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Biomedical subjects

R Howard

Publications and source records attributed to R Howard.

At least 19 recordsLinked to original sources
PubMed2006

EFNS guideline on diagnosis and management of post-polio syndrome. Report of an EFNS task force.

Post-polio syndrome (PPS) is characterized by new or increased muscular weakness, atrophy, muscle pain and fatigue several years after acute polio. The aim of the article is to prepare diagnostic criteria for PPS, and to evaluate the existing evidence for therapeutic interventions. The Medline, EMBASE and ISI databases were searched. Consensus in the group was reached after discussion by e-mail. We recommend Halstead's definition of PPS from 1991 as diagnostic criteria. Supervised, aerobic muscular training, both isokinetic and isometric, is a safe and effective way to prevent further decline for patients with moderate weakness (Level B). Muscular training can also improve muscular fatigue, muscle weakness and pain. Training in a warm climate and non-swimming water exercises are particularly useful (Level B). Respiratory muscle training can improve pulmonary function. Recognition of respiratory impairment and early introduction of non-invasive ventilatory aids prevent or delay further respiratory decline and the need for invasive respiratory aid (Level C). Group training, regular follow-up and patient education are useful for the patients' mental status and well-being. Weight loss, adjustment and introduction of properly fitted assistive devices should be considered (good practice points). A small number of controlled studies of potential-specific treatments for PPS have been completed, but no definitive therapeutic effect has been reported for the agents evaluated (pyridostigmine, corticosteroids, amantadine). Future randomized trials should particularly address the treatment of pain, which is commonly reported by PPS patients. There is also a need for studies evaluating the long-term effects of muscular training.

Advisory Committees↗
PubMed2005

Migrant status, age, gender and social isolation in very late-onset schizophrenia-like psychosis.

BACKGROUND: Data from two retrospective first contact studies suggest that the risk of developing very-late onset schizophrenia-like psychosis (SLP) may be raised in older migrant than British-born populations resident in the UK. OBJECTIVE: To investigate whether the relative excess of SLP observed amongst younger and male migrants in the above studies might have been explained by differences in the age-gender structures of migrant and British-born denominator populations. A secondary aim was to examine the associations of migrant group status and gender with markers of social isolation. METHOD: Eighty-six new referrals of SLP to the Mile End (1997-2003) and Maudsley (1995-2000) hospitals were identified from two retrospective case note studies. Local census data were used to estimate the denominator populations and to calculate rate ratios for migrant and British-born cases of SLP. Case notes were re-examined, to assess markers of social isolation in migrant and British-born patients. RESULTS: Migrant patients were more likely to be male (odds ratio = 4.8; CI(odds) = 1.8-13.2) than British-born patients. The ratio of first contact rates for migrant compared to British-born populations were highest amongst men. There was a lower mean age of onset of SLP in migrant than British-born patients (t = 4.30, 95% CI = 3.78-10.27), which was largely explained by a higher mean age of illness onset in British-born women. There were no differences between migrant and British-born patients with respect to markers of social isolation. Male patients were more likely to have never married than women (odds ratio = 0.28; 95% CI odds = 0.09-0.89). CONCLUSIONS: The age-gender structure of the background population is not sufficient to explain the socio-demographic differences between migrant and British-born patients with SLP. Male patients may be more socially isolated.

Age of Onset↗
PubMed2005

Assessing the accuracy of a computerized decision support system for digoxin dosing in primary care: an observational study.

