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Biomedical subjects

Richard Baker

Publications and source records attributed to Richard Baker.

At least 19 recordsLinked to original sources
PubMed2007

Patients' accounts of the differences in nurses' and general practitioners' roles in primary care.

AIM: This paper reports a study of patients' accounts of the differences in nurses' and general medical practitioners' roles in primary care. BACKGROUND: Nurses are now diagnosing and treating illnesses including conducting first contact care consultations. However, the findings of international studies reporting patients' views of developments in nursing roles are not consistent. Whilst some studies report higher satisfaction following nurse consultations, others suggest that patients do not want nurses to replace general medical practitioners. Healthcare professionals' views of the boundaries of their roles have been studied, but patients' views have not been reported. METHOD: Semi-structured interviews were conducted with 28 adults attending general practices for urgent 'same day' appointments during 2004. Participants were interviewed prior to their consultation with either the nurse or general medical practitioner and 19 participants were interviewed after the consultation. Data collection and analysis were concurrent, and based on the constant comparative method. FINDINGS: Participants' views reflected traditional hierarchies in primary care. They preferred to consult with general medical practitioners if they perceived their symptoms to be serious and with nurses for minor symptoms and reassurance. They thought that nurses had more time for them and were more compassionate. Interpersonal/relational continuity of care was important and for most participants this was with a general medical practitioner who knew them. Participants trusted known practitioners; they also placed trust in professional groups and familiar structures such as the practice. CONCLUSION: New nursing services should incorporate patients' views on continuity of care provider when developing models of care delivery. Patient information leaflets in general practices should be used to explain the roles of general practitioners and nurse practitioners/practice nurses. As these roles develop further, more research is needed into all aspects of their implementation and patients' views should particularly be evaluated.

Adult↗
PubMed2006

The nature and impact of urinary incontinence experienced by patients receiving community nursing services: a cross-sectional cohort study.

BACKGROUND: Nurses have played a pivotal role in the delivery of continence services yet little is known about the nature or impact of urinary symptoms experienced by patients in receipt of such care. AIM: To define the nature and impact of urinary symptoms experienced by patients in receipt of community nursing services. METHOD: The Leicestershire Urinary Symptoms Questionnaire was administered to 1078 patients with incontinence identified from 176 community nurses' caseloads in 157 general practices in England. Information included type and severity of urinary symptoms, impact on quality of life, help with coping, use of continence products and health service resources. RESULTS: Nine hundred and ninety nine (92.7%) patients (median age 79.0 years) returned completed questionnaires. Most patients had incontinence between 1 and 5 years duration, women were more likely than men to have had long standing ( > 5 years) symptoms and more than half the sample reported severe leakage. Women were more likely than men to report symptoms of stress incontinence (71.7% and 46.8%, respectively, p < 0.001) and urge incontinence UI (86.3% vs. 74.8%, respectively, p < 0.01). Half of the men and most women also experienced leakage as a result of difficulty getting to, on or off, a toilet/commode. Men were more likely than women to report getting up three or more times a night to pass urine (53.6% vs. 37.0%, respectively, p < 0.05). Most patients reported that their symptoms had a significant impact on many aspects of quality of life, and 45.7% would be very dissatisfied to continue "the way they are now". Professional help appeared principally one of containment. CONCLUSION: Many people with incontinence receiving community nursing services experience two or more urinary symptoms which, in the majority, have a significant impact on quality of life. Many older patients were not satisfied to "put up" with their urinary symptoms. Current service provision appears to be failing those who are most in need of such care.

Adaptation, Psychological↗
PubMed2006

On the expression of joint moments during gait.

