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Biomedical subjects

R M Pickering

Publications and source records attributed to R M Pickering.

At least 19 recordsLinked to original sources
PubMed2002

A single-centre study of treatment outcomes and survival in 120 patients with peripheral T-cell non-Hodgkin's lymphoma.

We conducted a retrospective study of treatment outcomes and survival in 120 consecutive, unselected patients with peripheral T-cell non-Hodgkin's lymphoma, presenting at a single centre over a 20-year period. Cases met the criteria of the Revised European-American Lymphoma (REAL) Classification and patients with peripheral T-cell lymphoma of the following subtypes were included: anaplastic large T-cell lymphoma (ALCL), angioimmunoblastic T-cell lymphoma (AILD), peripheral T-cell lymphoma unspecified (PTCLu), and intestinal T-cell lymphoma (ITCL). The study population consisted of 120 patients with a presenting diagnosis of peripheral T-cell lymphoma. Cases that had been previously confirmed as T-cell lymphoma at formal pathology review were identified from the lymphoma database of this institution. Staging investigations, treatment type and outcomes were taken from patient records. For each subtype, clinical characteristics, response to initial treatment, duration of response and any subsequent relapse were recorded. Overall, relapse, and progression-free survival figures were calculated. The ALCL group had the best response rate to first line treatment 19 of 22 (86 percent) while the AILD group had the lowest response 12 of 29 (41 percent). Relapse rates were PTCLu 13 of 35 (37 percent), ITCL 10 of 34 (29 percent), ALCL 6 of 22 (27 percent) and AILD 7 of 29 (24 percent). In terms of median overall survival, a significantly superior survival was demonstrated for the ALCL group (7.05 years) compared to the remaining three groups. The ALCL group had the lowest risk of death while the ITCL group had the highest risk (hazard ratio: 2.82). Five-year survival rates were estimated to be ALCL 60 percent, PTCLu 40 percent, AILD 30 percent and ITCL 25 percent. This single-centre study demonstrated different outcomes for each group with significant differences in overall survival rates. These findings support the clinical utility of the REAL lymphoma classification in respect to the PTCL subgroups included in this study.

Adult↗
PubMed2001

Therapeutic nursing or unblocking beds? A randomised controlled trial of a post-acute intermediate care unit.

OBJECTIVES: To compare post-acute intermediate care in an inpatient nurse-led unit with conventional post-acute care on general medical wards of an acute hospital and to examine the model of care in a nurse-led unit. DESIGN: Randomised controlled trial with six month follow up. SETTING: Urban teaching hospital and surrounding area, including nine community hospitals. PARTICIPANTS: 238 patients accepted for admission to nurse-led unit. INTERVENTIONS: Care in nurse-led unit or usual post-acute care. MAIN OUTCOME MEASURES: Patients' length of stay, functional status, subsequent move to more dependent living arrangement. RESULTS: Inpatient length of stay was significantly longer in the nurse-led unit than in general medical wards (14.3 days longer (95% confidence interval 7.8 to 20.7)), but this difference became non-significant when transfers to community hospitals were included in the measure of initial length of stay (4.5 days longer (-3.6 to 12.5)). No differences were observed in mortality, functional status, or living arrangements at any time. Patients in the nurse-led unit received significantly fewer minor medical investigations and, after controlling for length of stay, significantly fewer major reviews, tests, or drug changes. CONCLUSIONS: The nurse-led unit seemed to be a safe alternative to conventional management, but a full accounting of such units' place in the local continuum of care and the costs associated with acute hospitals managing post-acute patients is needed if nurse-led units are to become an effective part of the government's recent commitment to intermediate care.

Acute Disease↗
PubMed2001

Invasiveness of cutaneous malignant melanoma is influenced by matrix metalloproteinase 1 gene polymorphism.