BACKGROUND: This study was carried out as part of a European Union funded project (PharmDIS-e+), to develop and evaluate software aimed at assisting physicians with drug dosing. A drug that causes particular problems with drug dosing in primary care is digoxin because of its narrow therapeutic range and low therapeutic index. OBJECTIVES: To determine (i) accuracy of the PharmDIS-e+ software for predicting serum digoxin levels in patients who are taking this drug regularly; (ii) whether there are statistically significant differences between predicted digoxin levels and those measured by a laboratory and (iii) whether there are differences between doses prescribed by general practitioners and those suggested by the program. METHODS: We needed 45 patients to have 95% Power to reject the null hypothesis that the mean serum digoxin concentration was within 10% of the mean predicted digoxin concentration. Patients were recruited from two general practices and had been taking digoxin for at least 4 months. Exclusion criteria were dementia, low adherence to digoxin and use of other medications known to interact to a clinically important extent with digoxin. RESULTS: Forty-five patients were recruited. There was a correlation of 0.65 between measured and predicted digoxin concentrations (P < 0.001). The mean difference was 0.12 microg/L (SD 0.26; 95% CI 0.04, 0.19, P = 0.005). Forty-seven per cent of the patients were prescribed the same dose as recommended by the software, 44% were prescribed a higher dose and 9% a lower dose than recommended. CONCLUSION: PharmDIS-e+ software was able to predict serum digoxin levels with acceptable accuracy in most patients.

Aged↗
PubMed2005

ATP8B1 mutations in British cases with intrahepatic cholestasis of pregnancy.

BACKGROUND: Intrahepatic cholestasis of pregnancy (ICP) affects approximately 0.7% of pregnancies in the UK and is associated with prematurity, fetal distress, and intrauterine death. Homozygous mutations in the ATP8B1 gene cause cholestasis with a normal serum gamma-glutamyl transpeptidase (gamma-GT), and have been reported in two forms of cholestasis: progressive familial intrahepatic cholestasis type 1 (PFIC1) and benign recurrent intrahepatic cholestasis (BRIC). AIMS: To establish whether mutations in ATP8B1 are associated with ICP in British cases PATIENTS: Sixteen well phenotyped women with ICP without raised gamma-GT were selected for sequence analysis. Subsequently, 182 patients and 120 controls were examined for the presence of the variants detected. METHODS: All coding exons were sequenced in 16 cases. Eight ICP cases, including two women carrying a mutation, were investigated using in vivo hepatic (31)P magnetic resonance spectroscopy (MRS) RESULTS: Two heterozygous ATP8B1 transitions (208G>A and 2599C>T) that resulted in amino acid substitutions were identified; 208G>A was identified in three cases. MRS revealed an increased phosphodiester signal (Mann-Whitney U test, p = 0.03) and a decreased phosphomonoester/phosphodiester ratio (p = 0.04) in ICP cases compared with controls. CONCLUSIONS: We were able to demonstrate ATP8B1 mutations in ICP. MRS studies suggest that susceptibility to ICP is associated with a relative rise in biliary phospholipid. These data also suggest that MRS may be used for non-invasive assessment of the liver and biliary constituents in cholestasis.

Adenosine Triphosphatases↗
PubMed2004

Alpha lipoic acid for dementia.

BACKGROUND: Oxidative processes have been implicated in the pathogenesis of neurodegenerative dementias including Alzheimer's disease. Protecting the central nervous system against these damaging mechanisms may be a useful therapeutic approach. Alpha lipoic acid (ALA) is an endogenous antioxidant that interrupts cellular oxidative processes in both its oxidized and reduced forms. These properties might qualify ALA for a modulatory role in the treatment of people with dementia. OBJECTIVES: To assess the role and clinical efficacy of alpha lipoic acid in the treatment of dementia. SEARCH STRATEGY: A search of the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (CDCIG) on 3 February 2003 using the terms 'alpha lipoic acid' and 'thioctic'. The CDCIG Specialized register is updated regularly and contains records from all major health care databases (MEDLINE, EMBASE, PsycInfo, CINAHL) as well as from many trials databases. SELECTION CRITERIA: All double-blind randomized placebo-controlled trials examining the efficacy of alpha lipoic acid in dementia DATA COLLECTION AND ANALYSIS: No trials were found that met the selection criteria MAIN RESULTS: No meta-analysis could be performed. A systematic search of the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group, as well as registers of ongoing and unpublished trials could not identify any studies investigating the use of ALA for dementia. REVIEWER'S CONCLUSIONS: In the absence of randomized double-blind placebo-controlled trials investigating ALA for dementia, no evidence exists to explore any potential effects. Until data from trials become available for analysis, ALA cannot be recommended for people with dementia.

