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Biomedical subjects

C M Roberts

Publications and source records attributed to C M Roberts.

At least 19 recordsLinked to original sources
PubMed2006

Admissions to hospital with exacerbations of chronic obstructive pulmonary disease: Effect of age related factors and service organisation.

BACKGROUND: Exacerbations of chronic obstructive pulmonary disease (COPD) have a high rate of mortality which gets worse with advancing age. It is unknown whether this is due to age related deficiencies in process of care. A study was undertaken in patients with COPD exacerbations admitted to UK hospitals to assess whether there were age related differences in the process of care that might affect outcome, and whether different models of care affected process and outcome. METHODS: 247 hospital units audited activity and outcomes (inpatient death, death within 90 days, length of stay (LOS), readmission within 90 days) for 40 consecutive COPD exacerbation admissions in autumn 2003. Logistic regression methods were used to assess relationships between process and outcome at p < 0.001. RESULTS: 7514 patients (36% aged > or = 75 years) were included. Patients aged > or = 75 years were less likely to have blood gases documented, to have FEV1 recorded, or to be given systemic corticosteroids. Those admitted under care of the elderly (CoE) physicians were less likely to enter early discharge schemes or to receive non-invasive ventilation when acidotic. Overall inpatient and 90 day mortality was 7.4% and 15.3%, respectively. Inpatient and 90 day adjusted odds mortality rates for those aged > or = 85 years (versus < or = 65 years) were 3.25 and 2.54, respectively. Mortality was unaffected by admitting physician (CoE v general v respiratory). Age predicted LOS but not readmission. Age related deficiencies in process of care did not predict inpatient or 90 day mortality, readmission, or LOS. CONCLUSIONS: Management of COPD exacerbations varies with age in UK hospitals. Inpatient and 90 day mortality is approximately three times higher in very elderly patients with a COPD exacerbation than in younger patients. Age related deficiencies in the process of care were not associated with mortality, but it is likely that they represent poorer quality of care and patient experience. Recommended standards of care should be applied equally to elderly patients with an exacerbation of COPD.

Acute Disease↗
PubMed2006

Quantifying the environmental impacts of artisanal fishing gear on Kenya's coral reef ecosystems.

The environmental impacts of artisanal fishing gear on coral reef ecosystems were studied in the multi-gear fishery of southern Kenya to evaluate which types of gear have the greatest impact on coral reef biodiversity. The gear types studied were large and small traps, gill nets, beach seines, hand lines and spear guns. Levels of coral damage, proportion of juvenile fish and discards, size and maturity stage at first capture were quantified and compared amongst the gear types. Results indicate that fishers using beach seines, spears and gill nets cause the most direct physical damage to corals. Spear fishers showed the highest number of contacts to live corals per unit catch followed by fishers using gill nets (12.6+/-1.8 and 5.9+/-2.0 coral contacts per kg fish caught per trip respectively). Apart from discarding 6.5% of their daily catch in the sea, as it was too small, beach seine fishers also landed the highest percentage of juvenile fish (68.4+/-15.7%), a proportion significantly higher (p<0.001) than in any other gear. The size and maturity stage at first capture for 150 of 195 species caught by all gear types was well below the lengths at which they mature. For example, 100% of Lethrinus xanthochilus, 99% of Lethrinus nebulosus and 94% of Lethrinus harak caught were juveniles. Across all gear types, 50.1+/-22.7% of the catch consisted of juvenile fish, indicating serious growth overfishing. Field assessment of levels of coral density showed that fishing grounds where beach seines were still in use had a significantly lower density than where beach seining was not used. This correlation is likely to arise in part because seines cannot be used in the most coral rich areas, and in part because coral loss is a consequence of seine use. On a per gear basis therefore, beach seines had the most impact on coral reef biodiversity. This study emphasizes the need to enforce restrictions on destructive gear and mesh sizes.

Animals↗
PubMed2006

UK National COPD Audit 2003: Impact of hospital resources and organisation of care on patient outcome following admission for acute COPD exacerbation.