The matrix metalloproteinases (MMPs) are implicated in connective tissue destruction during cancer invasion and metastasis. A naturally occurring variant arising from the insertion or deletion of a guanine in the promoter of the MMP-1 gene has recently been reported and shown to influence its transcriptional activity in melanoma cells. In this study, MMP-1 genotype was determined in 139 Caucasian patients with cutaneous malignant melanoma. The insertion allele was associated with deep invasive, and therefore poorer-prognosis, primary tumors [(34% of patients with vertical growth phase tumor were homozygous for the insertion allele compared with 17% of patients with horizontal growth phase tumor (P = 0.0333; odds ratio = 2.51)]. These data suggest that the invasiveness of cutaneous malignant melanoma is influenced by variation in the MMP-1 gene promoter that affects MMP-1 expression.

Cell Division↗
PubMed2001

Head and pelvic movements during a dynamic reaching task in sitting: implications for physical therapists.

OBJECTIVES: To describe the distance reached, speed, and movement of the head and pelvis of healthy volunteers; to describe any influence of age on these variables; and to compare healthy volunteers and subjects with hemiplegia while performing a seated reaching task. DESIGN: Age-matched, case-control study. SETTING: Gait laboratory in a general hospital. PARTICIPANTS: A convenience sample of 53 healthy volunteers (30 women; 23 men; mean age, 57yr; range, 30-79yr) and 5 subjects with hemiplegia (2 women, 3 men; mean age, 65yr; range, 60-78yr) were recruited within 6 weeks poststroke. INTERVENTIONS: Participants sat on a bench with feet supported and reached laterally as far as they could without falling. MAIN OUTCOME MEASURES: The speed, distance reached, and angular movements of the head and pelvis were recorded by using the 3-dimensional movement analysis system. RESULTS: A significant age-related reduction in the distance reached (p < .001), velocity of the movement (p =.000), and pelvic tilt used (p < .01) was found among healthy volunteers. Comparison of data from healthy volunteers and subjects with hemiplegia showed a significant reduction in the angular movements of the heads of subjects with hemiplegia. CONCLUSIONS: The findings suggest conservation of movement with increasing age and stroke. This movement reduction could have negative effects on a subject's ability to make postural changes in response to disturbance and activity. Such information may assist therapists to gain insight into the nature of balance deficits and the adaptive behavior that could result.

Adult↗
PubMed2001

An investigation into the feasibility of comparing three management options (augmentation, conservative and water) for nulliparae with dystocia in the first stage of labour.

OBJECTIVE: to evaluate the feasibility of a randomised controlled trial (RCT) examining the effect of three options (augmentation, conservative and water) for the management of dystocia in nulliparae. The main objectives were to explore the feasibility of trial procedures in the clinical environment, consent rates and acceptability of the management options to women, local incidence of dystocia in nulliparae and the size of the subsequent study. DESIGN: a two part study: a pilot, RCT with follow-up through to delivery with postnatal maternal surveys, and a case review of nulliparae with dystocia. SETTING: a large maternity unit in the South of England in May-July 1997 inclusive. PARTICIPANTS: nulliparae with dystocia in the first stage of labour who had an otherwise uncomplicated obstetric background. INTERVENTIONS: women in the pilot RCT received one of three management options: labouring in a waterbirth pool, conservative management or augmentation of labour, which is the standard management of women with dystocia condition in the Unit. FINDINGS: it is feasible to conduct an RCT of management of dystocia in the Unit. Seventy per cent (95% confidence interval 47% to 87%) of women approached agreed to participate. Conservative management was the least acceptable option to women and has been dropped from the subsequent trial. The audit provided some idea of possible differences in operative delivery and epidural rates depending on augmentation or not. A sample of 220 women should be large enough to detect moderate changes and will require a 2-year recruitment period. CONCLUSIONS: a subsequent trial is feasible and is now underway. It has the potential to provide information enabling women and practitioners to have a greater choice of care options in the presence of dystocia, or provide a good basis for an even larger trial.

Baths↗
PubMed2001

A community-dwelling sample of people with Parkinson's disease: characteristics of fallers and non-fallers.