Dementia↗
PubMed2004

Investigation of occiput posterior delivery by intrapartum sonography.

OBJECTIVE: To investigate if occiput posterior delivery is the consequence of persistence of an initial occiput posterior position or malrotation from an initial occiput anterior or transverse position. METHODS: This was a cross-sectional study involving transabdominal sonography to determine fetal occipital position in 918 singleton pregnancies with cephalic presentation in active labor at 37-42 weeks of gestation. The relationship between occipital position in labor and at delivery was examined. RESULTS: The occiput was posterior in 33.0% (149/452), 33.9% (101/298) and 19.0% (32/168) of fetuses at the respective cervical dilatations of 3-5, 6-9 and 10 cm and this persisted at delivery in 21.5% (32/149), 31.7% (32/101) and 43.8% (14/32) of cases. In 70% (32/46), 91% (32/35) and 100% (14/14) of occiput posterior deliveries there was persistence from this position at 3-5, 6-9 and 10 cm of cervical dilation. CONCLUSIONS: The majority of occiput posterior positions during labor rotate to the anterior position even at 10 cm of cervical dilatation. However, the vast majority of occiput posterior positions at delivery are a consequence of persistence of this position during labor rather than malrotation from an initial occiput anterior or transverse position.

Adolescent↗
PubMed2004

Peripheral opioids in inflammatory pain.

Topically applied opioids have provided effective analgesia without adverse effects, including tolerance, in adult patients with painful inflammatory conditions. The presumed mechanism of action is by interaction with opioid receptors which are sited on sensory nerve terminals and which may be up-regulated in inflammation. The use of peripherally acting opioids has not been studied in paediatric patients. The use of topical morphine gel is reported in two children with epidermolysis bullosa, where acute inflammatory pain is a major symptom and where effective analgesia is a major clinical problem. The gel provided rapid reduction in pain scores in the patients and without any reported adverse effects or tolerance. A topical route of analgesia might be extremely beneficial for children with other painful skin lesions, including burns or post-surgical wounds, and further studies are now required.

Administration, Topical↗
PubMed2004

Rocking bed and prolonged independence from nocturnal non-invasive ventilation in neurogenic respiratory failure associated with limb weakness.

A 40 year old mother of three with autosomal dominant scapuloperoneal muscular dystrophy presented with severe neurogenic respiratory failure requiring nocturnal non-invasive ventilation (NIV). Because of the development of profound proximal muscular weakness as a consequence of the progressive nature of her neurological disease, she eventually was unable to apply and remove the facial interface to set up her NIV circuit. She therefore became dependent on her children and carers to start and stop NIV during the night. A rocking bed was successfully employed as an alternative to nocturnal NIV. Ventilation was facilitated by the passive movement of the diaphragm as a consequence of the movement of the abdominal contents under the effect of gravity. Benefit was demonstrated objectively by pulse oximetry and subjectively by the improvement in the patient's symptomatology and continued independence at night. The ease of use of a rocking bed should be borne in mind when the necessity for nocturnal ventilatory support in neuromuscular disease results in the potential loss of independence for a patient.

Adult↗
PubMed2004

Multiple system atrophy presenting as central sleep apnoea.

A 61-yr-old male presented with apparent idiopathic central sleep apnoea but after 4 yrs developed features of autonomic, cerebellar and extrapyramidal dysfunction consistent with a diagnosis of multiple system atrophy (MSA). Though central sleep apnoea can occur in multiple sleep apnoea, it is less frequent than obstructive sleep apnoea and occurs in the later stages of the disease. The pathogenesis of MSA involves gliosis and neuronal cell loss in specific areas of the central nervous system. Central sleep apnoea in MSA may be due to the depletion of cholinergic neurons in the arcuate nucleus of the medulla by apoptosis. This is the first description of multiple system atrophy presenting as central sleep apnoea. The current authors believe that multiple system atrophy should be considered in the differential diagnosis of late onset central sleep apnoea and progressive hypoventilation.

Diagnosis, Differential↗
PubMed2003

Psychosis and schizophrenia-like disorders in the elderly.

