AIMS AND OBJECTIVES: This national clinical audit aimed to develop and implement a methodology to assess the appropriateness of prescribing for patients over the age of 65 in hospitals, general practice and nursing homes. METHODS: Organizations providing health care in the National Health Service in these three sectors were recruited into multi-disciplinary and inter-organizational local coalition teams. Prescription data and relevant clinical data were collected electronically on a customized database. The appropriateness of prescribing for specific conditions among the patients sampled was assessed by simple computerized algorithms, and users were provided with feedback to stimulate discussion and change. Use of the software tool was demonstrated to be feasible and its data reliable. Participants were re-audited, after a period of nationally guided and locally driven intervention, to evaluate levels of change. Local efforts to stimulate change and barriers to change were collected qualitatively. RESULTS AND CONCLUSIONS: The investigation revealed encouraging results and demonstrated the ability of audit to improve the quality of clinical services in given circumstances, although a multiplicity of questions relating to cost and methodology remain to be addressed.

Aged↗
PubMed2002

Clinical function after primary surgery for oral and oropharyngeal cancer: an 11-item examination.

The aim of this study was to record clinical function using an 11-item clinical examination and identify the main postoperative functional deficits. Of 132 consecutive patients undergoing surgery for previously untreated disease between January 1995 and June 1997, 130 were recruited in the study. An 11-domain clinical examination was made on the day before operation, and at 6 and 12 months afterwards. This examination assessed lip competence, tongue movement, oral mucosa, dental state, mouth opening, speech, drooling, diet, appearance, oral sensation and shoulder movement. Preoperatively there were deficits in natural dentition, consistency of diet and tongue protrusion. Postoperatively functional scores fell particularly for tongue movements, mouth opening, mucosa, dentition, speech, diet, appearance, lip sensation and tongue sensation. At 1 year, dental status, sensation and oral mucosa were particularly defective. Patients with large tumours, free tissue transfer, or adjuvant radiotherapy had the worst levels of function.A simple clinical examination provides a rapid assessment of function that can be used in conjunction with validated questionnaires to provide a more comprehensive evaluation of outcome.

Activities of Daily Living↗
PubMed2002

Health-related quality of life and clinical function after primary surgery for oral cancer.

Clinical function and health-related quality of life (HRQoL) are both important outcome parameters following surgery for oral and oropharyngeal cancer. The aim of this project was to explore the relationship between an 11-point clinical examination and HRQoL. Of 132 consecutive patients undergoing surgery for previously untreated disease between January 1995 and June 1997, 130 were recruited into the study. The University of Washington Quality of Life Questionnaire (UW-QoL) was completed by each patient on the day before operation and 6 and 12 months later. On each occasion the first author made an 11-point clinical examination. The main predictors of cumulative UW-QoL scores were tumour size, clinical functional score and type of operation. The trend was for a fall from preoperative levels at 6 months and then for a slight improvement at 1 year. The differential in respect of baseline function was present at all three time points in each patient group. This suggests that functional deficits at presentation persist following treatment.

Activities of Daily Living↗
PubMed2002

Importance-rating using the University of Washington quality of life questionnaire in patients treated by primary surgery for oral and oro-pharyngeal cancer.

BACKGROUND: There are now several validated and widely accepted head and neck cancer questionnaires. These record patients subjective levels of function and dysfunction, as well as symptoms related to their cancer and its treatment. One popular measure is the University of Washington head and neck cancer questionnaire (UW-QOL). Domain importance-ratings were added to the second version of the questionnaire, which was published in 1997. It is unique amongst head and neck cancer questionnaires in this respect. AIM: The purpose of the study was to evaluate UW-QOL with particular reference to domain importance-rating. It was also the intention to investigate how the importance-ratings related to 'quality of life' and comment on the cumulative scoring of the questionnaire. METHODS: Forty-eight patients with previously untreated oral or oro-pharyngeal cancer were recruited. All were treated by primary surgery. Questionnaires were completed pre-operatively, 6 months and 1 year post-operatively. RESULTS: This study demonstrates a wide variation in importance-ratings. Both pre- and post-treatment there was a general lack of correlation between importance-rating and domain scores. At all time points, patients tended to rate speech, chewing and swallowing as more important than the other UW-QOL domains. The cumulative UW-QOL score correlated strongly with the new single item QOL question. CONCLUSION: It remains unclear how best to incorporate importance-ratings into a single UW-QOL total score. However, for individual patients they can assist in setting priorities in treatment strategies.

Activities of Daily Living↗
PubMed2002

Clinical audit indicators of outcome following admission to hospital with acute exacerbation of chronic obstructive pulmonary disease.

BACKGROUND: The 1997 BTS/RCP national audit of acute chronic obstructive pulmonary disease (COPD) in terms of process of care has previously been reported. This paper describes from the same cases the outcomes of death, readmission rates within 3 months of initial admission, and length of stay. Identification of the main pre-admission predictors of outcome may be used to control for confounding factors in population characteristics when comparing performance between units. METHODS: Data on 74 variables were collected retrospectively using an audit proforma from patients admitted to UK hospitals with acute COPD. Important prognostic variables for the three outcome measures were identified by relative risk and logistic regression was used to place these in order of predictive value. RESULTS: 1400 admissions from 38 acute hospitals were collated. 14% of cases died within 3 months of admission with variation between hospitals of 0-50%. Poor performance status, acidosis, and the presence of leg oedema were the best significant independent predictors of death. Age above 65, poor performance status, and lowest forced expiratory volume in 1 second (FEV(1)) tertile were the best predictors of length of stay (median 8 days). 34% of patients were readmitted (range 5-65%); lowest FEV(1) tertile, previous admission, and readmission with five or more medications were the best predictors for readmission. CONCLUSIONS: Important predictors of outcome have been identified and formal recording of these may assist in accounting for confounding patient characteristics when making comparisons between hospitals. There is still wide variation in outcome between hospitals that remains unexplained by these factors. While some of this variance may be explained by incomplete recording of data or patient factors as yet unidentified, it seems likely that deficiencies in the process of care previously identified are responsible for poor outcomes in some units.

Acute Disease↗