The purpose of the current study was to examine the effect of different reference frames on lower limb joint moments during gait with a view to identifying a recommended convention for clinical purposes. Data were collected from 10 subjects (nine able-bodied adults and one child with diplegic cerebral palsy) whilst walking at a self-selected speed. Calculations utilised a three-dimensional inverse dynamics model. For each joint, moments were expressed in four different reference frames. Three of the frames were orthogonal: laboratory frame; anatomical frame of proximal segment; anatomical frame of distal segment. The fourth reference frame was a non-orthogonal joint coordinate system (JCS). Significant differences in the joint moment profiles during gait were found with alternative references frames. This was apparent primarily for the transverse plane joint moments for able-bodied adult gait. For the pathological gait pattern presented, there were also marked differences in the frontal plane joint moments and more subtle ones in the sagittal plane. Whilst it is recognised that all possible reference frames for the expression of the net moment vector are mathematically valid, a decision needs to be made as to which one is more clinically useful. It is proposed that the non-orthogonal JCS is most logical on the basis of what, biomechanically, the joint moment actually represents.

Biomechanical Phenomena↗
PubMed2006

The costs of epilepsy misdiagnosis in England and Wales.

BACKGROUND: The management of epilepsy incurs significant costs to the United Kingdom (UK) National Health Service (NHS). Making a diagnosis of epilepsy can, however, be difficult and misdiagnosis frequently occurs when patients are seen by non-specialists. This study estimates the financial costs of epilepsy misdiagnosis in the NHS in England and Wales. METHODS: Standard costing methods were applied to estimate the costs attributable to epilepsy misdiagnosis. The primary data were published in UK studies on the prevalence of epilepsy, epilepsy misdiagnosis and costs identified from Medline, Cinahl and Embase (1996-May 2006). RESULTS: An estimated total of 92,000 people were misdiagnosed with epilepsy in England and Wales in 2002. The average medical cost per patient per year of misdiagnosis was 316 pounds sterling, with the chief economic burdens being inpatient admissions (45%), inappropriate prescribing of antiepileptic drugs (AEDs) (26%), outpatient attendances (16%) and general practitioner (GP) care (8%). The estimated annual medical costs in England and Wales were 29,000,000 pounds sterling, while total costs could reach up to 138,000,000 pounds sterling a year. CONCLUSIONS: Allowing for uncertainty, and considering the analysis exclusively from the NHS/CBS (community based services) perspective the opportunity costs of misdiagnosis are substantial. There is a need for health care commissioners to ensure that misdiagnosis is kept to a minimum by ensuring that individuals with a recent onset suspected seizure are seen as soon as possible by a specialist medical practitioner with training and expertise in epilepsy.

Cost of Illness↗
PubMed2006

Gait analysis methods in rehabilitation.

INTRODUCTION: Brand's four reasons for clinical tests and his analysis of the characteristics of valid biomechanical tests for use in orthopaedics are taken as a basis for determining what methodologies are required for gait analysis in a clinical rehabilitation context. MEASUREMENT METHODS IN CLINICAL GAIT ANALYSIS: The state of the art of optical systems capable of measuring the positions of retro-reflective markers placed on the skin is sufficiently advanced that they are probably no longer a significant source of error in clinical gait analysis. Determining the anthropometry of the subject and compensating for soft tissue movement in relation to the under-lying bones are now the principal problems. Techniques for using functional tests to determine joint centres and axes of rotation are starting to be used successfully. Probably the last great challenge for optical systems is in using computational techniques to compensate for soft tissue measurements. In the long term future it is possible that direct imaging of bones and joints in three dimensions (using MRI or fluoroscopy) may replace marker based systems. METHODS FOR INTERPRETING GAIT ANALYSIS DATA: There is still not an accepted general theory of why we walk the way we do. In the absence of this, many explanations of walking address the mechanisms by which specific movements are achieved by particular muscles. A whole new methodology is developing to determine the functions of individual muscles. This needs further development and validation. A particular requirement is for subject specific models incorporating 3-dimensional imaging data of the musculo-skeletal anatomy with kinematic and kinetic data. METHODS FOR UNDERSTANDING THE EFFECTS OF INTERVENTION: Clinical gait analysis is extremely limited if it does not allow clinicians to choose between alternative possible interventions or to predict outcomes. This can be achieved either by rigorously planned clinical trials or using theoretical models. The evidence base is generally poor partly because of the limited number of prospective clinical trials that have been completed and more such studies are essential. Very recent work has started to show the potential of using models of the mechanisms by which people with pathology walk in order to simulate different potential interventions. The development of these models offers considerable promise for new clinical applications of gait analysis.