BACKGROUND: people with Parkinson's disease often fall. OBJECTIVES: to report the frequency of falls and characteristics of fallers and non-fallers in a community-based sample of people with Parkinson's disease. METHOD: we administered a battery of standardized tests in the home and the laboratory. RESULTS: we recruited 63 people with Parkinson's disease through general practices. Forty (64%, 95% confidence interval 51-74%) had fallen in the previous 12 months. Many factors associated with falling in the general population were associated with Parkinson's disease fallers (e.g. use of multiple medication and greater physical disability). Fallers were more likely to be depressed and anxious than non-fallers. Condition-specific factors associated with falling included greater disease severity (although there were exceptions) and more marked response to levodopa treatment, including more dyskinesia and on-off phenomena. Fallers took more steps to complete a test of mobility. They also had a shorter functional reach and greater postural sway whilst completing a dual task than non-fallers. CONCLUSION: this community-based study confirms the high risk of falling in Parkinson's disease. Our results suggest that disease-specific factors contribute to the increased risk and that there is scope for specific therapeutic interventions.

Accidental Falls↗
PubMed2001

Comparative study of mortality rates and cardiac dysrhythmias in post-marketing surveillance studies of sertindole and two other atypical antipsychotic drugs, risperidone and olanzapine.

Sertindole (Serdolect), an atypical antipsychotic, was voluntarily suspended in the European Union in 1998 following regulatory concerns over reports of serious cardiac dysrhythmias and sudden unexpected deaths. The reported causes of death, their frequency, prolongation of the rate corrected QT interval (QTc) and cardiac dysrhythmias in patients prescribed sertindole were compared with those for patients treated with two other atypical antipsychotics. All patients in England, prescribed atypical antipsychotics by general practitioners during each drug's immediate post-marketing period, were identified using an observational cohort technique, prescription-event monitoring. Mortality rates in the sertindole cohort were compared with those in a comparator cohort using standardized mortality ratios and incidence rate ratios. Cardiovascular events were reviewed and followed up to identify cases of prolongation of QTc interval. There was no statistically significant difference in mortality rates between sertindole and the comparator cohort, although confidence intervals (CI) were wide due to small numbers in the sertindole cohort. A much smaller number of patients were prescribed sertindole than the other antipsychotics. Six cases of prolongation of QTc interval were identified in 462 patients (1.3%, 95% CI 0.5-2.8) treated with sertindole and one with unspecified electrocardiogram changes in the comparator cohort of 16,542 patients. This study contributes to the understanding of the occurrence of prolongation of QTc interval during clinical use of sertindole, the incidence of which was similar to that in clinical trials. Although no statistically significant difference was shown in mortality rates between sertindole and comparator cohort, the sertindole cohort was too small to rule out an association between the use of this drug and cardiovascular deaths.

Adult↗
PubMed2000

Biochemical diagnosis of ventricular dysfunction in elderly patients in general practice: observational study.

OBJECTIVE: To investigate the usefulness of measuring plasma concentrations of B type natriuretic peptide in the diagnosis of left ventricular systolic dysfunction in an unselected group of elderly people. DESIGN: Observational study. SETTING: General practice with four centres in Poole, Dorset. PARTICIPANTS: 155 elderly patients aged 70 to 84 years. MAIN OUTCOME MEASURES: Diagnostic characteristics of plasma B type natriuretic peptide measured by radioimmunoassay as a test for left ventricular systolic dysfunction assessed by echocardiography. RESULTS: The median plasma concentration of B type natriuretic peptide was 39.3 pmol/l in patients with left ventricular systolic dysfunction and 15.8 pmol/l in those with normal function. The proportional area under the receiver operator curve was 0.85. At a cut-off point of 18.7 pmol/l the test sensitivity was 92% and the predictive value 18%. CONCLUSIONS: Plasma concentration of B type natriuretic peptide could be used effectively as an initial test in a community screening programme and, possibly, using a low cut-off point, as a means of ruling out left ventricular systolic dysfunction. It is, however, not a good test to "rule in" the diagnosis, and access to echocardiography remains essential for general practitioners to diagnose heart failure early.

Aged↗
PubMed2000

Effects of a clinical-practice guideline and practice-based education on detection and outcome of depression in primary care: Hampshire Depression Project randomised controlled trial.