BACKGROUND: Acute chronic obstructive pulmonary disease (COPD) exacerbations use many hospital bed days and have a high rate of mortality. Previous audits have shown wide variability in the length of stay and mortality between units not explained by patient factors. This study aimed to explore associations between resources and organisation of care and patient outcomes. METHODS: 234 UK acute hospitals each prospectively identified 40 consecutive acute COPD admissions, documenting process of care and outcomes from a retrospective case note audit. Units also completed a resources and organisation of care proforma. RESULTS: Data for 7529 patients were received. Inpatient mortality was 7.4% and mortality at 90 days was 15.3%; the readmission rate was 31.4%. Mean length of stay for discharged patients was 8.7 days (median 6 days). Wide variation was observed in all outcomes between hospitals. Both inpatient mortality (odds ratio (OR) 0.67, CI 0.50 to 0.90) and 90 day mortality (OR 0.75, CI 0.60 to 0.94) were associated with a staff ratio of four or more respiratory consultants per 1000 hospital beds. The length of stay was reduced in units with more respiratory consultants, better organisation of care scores, an early discharge scheme, and local COPD management guidelines. CONCLUSIONS: Units with more respiratory consultants and better quality organised care have lower mortality and reduced length of hospital stay. This may reflect unit resource richness. Dissemination of good organisational practice and recruitment of more respiratory specialists offers the potential for improved outcomes for hospitalised COPD patients.

Acute Disease↗
PubMed2006

Understanding the internet-based distance learning preferences of European respiratory specialists.

We studied the learning preferences of 160 respiratory specialists from four European countries who participated in ten internet-based learning modules and answered linked survey questions. Specialists were enthusiastic for internet learning amongst all national groups and particularly wanted to access material for teaching others. The value of social interactive learning was acknowledged but British and German subjects appeared more reluctant to participate. Internet delivered distance learning is well perceived amongst respiratory specialists. There is potential for both individual and group learning that could be realized by developing Europe-wide continuing professional development communities.

Choice Behavior↗
PubMed2006

Practical experience of using directly observed procedures, mini clinical evaluation examinations, and peer observation in pre-registration house officer (FY1) trainees.

This paper describes an eight month experience with three of the four main assessment tools that will be used to validate the successful completion of the FY1 placement. The practical issues around the implementation of these new tools is of great concern to all involved in the management of postgraduate training and it is hoped that this paper will contribute some of the practical elements so far unavailable from Department of Health sources.

Clinical Competence↗
PubMed2006

Benefits of an education programme on the self-management of aerosol and airway clearance treatments for children with cystic fibrosis.

Adherence to recommended aerosol medicines and airway clearance techniques (ACT) for children with cystic fibrosis (CF) requires self-management skills. A multi-centre, randomized, controlled trial was conducted to investigate the effectiveness of a self-management education programme called 'Airways' for six- to 11-year old children with CF and their caregivers. Assessments were conducted immediately before and after the intervention period, and six and 12 months after the post-intervention assessment. The pen and paper education programme was completed by the child and caregiver together at home. Participants in the intervention and control groups had similar baseline characteristics. A per-protocol analysis was conducted and for variables that changed significantly, an additional intention-to-treat analysis was performed that included data from participants in the intervention group who withdrew from the study during the intervention period. The intervention group increased the percentage of prescribed aerosols taken (P < 0.001) and this was maintained at 12-month follow-up (P < 0.001). There was no change in the percentage of prescribed ACT performed, although when the child was unwell, caregivers in the intervention group increased the frequency and/or duration of ACT (P = 0.028) in the per-protocol analysis but not in the intention-to-treat analysis. Children in the intervention group increased their knowledge of ACT (P < 0.001) which was maintained at 12-month follow-up (P < 0.001) and felt more positively about their chest treatment regimens immediately following the intervention (P = 0.017) but not at 12-month follow-up. There were no significant changes in the control group for these variables over time. No significant changes occurred in the caregivers' reports of self-management behaviours and self-efficacy in either group. The positive results suggest that 'Airways' is a valuable educational tool for primary school-aged children with CF and their caregiver.

Administration, Inhalation↗
PubMed2004

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

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

Humans↗
PubMed2004

Implementation of British Thoracic Society guidelines for acute exacerbation of chronic obstructive pulmonary disease: impact on quality of life.