Journal Article↗
PubMed2006

Gait classification in children with cerebral palsy: a systematic review.

This systematic review of the literature evaluates the validity of existing classifications of gait deviations in children with cerebral palsy (CP). Numerous efforts have been made to develop classification systems for gait in CP to assist in diagnosis, clinical decision-making and communication. The internal and external validity of gait classifications in 18 studies were examined, including their sampling methods, content validity, construct validity, reliability and clinical utility. Half of the studies used qualitative pattern recognition to construct the gait classification and the remainder used statistical techniques such as cluster analysis. Few adequately defined their samples or sampling methods. Most classifications were constructed using only sagittal plane gait data. Many did not provide adequate guidelines or evidence of reliability and validity of the classification system. No single classification addressed the full magnitude or range of gait deviations in children with CP. Although gait classification in CP can be useful in clinical and research settings, the methodological limitations of many classifications restrict their clinical and research applicability.

Cerebral Palsy↗
PubMed2006

Differences in lower limb transverse plane joint moments during gait when expressed in two alternative reference frames.

When comparing previous studies that have measured the three-dimensional moments acting about the lower limb joints (either external moments or opposing internal joint moments) during able-bodied adult gait, significant variation is apparent in the profiles of the reported transverse plane moments. This variation cannot be explained on the basis of adopted convention (i.e. external versus internal joint moment) or inherent variability in gait strategies. The aim of the current study was to determine whether in fact the frame in which moments are expressed has a dominant effect upon transverse plane moments and thus provides a valid explanation for the observed inconsistency in the literature. Kinematic and ground reaction force data were acquired from nine able-bodied adult subjects walking at a self-selected speed. Three-dimensional hip, knee and ankle joint moments during gait were calculated using a standard inverse dynamics approach. In addition to calculating internal joint moments, the components of the external moment occurring in the transverse plane at each of the lower limb joints were calculated to determine their independent effects. All moments were expressed in both the laboratory frame (LF) as well as the anatomical frame (AF) of the distal segment. With the exception of the ankle rotation moment in the foot AF, lower limb transverse plane joint moments during gait were found to display characteristic profiles that were consistent across subjects. Furthermore, lower limb transverse plane joint moments during gait differed when expressed in the distal segment AF compared to the LF. At the hip, the two alternative reference frames produced near reciprocal joint moment profiles. The components of the external moment revealed that the external ground reaction force moment was primarily responsible for this result. Lower limb transverse plane joint moments during gait were therefore found to be highly sensitive to a change in reference frame. These findings indicate that the different transverse plane joint moment profiles during able-bodied adult gait reported in the literature are likely to be explained on this basis.

Adolescent↗
PubMed2006

A method for comparing manual muscle strength measurements with joint moments during walking.

This paper describes a protocol for dynamometer assisted manual muscle testing of the major muscle groups of the lower extremity and its application to 11 able-bodied children who also had conventional gait analysis to obtain joint kinetics. Data from the manual muscle testing was processed in such a way that the results for maximum muscle strength (grade 5) and resistance against gravity alone (grade 3) were presented in Nm/kg allowing direct comparison with conventional joint kinetics. The strength measurements of the hip muscles and the knee extensors were between two and three times the moments exerted during normal walking. Those of the knee flexors and dorsiflexors were about five times the joint moments. Measured plantarflexor strength was only just greater than the moment exerted during walking. These results, particularly those for the plantarflexors, question how valid it is to use measures of isometric muscle strength as indicators of muscle function during activity. The study also compares grade 3 muscle strength with both grade 5 strength and the maximum joint moments. For all muscle groups tested grade 3 muscle strength was less than the maximum moment exerted during normal walking. For the plantarflexors it was less than 1% of that moment. The study demonstrates that reliable isometric muscle testing is possible in able-bodied children but requires considerable care and is time consuming. More work is required to understand how measurements made in this way relate to how muscles function during activity.