BACKGROUND: Depression is a major individual and public-health burden throughout the world and is managed mainly in primary care. The most effective strategy to reduce this burden has been believed to be education of primary-care practitioners. We tested this assumption by assessing the effectiveness of an educational programme based on a clinical-practice guideline in improving the recognition and outcome of primary-care depression. METHODS: We carried out a randomised controlled trial in a representative sample of 60 primary-care practices (26% of the total) in an English health district. Education was delivered to practice teams and quality tested by feedback from participants and expert raters. The primary endpoints were recognition of depression, defined by the hospital anxiety and depression (HAD) scale, and clinical improvement. Analysis was by intention to treat. FINDINGS: The education was well received by participants, 80% of whom thought it would change their management of patients with depression. 21409 patients were screened, of whom 4192 were classified as depressed by the HAD scale. The sensitivity of physicians to depressive symptoms was 39% in the intervention group and 36% in the control group after education (odds ratio 1.2 [95% CI 0.88-1.61]). The outcome of depressed patients as a whole at 6 weeks or 6 months after the assessment did not significantly improve. INTERPRETATION: Although well received, this in-practice programme, which was designed to convey the current consensus on best practice for the care of depression, did not deliver improvements in recognition of or recovery from depression.

Antidepressive Agents, Tricyclic↗
PubMed1999

Prevalence and clinical characteristics of left ventricular dysfunction among elderly patients in general practice setting: cross sectional survey.

OBJECTIVE: To assess the prevalence and clinical characteristics of left ventricular dysfunction among elderly patients in the general practice setting by echocardiographic assessment of ventricular function. DESIGN: Cross sectional survey. SETTING: Four centre general practice in Poole, Dorset. SUBJECTS: 817 elderly patients aged 70-84 years. MAIN OUTCOMES: Echocardiographic assessment of left ventricular systolic function including measurement of ejection fraction by biplane summation method where possible, clinical symptoms, and signs of left ventricular dysfunction. RESULTS: The overall prevalence of left ventricular systolic dysfunction was 7.5% (95% confidence interval 5.8% to 9.5%); mild dysfunction (5.0%) was considerably more prevalent than moderate (1.6%) or severe dysfunction (0.7%). Measurement of ejection fraction was possible in 82% of patients (n=667): in patients categorised as having mild, moderate, or severe dysfunction, the mean ejection fraction was 48% (SD 12.0), 38% (8.1), and 26% (7.9) respectively. At all ages the prevalence was much higher in men than in women (odds ratio 5.1, 95% confidence interval 2.6 to 10.1). No clinical symptom or sign was both sensitive and specific. In around half the patients with ventricular dysfunction (52%, 32/61) heart failure had not been previously diagnosed. CONCLUSIONS: Unrecognised left ventricular dysfunction is a common problem in elderly patients in the general practice setting. Appropriate treatment with angiotensin converting enzyme inhibitors has the potential to reduce hospitalisation and mortality in these patients, but diagnosis should not be based on clinical history and examination alone. Screening is feasible in general practice, but it should not be implemented until the optimum method of identifying left ventricular dysfunction is clarified, and the cost effectiveness of screening has been shown.

Aged↗
PubMed1999

Mobility and dementia: is physiotherapy treatment during respite care effective?

BACKGROUND: Mobility problems experienced by elderly people with a dementia are associated with falls, fractures and admission to long-term care. A hospital respite care admission is therefore often seen as an opportunity to provide physiotherapy treatment. AIM: To find whether elderly people with a dementia and a mobility problem show a greater improvement in mobility skills if given physiotherapy treatment than if given non-physical activities intervention during a hospital respite admission. METHOD: A controlled randomized multicentre trial with independent blinded assessment. The Southampton Mobility Assessment (mobility score) and Two Minute Walking Test (distance walked) were undertaken at the beginning and end of the study admission and beginning of the next respite admission. Following the first assessment, participants were randomized to either physiotherapy or activities. RESULTS: Eighty-one participants, from 12 clinical centres, with a mean age of 81.9 years and CAPE I/O score of 2. During the study admission there was a non-significant trend for a lower reduction in mobility score of the physiotherapy group (Mann-Whitney; p = 0.614) and a non-significant trend for greater decrease in distance walked in the activities group (t-test; p = 0.325). DISCUSSION: The results of this trial do not support the positive changes demonstrated elsewhere. However, changes in respite care during the early stages of this trial may have produced differences between the sample for this trial and that for the pilot study. This trial was therefore underpowered. CONCLUSION: This trial suggests that future research needs to change the focus from clinical settings to presentations.