Non-organic, non-affective psychoses that have their first onset in late life have been the subject of diagnostic dispute for many years. Do they represent the late manifestation of more typical schizophrenia but with a delayed onset? Are they cases of "symptomatic schizophrenia" in which some organic brain change associated with ageing gives rise to schizophrenic symptoms? A recent International Consensus established that while cases of schizophrenia are sometimes delayed in their onset to 40 to 59 years of age (late-onset schizophrenia), onset after the age of 60 years is generally associated with a different symptom profile and associated risk factors (very late-onset schizophrenia-like psychosis). In this paper we review the data on the very late-onset schizophrenia-like psychosis patient group and suggest research directions for the future.

Age of Onset↗
PubMed2002

Ageing and the nigrostriatal dopaminergic system.

BACKGROUND: Brain dopamine has been the focus of numerous studies owing to its crucial role in motor function and in neurological and psychiatric disease processes. Whilst early work relied on postmortem data, functional imaging has allowed a more sophisticated approach to the quantification of receptor density, affinity and functional capacity. This review aims to summarise changes in the nigrostriatal dopaminergic system which accompany normal ageing. METHODS: A literature search focussed on postmortem and neuroimaging studies of normal ageing within the nigrostriatal dopaminergic tract. The functional significance of age-related effects was also considered. RESULTS: There are significant reductions in pre- and post-synaptic markers of brain dopamine activity during normal ageing: However the rate of decline (linear or exponential), the effects of gender and heterogeneity and the mechanisms by which these changes occur remain undetermined. Limited data suggest there is a significant association between postsynaptic receptor density and specific aspects of motor and cognitive function. CONCLUSION: The identification of strategies to improve dopaminergic transmission may delay the onset of motor and cognitive deficits associated with normal ageing. In order to develop effective preventative strategies, the causative mechanisms underlying age-related changes and the interaction between synaptic structure and function need to be more clearly elucidated.

Adolescent↗
PubMed2002

Service contact and psychopathology in very-late-onset schizophrenia-like psychosis: the effects of gender and ethnicity.

BACKGROUND: Epidemiological data on very-late-onset (>60 years) schizophrenia-like psychosis (SLP) are scarce. There are only two published follow-up studies. OBJECTIVE: To examine the associations of gender and ethnicity with health service contact and psychopathology in SLP. METHOD: We identified all new referrals of SLP to the Maudsley hospital between 1995-2000. Demographic details and information on the course of the illness were obtained from case notes. Those patients who agreed to take part were seen at home and assessed with respect to psychopathology and neurological side effects. RESULTS: The median duration of illness at the time of assessment was 3 years (range 1-6 years). Male patients were more likely to be admitted to hospital compulsorily and to be lost to follow-up than female patients. Caribbean-born patients were more likely to refuse to take part than British-born patients. Of the 26 (48%) patients who were interviewed, 38% were experiencing paranoid symptoms, 94% of patients receiving medication were in regular contact with a community psychiatric nurse (CPN). Treatment response was dose related and was not increased by the use of a depot. CONCLUSION: The effects of gender and ethnicity on outcome need to be further investigated through larger studies. High loss to follow-up amongst male patients may be indicative of a poor prognosis. Regular contact with a CPN may be more important than the use of a depot in maintaining treatment response.

Africa↗
PubMed2002

The social functioning of older adults with schizophrenia.

A cross-sectional survey of the social functioning of community dwelling older adults was undertaken. Older adults with no psychiatric morbidity, depressed older adults and older adults with schizophrenia were surveyed to see if there were differences in the level of social functioning of the three groups. The setting was two old age psychiatric services, one in an urban area of London and the other in a semi-rural area of Leicestershire. Participants consisted of depressed (n = 81) or normal (n = 101) older persons identified as part of a general practice over 75 years check and clients over 65 years with schizophrenia (n = 30) known to mental health teams for older adults. All participants were interviewed by one of two trained researchers and completed the Mini-Mental State Examination questionnaire, the 15-item Geriatric Depression Scale, a social functioning questionnaire, and the Schedules for Clinical Assessment in Neuropsychiatry or the Brief Psychiatric Rating Scale. In our sample population, community dwelling older persons without any psychiatric diagnosis were the least isolated from their local community, reported more private leisure activities, and had the least contact with professional community services. Clients with schizophrenia reported more isolation from their local community and fewer private leisure activities than clients with a diagnosis of depression.

