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Biomedical subjects

C D Wolfe

Publications and source records attributed to C D Wolfe.

At least 55 records · Page 3Linked to original sources
PubMed1997

Management and survival of ovarian cancer patients in south east England.

The aim of this study was to audit the effect of adherence to regionally developed guidelines on survival in women with ovarian cancer. A prospective audit of 118 newly diagnosed cases of ovarian cancer in seven district health authorities of South East Thames, U.K. was undertaken. Appropriateness of clinical investigation and management and survival by type of hospital were examined: 118 incident cases were registered in 1991 for the audit. The mean age of the women was 61.29 years (S.D. 14.24) (range 27-92). 25 (21%) were stage I, 15 (13%) stage II, 77 (66%) stage III/IV. 62 (53%) women had the appropriate pre-operative investigations and 75 (64%) were staged in the notes. Management took place in hospitals treating as few as 1 case a year. Overall, 47 (43%) women were appropriately managed which was influenced by type of hospital of surgery (19 (66%) teaching, 20 (45%) non-teaching with oncology support, 8 (28%) non-teaching (P = 0.02). 64 women (54% died by 1 June 1994) (mean follow-up 2.1 years) (minimum 2.41 years, maximum 3.41 years). In multiple regression analysis, death was significantly more likely in women who had been inappropriately managed, those with more advanced disease and those with postoperative complications. This audit indicates that despite the development of guidelines, investigation and management of ovarian cancer varied considerably between hospitals. Management of this cancer of intermediate incidence occurs in hospitals managing as few as 1 case per year. Pre-operative and operative management was inappropriate for the majority of women and this significantly influenced survival. These data have implications for the purchasing of cancer services for this disease.

Adult↗
PubMed1997

The uptake and costs of guidelines for stroke in a district of southern England.

STUDY OBJECTIVE: To assess the impact of guidelines for stroke management on the utilisation of services by patients and the cost consequences of implementation. DESIGN: Prospective audit. SETTING: District health authority in southern England. PATIENTS: A total of 468 live non-comatose stroke patients registered between November 1991 and May 1993. MAIN OUTCOME MEASURES: A comparison between the three, six month periods for investigations performed and rehabilitation received and their associated costs. RESULTS: The appropriateness of the use of investigations improved over time to between 88 and 92% except for computed tomography (CT) (24%). Younger, more severely impaired patients in a medical bed were more likely to have CT. Overall levels of rehabilitation were low. There was no change in use of physiotherapy (61% to 63%), a significant increase in occupational therapy (26% to 39%) and a non significant change in speech therapy (34% to 25%) over time. Guideline introduction caused a modest 23 Pounds increase in costs per patient in the 2nd six months and 41 Pounds in the 3rd six months but this sum could rise to 430 Pounds per patient if full implementation of the guidelines occurred which is still only around 13% of the costs of nursing care while in hospital. CONCLUSIONS: This 18 month aduit shows only modest changes in practice compared with guidelines, and overall levels of rehabilitation were low. The costs of full implementation seem considerable, but in fact constitute only a small proportion of nursing care costs.

Adolescent↗
PubMed1997

Longer term quality of life and outcome in stroke patients: is the Barthel index alone an adequate measure of outcome?

OBJECTIVES: To consider whether the Barthel Index alone provides sufficient information about the long term outcome of stroke. DESIGN: Cross sectional follow up study with a structured interview questionnaire and measures of impairment, disability, handicap, and general health. The scales used were the hospital anxiety and depression scale, mini mental state examination, Barthel index, modified Rankin scale, London handicap scale, Frenchay activities index, SF36, Nottingham health profile, life satisfaction index, and the caregiver strain index. SETTING: South east London. SUBJECTS: People, and their identified carers, resident in south east London in 1989-90 when they had their first in a life-time stroke aged under 75 years. INTERVENTIONS: Observational study. MAIN OUTCOME MEASURES: Comparison and correlation of the individual Barthel index scores with the scores on other outcome measures. RESULTS: One hundred and twenty three (42%) people were known to be alive, of whom 106 (86%) were interviewed. The median age was 71 years (range 34-79). The mean interval between the stroke and follow up was 4.9 years. The rank correlation coefficients between the Barthel and the different dimensions of the SF36 ranged from r = 0.217 (with the role emotional dimension) to r = 0.810 (with the physical functioning dimension); with the Nottingham health profile the range was r = -0.189 (with the sleep dimension, NS) to r = -0.840 (with the physical mobility dimension); with the hospital and anxiety scale depression component the coefficient was r = -0.563, with the life satisfaction index r = 0.361, with the London handicap scale r = 0.726 and with the Frenchay activities index r = 0.826. CONCLUSIONS: The place of the Barthel index as the standard outcome measure for populations of stroke patients is still justified for long term follow up, and may be a proxy for different outcome measures intended for the assessment of other domains.