BACKGROUND: The British Thoracic Society (BTS) guidelines have not been examined collectively for their impact on chronic obstructive pulmonary disease (COPD). Whether intensive outpatient follow up of COPD patients after acute admission, using these guidelines, improved quality of life compared to the "usual practice" of primary care follow up was investigated. METHODS: Altogether 103 patients with a new diagnosis of COPD were admitted and screened over a four year period. Seventy patients were excluded because of another dominant medical condition or a mandatory requirement for intervention. Patients were randomised to regular primary care (control group, n = 15) or chest clinic follow up (intervention group, n = 10). Spirometry, oxygen saturation, St George's Respiratory Questionnaire (SGRQ), and Short Form 36 questionnaire were measured at baseline and six months. The intervention group was reviewed at least four times in the six month period and received spirometry, ambulatory oxygen assessment, smoking cessation advice, nebuliser assessment, a steroid trial, advice about nutrition/exercise, and introduction to a patient support group. RESULTS: There was no significant difference between baseline measurements in the two groups. There was a significant mean (SD) improvement in the SGRQ symptom score from baseline to six months in the intervention group [20.98 (20.36)] compared with the controls [0.23 (12.55)] (p = 0.004). At six months the SGRQ symptom score, impact score, and total score was significantly better in the intervention than the control group (p = 0.01, 0.02, and 0.02). CONCLUSION: Aggressive implementation of BTS guidelines after initial hospitalisation may improve respiratory health specific quality of life scores in patients with COPD. Larger studies are needed to confirm this finding.

Acute Disease↗
PubMed2004

Is virtual bronchoscopy useful for physicians practising in a district general hospital?

BACKGROUND: Virtual bronchoscopy software is now available to district general hospitals (DGHs). There is limited information on the clinical utility of virtual bronchoscopy and whether it offers any additional information over conventional axial computed tomography in the setting of a busy DGH chest unit. METHODS: Virtual bronchoscopy and computed tomography findings were compared in all patients who had a virtual bronchoscopy study over a 12 month period. RESULTS: Eighteen consecutive patients had virtual bronchoscopy for a specific clinical indication over the study period. Additional information was conveyed by virtual bronchoscopy in five patients (in four patients the airways distal to an obstruction were better visualised thereby influencing decisions about airway stenting and in one patient the virtual bronchoscopy study showed an endobronchial lesion missed on computed tomography). In nine patients who were unfit for fibreoptic bronchoscopy (FOB) the radiologist was more confident in excluding an obstructive airway lesion. The main indication for performing a virtual bronchoscopy study was to rule out an obstructive airway lesion in patients who were unfit for FOB (n = 11). CONCLUSION: Virtual bronchoscopy is feasible and useful in the management of a few selected patients in a DGH chest unit. Virtual bronchoscopy may convey additional information over computed tomography when the distal airways need to be visualised and for discrete endoluminal lesions.

Adult↗
PubMed2003

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

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

Aged↗
PubMed2003

Oxygen supplementation before or after submaximal exercise in patients with chronic obstructive pulmonary disease.

BACKGROUND: Evidence for improved exercise tolerance or relief of breathlessness by short term use of oxygen before or after exercise in patients with chronic obstructive pulmonary disease (COPD) is scant, and guidelines for this treatment are lacking despite widespread provision in the UK. METHODS: The effect of oxygenation either before or after exercise on perception of breathlessness and walk distance was studied in a group of patients with moderate to severe COPD (mean forced expiratory volume in 1 second (FEV(1)) 34% of predicted, mean 6 minute walk distance on air 283 m), all of whom desaturated by at least 4% on submaximal exercise. Oxygen (28%) or air was delivered double blind and in random order, either for 5 minutes before a standard 6 minute walk test (n=34) or for 5 minutes following the end of the test (n=18). Exercise tolerance was measured as the distance achieved and breathlessness was assessed using visual analogue scales (VAS) which were scored before and after exercise and during recovery. RESULTS: No increase in mean walk distance after oxygen (288 v 283 m) and no improvement in mean breathlessness scores (58 v 54 mm) or recovery times occurred with oxygen taken either before (177 v 184 seconds) or after exercise (182 v 151 seconds). CONCLUSIONS: This group of patients with COPD derived no physiological or symptomatic benefit from oxygen breathed for short periods before or after submaximal exercise. Domiciliary oxygen should only be prescribed for such patients if they have shown objective evidence of benefit on exercise testing.