Biomechanical Phenomena↗
PubMed2006

Atraumatic hand infection in an infant.

We report a rare case of atraumatic infection of the extensor tendon sheaths. Acute medical staff should be aware of the insidious nature of presentation of this condition, as early aggressive treatment is required to prevent tendon rupture. In this instance, an excellent functional outcome was achieved by surgical drainage and early tendon reconstruction.

Female↗
PubMed2006

Cluster randomized controlled trial of the effectiveness of audit and feedback and educational outreach on improving nursing practice and patient outcomes.

BACKGROUND: Current understanding of implementation methods is limited, and research has focused on changing doctors' behaviors. AIM: Our aim was to evaluate the impact of audit and feedback and educational outreach in improving nursing practice and patient outcomes. METHODS: Using a factorial design, cluster randomized controlled trial, we evaluated 194 community nurses in 157 family practices and 1078 patients with diagnosis of urinary incontinence (UI) for nurses compliance with evidence-linked review criteria for the assessment and management of UI and impact on psychologic and social well-being and symptoms. In the outreach arms, nurses' self-reported barriers informed development of tailored strategies. RESULTS: In comparison with educational materials alone, the implementation methods tested did not improve care at 6 months follow-up. Moderate rates of improvement (10-17% of patients) in performance for the assessment of UI and greater rates of improvement (20-30% of patients) for the management of care were found but effects were similar across arms. Improvement in patient outcomes was more consistently positive for educational outreach than for audit and feedback but differences were not significant. Adjustment for caseload size, severity or duration of UI and patients' age did not alter results. CONCLUSIONS: Printed educational materials alone may be as effective as audit and feedback and educational outreach in improving nurses' performance and outcomes of care for people with UI. Greater understanding of the underlying processes in improving performance within multidisciplinary teams through further, theory-driven studies with "no intervention" control groups and longer follow-up are needed.

Education, Nursing, Continuing↗
PubMed2006

Diabetes management in the USA and England: comparative analysis of national surveys.

OBJECTIVES: To compare diabetes management in adults between England and the United States, particularly focusing on the impact of a universal access health insurance system. DESIGN: Analysis of the nationally-representative surveys Health Survey of England, 2003 (unweighted n =14 057) and the National Health and Nutrition Examination Survey, 2001-2002 (unweighted n =5411). SETTING AND PARTICIPANTS: Adults 20-64 years of age; individuals >65. MAIN OUTCOME MEASURES: Glycaemic, lipid and blood pressure control and medication use among individuals with previously diagnosed diabetes. RESULTS: Among those aged 20-64 the prevalence of diagnosed diabetes was lower in England (2.7%) than in the USA (5.0%). The proportion with diabetes receiving treatment was similar for the two countries. However, the mean HbA1c in England was 7.6%: in the USA it was 7.5% for those with insurance and 8.6% for those without insurance. The proportion of individuals on ACE inhibitors in England was 39%: in USA it was 39% for those with insurance, and 14% for those without. CONCLUSIONS: Individuals in a healthcare system providing universal access have better managed diabetes than those in a market based system once one accounts for insurance.

Adult↗
PubMed2006

Randomised controlled trial of near-patient testing for glycated haemoglobin in people with type 2 diabetes mellitus.