Activities of Daily Living↗
PubMed1997

A long-term follow-up of stroke patients.

BACKGROUND AND PURPOSE: Two hundred ninety-one residents of southeast London, younger than 75 years, suffered their first stroke in 1989/1990. The objectives of this study were to determine the long-term outcome of this cohort of stroke patients in terms of impairment, disability, handicap, and quality of life and their use of services and prevention measures subsequent to their stroke. METHODS: The survivors and their identified caregivers were traced and completed a structured interview questionnaire that included the Barthel Index, modified Rankin Scale, Hospital Anxiety and Depression Scale (HAD), Mini-Mental State Examination, Frenchay Activities Index, and Caregiver Strain Index. RESULTS: One hundred twenty-three people (42%) were alive, of whom 106 were interviewed. The mean interval between the stroke and the long-term follow-up was 4.9 years. Thirty-one of the survivors (29%) were severely or moderately disabled, 39 (37%) were mildly disabled, and 36 (34%) were functionally independent. Of the 96 people who completed the HAD, 35 (36%) had scores suggesting that they were depressed or had borderline depression. The most likely nontherapy services to have been provided were chiropody and district nursing. Five people had received respite care. Of the 104 subjects for whom information about their home was available, 53 (51%) had had an adaptation. Seventy-five people (71%) had an aid or appliance. Sixty-five people (61%) were on aspirin, and an additional 14 (13%) were on warfarin. Fifty subjects (47%) identified a main caregiver. No one with a moderate or more severe disability was living at home without an identified caregiver. CONCLUSIONS: The levels of both health and social service provision are likely to be inadequate for this population. The use of prevention measures is encouraging. There is a clear need for a coordinated policy to guide assessment and management across sectors.

Aged↗
PubMed1996

Variations in the screening history and appropriateness of management of cervical cancer in South East England.

In seven health districts in southern England, an audit of the management of cervical cancer compared with regionally developed guidelines was undertaken between 1988 and 1991. Four hundred and sixty-nine regional residents were treated in the study district hospitals. 73 (15.6%) women were appropriately staged, with increasing likelihood of appropriate staging investigations observed with higher stages (P < 0.0001) and type of hospital [Teaching 23 (21%), Non-Teaching with oncology support 11 (11.5%), Non-teaching 4 (7%), P < 0.0001] but with no change over the study period. There was no significant trend in the proportion of women treated appropriately over time, with 270 (59%) being appropriately treated, 91 (20%) under-treated and 98 (21%) over-treated overall. Appropriateness of treatment increased with higher stages (P < 0.0001) and hospital workload for cancer of the cervix (P = 0.038). Multivariable analysis indicated that survival independently and significantly decreased with age and stage, under-treatment and in cases where lymph nodes were involved or not examined. There was no change in the appropriateness of management over the 4 years, with high levels of inappropriate care. Survival was not only influenced by biological and demographic factors, but by inappropriate care.

Adult↗
PubMed1996

Variations in the management and survival of women under 50 years with breast cancer in the South East Thames region.

A retrospective, population-based study was undertaken to determine variations in the management of women aged less than 50 years with primary breast cancer in different hospital settings and the influence of these variations on survival. A total of 1757 women who were resident in the South East Thames Health Region aged less than 50 years at the time of diagnosis of breast cancer and who presented during a 5 year period (January 1984 to December 1988) were recorded by the Thames Cancer Registry. The hospitals at which primary surgery was undertaken were categorised as teaching or non-teaching hospitals. The non-teaching hospitals were grouped according to the mean number of patients treated annually during the study period (< or = 2, 3-9, > or = 10 each year). The following factors were compared between these groups: age, extent of disease, tumour morphology, extent of primary surgery (mastectomy vs less than mastectomy), use of axillary surgery (any vs none) and use of systemic adjuvant therapy. Survival rates for the different groups were compared. Registration rates did not differ significantly between health districts. A total of 1485 (85%) women underwent surgery in over 90 different hospitals. In 1324 (86%) of these cases the surgery was undertaken in a total of 42 NHS hospitals within SE Thames Health Region or in seven teaching hospitals in adjacent regions. Mastectomy rates decreased from 52% in 1984 to 28% in 1988 (P<0.0001), but were consistently higher in teaching hospitals (P=0.01). The use of any form of axillary surgery decreased from 49% to 36% over the 5 year period (P=0.003), with significantly lower rates of axillary surgery being performed in non-teaching hospitals (P<0.0001). The proportion of cases recorded as having non-specific morphology was higher in nonteaching than in teaching hospitals (P<0.0001). On multivariate analysis survival was significantly (P<0.001) influenced by stage and tumour histology. Among patients who underwent surgery, the type of hospital in which this was undertaken did not appear to influence survival significantly. This analysis of routine cancer registry data indicates that patients were widely dispersed in a large number of different hospitals and that there were marked variations in practice according to the type of hospital to which patients presented. The treatments provided were frequently at variance with those recommended at a consensus conference held during the study period, particularly in relation to the use of axillary surgery and adjuvant systemic therapy. The way in which services are currently provided may hamper the delivery of appropriate management and comprehensive support. These data thus have implications for the purchasing and provision of services for this common condition.