Aged↗
PubMed2002

Intrapartum sonography to determine fetal head position.

OBJECTIVE: To investigate the accuracy of intrapartum transvaginal digital examination in defining the position of the fetal head. PATIENTS AND METHODS: In 496 singleton pregnancies in labor at term, the fetal head position was determined by routine transvaginal digital examination by the attending midwife or obstetrician. Immediately before or after the clinical examination, the fetal head position was determined using transabdominal ultrasound by an appropriately trained sonographer who was not aware of the clinical findings. The digital examination was considered to be correct if the fetal head position was within 45 degrees of the ultrasound finding. The accuracy of the digital examination was examined in relation to maternal characteristics and the progress of labor. RESULTS: The position of the fetal head was determined by ultrasound examination in all 496 cases examined. Digital examination failed to define the fetal head position in 166 (33.5%) cases and, in 330 cases where the position was determined, the findings of the digital and sonographic examinations were in agreement in only 163 (49.4%) cases. The rate of correct identification of the fetal position by digital examination increased with cervical dilatation, from 20.5% at 3-4 cm to 44.2% at 8-10 cm, and was higher if the examination was carried out by an obstetrician than a midwife (50% versus 30%) and if there was absence rather than presence of caput (33% versus 25%). CONCLUSIONS: Routine digital examination during labor fails to identify the correct fetal position in the majority of cases.

Adolescent↗
PubMed2002

Incidence and case fatality rates of stroke subtypes in a multiethnic population: the South London Stroke Register.

OBJECTIVE: To identify sociodemographic differences in the incidence of the subtypes of first ever stroke in a multiethnic population. METHODS: A prospective community stroke register (1995-8) was developed using multiple notification sources and pathological and clinical classifications of stroke. Standardisation of rates was to European and World populations and adjusted for age, sex and socioeconomic status in multivariate analyses. A multiethnic population of 234 533 in south London, of whom 21% are black was studied. RESULTS: A total of 1254 cases were registered. The average age of stroke was 71.7 years with black patients being 11.3 years younger than white patients (p<0.0001). The incidence rate/1000 population was 1.33 (crude) (95% CI 1.26 to 1.41), 1.28 (European adjusted) (95% CI 1.2 to 1.35) with a 2.18 (95% CI 1.86 to 2.56) (p<0.0001) age and sex adjusted incidence rate ratio in the black population. Radiological diagnosis was confirmatory in 1107 (88.3%) with 862 (68.7%) infarction, 168 (13.4%) primary intracerebral haemorrhage, and 77 (6.2%) subarachnoid haemorrhage. Of the cerebral infarction cases 189 (21.9%) were total anterior circulatory, 250 (29%) partial anterior, 141 (16.4%) posterior (POCI) and 282 (32.7%) lacunar infarcts. The black group had a significantly higher incidence of all subtypes of stroke except for POCI and unclassified strokes. The incidence rate ratio (IRR) for men compared with women was 1.34 (95% confidence interval (95% CI) 1.19 to 1.50; p<0.001). The IRR for manual versus non-manual occupations in those aged 35-64 years was 1.64 (95%CI 1.22 to 2.23; p<0.0001). There was a borderline significant increase in adjusted survival at 6 months in the black group 95% (CI 0.61 to 1.03, p=0.078) with a hazard ratio of 0.79 after adjustment and stratification. CONCLUSIONS: Although the black population is at increased risk of stroke and most subtypes of stroke, this is not translated into significant differences in survival. Hence black/white differences in mortality are mainly driven by incidence of stroke. There are striking demographic inequalities in the risk of stroke in this multiethnic inner city population that need to be tackled through interagency working. Although the reasons for the increased risk in the black population are unclear, demographic factors such as socioeconomic status do seem to play a significant independent part.

Adolescent↗