BACKGROUND: Tight glycaemic control in people with type 2 diabetes can lead to a reduction in microvascular and possibly macrovascular complications. The use of near-patient (rapid) testing offers a potential method to improve glycaemic control. AIM: To assess the effect and costs of rapid testing for glycated haemoglobin (HbA1c) in people with type 2 diabetes. DESIGN OF STUDY: Pragmatic open randomised controlled trial. SETTING: Eight practices in Leicestershire, UK. METHOD: Patients were randomised to receive instant results for HbA1c or to routine care. The principal outcome measure was the proportion of patients with an HbA1c <7% at 12 months. We also assessed costs for the two groups. RESULTS: Of the 681 patients recruited to the study 638 (94%) were included in the analysis. The mean age at baseline was 65.7 years (SD = 10.8 years) with a median (interquartile range) duration of diabetes of 4(1-8) years. The proportion of patients with HbA1c < 7% did not differ significantly between the intervention and control groups (37 versus 38%, odds ratio 0.95 [95% confidence interval = 0.69 to 1.31]) at 12 months follow up. The total cost for diabetes-related care was 390 UK pounds per patient for the control group and 370 UK pounds for the intervention group. This difference was not statistically significant. CONCLUSION: Near-patient testing for HbA1c alone does not lead to outcome or cost benefits in managing people with type 2 diabetes in primary care. Further research is required into the use of rapid testing as part of an optimised patient management model including arrangements for patient review and testing.

Aged↗
PubMed2006

How are different types of continuity achieved? A mixed methods longitudinal study.

BACKGROUND: In the context of developments in healthcare services that emphasise swift access to care, concern has been expressed about whether and how continuity of care, particularly interpersonal continuity, will continue to be achieved. AIM: To explore how patients regard and use primary care services in relation to continuity of provider and access to care, to identify factors that promote or hinder their success in achieving their preferences, and to describe what this means for how different types of continuity are achieved. DESIGN OF STUDY: Longitudinal, mixed methods. SETTING: Community in London and Leicester. METHOD: Purposive sample of 31 patients recruited from general practices, walk-in centres and direct advertising. Data collection involved in-depth interviews, consultation record booklets completed over 6 months and general practice records for the year including the study period. Data were analysed qualitatively. RESULTS: Four patterns were identified in the way patients used primary care. These were shaped by their own preferences, by the organisation and culture of their primary care practices, and by their own and their provider's efforts to achieve their preferences. Different configurations of these factors gave rise to different types of continuity. Patients were not always able to achieve the type they wanted. Patients with apparently similar consulting patterns could experience them differently. CONCLUSION: Within a programme of modernisation, policies that promote a commitment to meeting the preferences of different patients with flexibility and understanding are most likely to provide continued support for interpersonal and other types of continuity of care.

Adolescent↗
PubMed2005

Defining the knee joint flexion-extension axis for purposes of quantitative gait analysis: an evaluation of methods.

Minimising measurement variability associated with hip axial rotation and avoiding knee joint angle cross-talk are two fundamental objectives of any method used to define the knee joint flexion-extension axis for purposes of quantitative gait analysis. The aim of this experiment was to compare three different methods of defining this axis: the knee alignment device (KAD) method, a method based on the transepicondylar axis (TEA) and an alternative numerical method (Dynamic). The former two methods are common approaches that have been applied clinically in many quantitative gait analysis laboratories; the latter is an optimisation procedure. A cohort of 20 subjects performed three different functional tasks (normal gait; squat; non-weight bearing knee flexion) on repeated occasions. Three-dimensional hip and knee angles were computed using the three alternative methods of defining the knee joint flexion-extension axis. The repeatability of hip axial rotation measurements during normal gait was found to be significantly better for the Dynamic method (p<0.01). Furthermore, both the variance in the knee varus-valgus kinematic profile and the degree of knee joint angle cross-talk were smallest for the Dynamic method across all functional tasks. The Dynamic method therefore provided superior results in comparison to the KAD and TEA-based methods and thus represents an attractive solution for orientating the knee joint flexion-extension axis for purposes of quantitative gait analysis.

Adult↗