Aged↗
PubMed1997

What is the normal pattern of uterine involution? An investigation of postpartum uterine involution measured by the distance between the symphysis pubis and the uterine fundus using a paper tape measure.

OBJECTIVE: To describe normal postnatal uterine involution in a small sample of healthy primiparous women, and estimate the proportion who have a decline in the distance between the symphysis pubis and the uterine fundus (S-FD) slow enough to have the potentiality to trigger further clinical action, using currently accepted criteria for intervention. SETTING: A maternity unit in the south of England that has approximately 6000 deliveries per annum and the related community areas. METHODS: Daily measurement of the S-FD was carried out in 28 healthy women from within 18 hours of delivery until the uterine fundus was no longer palpable abdominally. Graphs showing the daily measurements and correlation coefficients were used to describe involution. The proportion of healthy women who would have been identified as healthy by the screening method was estimated (its specificity). FINDINGS: Considerable variability was found in the pattern of uterine involution that was experienced by the women who had a normal puerperium. The measurement of the S-FD has a low specificity with only 6 of the 28 women (21.4%; 95% CI 8.3% to 40.9% having had no episodes of the S-FD declining slowly (less than 1 cm over three days). There was a weak, positive correlation between the S-FD measurement on day one and the day on which the uterus ceased to be palpable (r = 0.426, P = 0.03). No relationship was found between method of baby feeding and the day on which the uterus ceased to be palpable. IMPLICATIONS FOR PRACTICE: The measurement of S-FD using a paper tape measure should not form part of routine postpartum assessment.

Adolescent↗
PubMed1997

Atypical lymphocyte morphology: an adverse prognostic factor for disease progression in stage A CLL independent of trisomy 12.

We studied 270 patients with Binet stage A chronic lymphocytic leukaemia looking for adverse prognostic factors. In a multivariate analysis the following features were found to be risk factors for disease progression: atypical lymphocyte morphology (defined as either > 10% prolymphocytes or > 15% lymphocytes with cleaved nuclei or lymphoplasmacytoid cells); more than two karyotypic abnormalities; lymphocyte count > 30 x 10(9)/l; lymphocyte doubling time < 1 year; enlargement of one or more lymph node groups. In a univariate analysis the presence of trisomy 12 also correlated with progressive disease, but this was largely a consequence of the association between trisomy 12 and atypical lymphocyte morphology. Atypical lymphocyte morphology is an important prognostic factor in stage A CLL, and one which incurs no additional investigational cost.

Adult↗
PubMed1997

The scalability of the Rivermead Motor Assessment in acute stroke patients.

OBJECTIVE: To examine the scalability of the Rivermead Motor Assessment with hospitalized acute stroke patients. DESIGN: This was a prospective study of hospitalized stroke patients. SUBJECTS: Fifty-one selected stroke patients, including those over the age of 65, were assessed at one, three and six weeks post-stroke using the Rivermead Motor Assessment. Coefficients of scalability and reproducibility were calculated for each of the three sections of the Rivermead Motor Assessment at each assessment. RESULTS: The items in the gross function and arm sections met scaling criteria at all three assessments which meant that they were in appropriate order of difficulty. There was an overall increase in the proportion of subjects passing each item at successive assessments, suggesting that patients in the study were recovering. The leg and trunk section did not meet scale criteria with these acute stroke patients. CONCLUSIONS: We recommend that only the gross function and arm sections should be used as hierarchical scales with selected acute stroke patients. The leg and trunk section should only be used as an assessment checklist.

Activities of Daily Living↗