Adult↗
PubMed1996

Family support services for stroke patients.

Provision of long-term support and rehabilitation after stroke varies in the UK. Patients and their carers are not always aware of services available. Family support service organisers can help increase awareness of risk factors and minimise recurrence of stroke.

Cerebrovascular Disorders↗
PubMed1995

Voluntary, named testing for HIV in a community based antenatal clinic: a pilot study.

Despite the increasing advantages of identifying HIV infection in pregnant women, only some 12% of HIV positive women attending antenatal clinics in London have been identified by named testing. As virtually all antenatal care will be community based within the next two to three years, we assessed the problems of introducing named HIV testing during pregnancy into the primary care setting. Planning the service took a considerable time and required the production of educational material for both staff and pregnant women and some reorganisation of procedures. Over a one year period an uptake of 44% was noted. Several problems were encountered including an average of 21 minutes needed to give information on AIDS and HIV, an adverse effect on the midwife-mother relationship, and anxiety (affecting both women and midwives). Possible solutions to this difficult problem are discussed.

Attitude of Health Personnel↗
PubMed1995

Is HIV testing in antenatal clinics worthwhile? Can we afford it?

Since 0.2-0.4% of pregnant women attending antenatal clinics (ANC) at St Thomas's Hospital are HIV positive, and as the Department of Health (DH) have recommended that universal voluntary HIV testing be made available to women attending ANC in areas of "known or suspected higher prevalence of HIV infection", we examined the implications of the DH initiative in an Inner London Teaching Hospital as well as in a General Practice involved in shared care. The cost of the programme (148,300 pounds to 193,900 pounds), 80% of which relates to the need to obtain informed consent, was approximately 2.7-3.5 times that calculated by the DH. The DH based much of their costing on additional time for counselling rather than calculating the additional staff required. We estimated that 25% of women will require specialized counselling since 17% are of African ethnicity and others are injecting drug users or 'worried well'. Various means of reducing costs were considered but, until such time as explicit, informed consent is no longer considered necessary, the above resources will be required. Unless the DH continues to provide central direction to Providing Agencies to give priority to these recommendations and, where necessary, provides additional funding, we fear that this important public health initiative will be unsuccessful.

AIDS Serodiagnosis↗
PubMed1995

Studies of death and disability from stroke: how can they effect change in service provision?

BACKGROUND: Although stroke is a major public health issue little is known about the need for stroke services or the most cost-effective methods of treating stroke patients. This paper discusses how stroke registry data can be used to inform and promote health service changes to meet these needs. METHODS AND RESULTS: Stroke registers were established in three districts of southern England. The initial study findings were that incidence rates reflected mortality rates in these districts, with the higher rates being observed in inner city districts. Hospitalization rates were high with significant use of health service resources but with only 5% being spent on rehabilitation. As a result of these findings a stroke steering group was established in the district with the highest incidence. Standards for care were developed and are currently being audited. A multidisciplinary rehabilitation team was set up in collaboration with the stroke registry. The local purchasers of health care have commissioned an evaluation of a community rehabilitation team to address the problem of low rehabilitation rates in the community. CONCLUSION: Although it is not possible to control for external influences within a health service this paper illustrates how research findings can influence local health service provision in a tangible way. Epidemiological research can only hope to effect such change if the original studies are undertaken rigorously and the researchers are proactive in the dissemination process, creating opportunities for further research to resolve questions raised by the studies.

Aged↗
PubMed1995

The association between small size for gestational age and perinatal and neonatal death in a UK Regional Health Authority.

Confidential enquiry into stillbirth and death in infancy is a health service requirement in England, Wales and Northern Ireland. A confidential review of perinatal death has been conducted in South-East Thames Region since 1988. Data collected for this review are analysed here. Among the 1662 singleton deaths in the enquiry from 1988 to 1991, 530 (32%) babies were small for gestational age (SGA < 10th centile): 338 of these (64%) were < 3rd centile and the remainder were between 3rd-10th centile. Small size for gestational age was significantly associated with a previous SGA baby (P = 0.02), proteinuric hypertension (P = 0.001) and increased placental-birthweight ratio (P = 0.008). Only 135 (25%) SGA fetuses were identified antenatally and multiple logistic regression showed that antenatal detection was independently related to proteinuric hypertension [odds ratio (OR) = 2.47, 95% confidence interval (CI) 1.47-4.17, P = 0.001) and to being < 3rd centile rather than 3rd-10th centile (OR = 3.16, 95% CI 1.96-5.10, P = 0.001). Although confidential enquiries have been criticised for a lack of objectivity the study indicates how data from such an enquiry can increase knowledge of events influencing peri- and neonatal outcome allowing strategies to be devised to effect change.