Aged↗
PubMed2003

Results of an extended tuberculosis screening programme among sixth formers in a London school--more questions than answers.

Following the death of an unvaccinated 16-year-old school student with isoniazid resistant pulmonary tuberculosis, extended screening of sixth formers took place to identify further cases of tuberculosis and to establish the need for BCG vaccination. Eight hundred and four 16-19 year olds in the school underwent Heaf testing and completed a demographics questionnaire. Forty-nine (5.5%) of these children had a positive Heaf test and were offered a chest radiograph. Four children were diagnosed with pulmonary or mediastinal tuberculosis, none linked to the index case. Fifty-four students (6.7%) with no prior BCG had a Heaf grade 0-1 reaction and were recommended for vaccination. Ninety-one percent of students were from ethnic minority groups and 29% had been born outside the UK. British Thoracic Society recommendations on the management of tuberculin positive cases of this is open to interpretation and we suggest that a more directed and aggressive approach to TB control should be considered in inner city schools with a high proportion of at risk ethnic minority students.

Adolescent↗
PubMed2002

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

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

Acute Disease↗
PubMed2001

Effects of marine reserves on adjacent fisheries.

Marine reserves have been widely promoted as conservation and fishery management tools. There are robust demonstrations of conservation benefits, but fishery benefits remain controversial. We show that marine reserves in Florida (United States) and St. Lucia have enhanced adjacent fisheries. Within 5 years of creation, a network of five small reserves in St. Lucia increased adjacent catches of artisanal fishers by between 46 and 90%, depending on the type of gear the fishers used. In Florida, reserve zones in the Merritt Island National Wildlife Refuge have supplied increasing numbers of world record-sized fish to adjacent recreational fisheries since the 1970s. Our study confirms theoretical predictions that marine reserves can play a key role in supporting fisheries.

Adolescent↗
PubMed2001

Audit of acute admissions of COPD: standards of care and management in the hospital setting.

Despite publication of several management guidelines for COPD, relatively little is known about standards of care in clinical practice. Data were collected on the management of 1400 cases of acute admission with Chronic Obstructive Pulmonary Disease in 38 UK hospitals to compare clinical practice against the recommended British Thoracic Society standards. Variation in the process of care between the different centres was analysed and a comparison of the management by respiratory specialists and nonrespiratory specialists made. There were large variations between centres for many of the variables studied. A forced expiratory volume in one second measurement was found in only 53% of cases. Of the investigations recommended in the acute management arterial blood gases were performed in 79% (interhospital range 40-100%) of admissions and oxygen was formally prescribed in only 64% (range 9-94%). Of those cases with acidosis and hypercapnia 35% had no further blood gas analysis and only 13% received ventilatory support. Long-term management was also deficient with 246 cases known to be severely hypoxic on admission yet two-thirds had no confirmation that oxygen levels had returned to levels above the requirements for long-term oxygen therapy. Only 30% of current smokers had cessation advice documented. To conclude, the median standards of care observed fell below those recommended by the guidelines. The lowest levels of performance were for patients not under the respiratory specialists, but specialists also have room for improvement. The substantial variation in the process of care between hospitals is strong evidence that it is possible for other centres with poorer performance to improve their levels of care.

Acute Disease↗
PubMed2000

The Holyoake Codependency Index: investigation of the factor structure and psychometric properties.

The Holyoake Codependency Index is being developed to measure the extent to which a person endorses codependent beliefs and attributions. A 28-item pilot version was administered to 39 male and 268 female clients of a family counseling agency. Factor analysis, used to identify the shortest version with acceptable reliability, yielded a 13-item final version comprising three subscales (external focus, self-sacrifice, and reactivity). The subscales correspond to key themes within the literature on codependency. Scores on each subscale correlated significantly in the predicted direction with relevant measures of psychological functioning; providing initial evidence of construct validity. The 13-item scale was administered to a general community sample of 303 women and the factor structure was fully replicated. Internal consistency of the subscales ranged from .74 to .84 with the family counseling sample and from .73 to .83 with the general community sample.

Adolescent↗