Data Collection↗
PubMed1995

Corticotrophin-releasing hormone and corticotrophin-releasing hormone binding protein in normal and pre-eclamptic human pregnancies.

OBJECTIVE: To measure the plasma levels of corticotrophin-releasing hormone and corticotrophin-releasing hormone binding protein in normal pregnancy and in pregnancies complicated by pre-eclampsia. SETTING: John Radcliffe Hospital, Oxford and St Thomas's Hospital, London. SUBJECTS: One hundred and twenty pregnant women sampled prospectively throughout gestation, of whom 91 experienced a normal pregnancy and eight developed pre-eclampsia; in a second study, 10 women with severe pre-eclampsia, presenting at a range of gestational ages, were sampled once and compared with appropriately matched normal pregnant women. MAIN OUTCOME MEASURE: Plasma levels of corticotrophin-releasing hormone determined by immunoradiometric assay. Plasma levels of corticotrophin-releasing hormone binding protein measured by direct radioimmunoassay. RESULTS: In the prospective study, plasma samples from women with pre-eclampsia exhibited higher (390.2 versus 292.7 pmol/l at 36 weeks) levels of corticotrophin-releasing hormone and significantly lower (5.24 versus 8.14 nmol/l at 36 weeks, P < 0.002) levels of corticotrophin-releasing hormone binding protein than normal controls. In the second, single time point study a significant elevation in CRH (P < 0.002) and reduction in CRH-BP (P < 0.001) was found in pre-eclamptic pregnancies compared with controls. CONCLUSIONS: In human pregnancies complicated by pre-eclampsia there is an elevated level of corticotrophin releasing hormone whilst there is less corticotrophin-releasing hormone binding protein; therefore there is a net increase in free potentially bioactive hormone which may play a role in the pathology of the disease.

Adolescent↗
PubMed1995

Use of the CRIB (clinical risk index for babies) score in prediction of neonatal mortality and morbidity.

A prospective study of the outcome of care of a regional cohort of very low birthweight (< 1500 g) and very preterm (< 32 weeks) infants was carried out. Its aims were to assess the ability of the CRIB (clinical risk index for babies) score, rather than gestational age or birthweight, to predict mortality before hospital discharge, neurological morbidity, and length of stay, and to access CRIB score as an indicator of neonatal intensive care performance. 676 live births fulfilled the criteria and complete data were available for 643 (95%). Compared with gestation and birthweight, CRIB was better for the prediction of mortality, was as good for the prediction of morbidity, and was not as good for the prediction of length of stay. CRIB adjusted mortality did not demonstrate better performance in units providing the highest level of care. Either the CRIB score was not sensitive to performance or the level 3 hospitals in this study were performing badly. On the basis of this analysis purchasers and providers of neonatal intensive care cannot yet rely on the CRIB score as a performance indicator.

Birth Weight↗
PubMed1995

Corticotrophin-releasing hormone (CRH)-binding protein interference with CRH antibody binding: implications for direct CRH immunoassay.

Direct immunoassay of plasma corticotrophin-releasing hormone (CRH) is potentially subject to interference from high levels of CRH-binding protein (CRH-BP) that exist in the human circulation. In this study, we tested the effect of CRH-free, native CRH-BP (6.4 nmol/l) purified from human plasma, CRH-BP diluent alone, normal human plasma (containing 5.8 nmol endogenous CRH-BP/l) and normal sheep plasma (containing no CRH-BP) on the binding of 125I-labelled CRH tracer to five N-terminal and four C-terminal CRH antibodies. All anti-(1-20)CRH N-terminal antibody dilution curves displayed marked inhibition of binding in the presence of purified CRH-BP and human plasma in comparison with the curves with the control diluent or sheep plasma. Almost no inhibition of binding was obtained with any of the C-terminal antibodies (all directed against epitopes within the last six amino acids of CRH) and the four dilution curves were nearly superimposable. Liquid-phase CRH IRMAs were then developed with different combinations of two of each of the N- and C-terminal antibodies, using radiolabelled IgG prepared from purified C-terminal antisera as tracer and raw N-terminal antisera as the link antibodies to the separating system. The addition of dilutions of purified CRH-BP over the range 1.25-20 nmol/l to the IRMA standard curve in assay buffer resulted in a dose-dependent reduction in the signal; with 5 nmol CRH-BP/l, a level commonly found in human plasma, the reduction in binding was 67% and 81% in two different IRMAs at a CRH concentration of 631 pmol/l.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