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Biomedical subjects

R Cleary

Publications and source records attributed to R Cleary.

At least 19 recordsLinked to original sources
PubMed1999

Associations between an asthma morbidity index and ideas of fright and bother in a community population.

There is a need for simple asthma outcome measures for primary care which are not only valid in terms of their relationship with lung function but also in terms of pragmatic psychological constructs. This study assesses the usefulness of adding items on the degree of 'bother' and 'fright' caused by the condition to a previously validated simple asthma morbidity index. A postal questionnaire survey comprising a simple asthma morbidity index and questions on 'fright' and 'bother' was conducted in one general practice in the north-east of England. Responses were obtained from 570 individuals. Of these, 184 (32%) reported low, 133 (23%) medium and 253 (44%) high morbidity. Twenty-nine per cent of respondents had felt frightened by their asthma in the previous 4 weeks. Both the 'fright' and 'bother' items were significantly associated with the morbidity index. The addition of 'bother' and/or 'fright' questions may improve both the content, construct and predictive validity of the morbidity index, but this needs to be established prospectively.

Anxiety↗
PubMed1999

Assessing the outcomes of total knee replacement.

The past few years have seen a growth of interest in outcome measurement in a variety of settings including audit, health care management and commissioning - besides the traditional applications in research work. This paper reports on a study of the outcomes of total knee replacement in an acute hospital where the outcomes were studied as part of an audit process. The outcome measures used included clinical and symptomatic measures as well as generic health status scales. The initial study in one hospital was expanded to include a number of others in the same region and a comparative database of outcomes developed. Examples of the results are shown. The technical measures using knee scores and general health status measure show significant improvement from pre-operatively to 3 months later. This improvement was maintained up to the 1-year follow-up on both measures. Although the information systems for collecting and measuring outcomes has been successful, the ability of such measures to lead to behavioural change has been limited. The problems in using outcome measures are discussed in particular in the context of an audit within hospitals, and for purchasing agencies.

Arthroplasty, Replacement, Knee↗
PubMed1999

Health outcome after total knee replacement in the very elderly.

Between 1992 and 1994 we performed a prospective study of the effect of total knee replacement (TKR) on the health status of 119 patients over the age of 80 years who had had a primary unilateral TKR. The Nottingham Health Profile was used to assess this before and at three and 12 months after operation. We found a significant improvement in the scores for pain, emotional reaction, sleep and physical mobility at three months. After 12 months, the scores for pain and sleep were well maintained. The other factors had deteriorated slightly but remained better than before operation. Our findings show that TKR leads to a significant improvement in the general health status of the very elderly.

Aged↗
PubMed1999

Predictive value of a simple asthma morbidity index in a general practice population.

BACKGROUND: There is a need in primary care for simple asthma outcome measures that are valid in terms of their relationship with lung function and capable of predicting those patients for whom additional management is indicated. AIM: To assess the predictive validity of a revised asthma morbidity index in United Kingdom (UK) general practice. METHOD: Morbidity index and peak flow rate data were gathered from nine general practices over a three-month period. Two postal questionnaire surveys, one year apart, were conducted in one Tyneside general practice. Morbidity index data from 570 asthmatic patients were gathered in the first survey and used to predict morbidity over the next year. RESULTS: For 120 responders with low morbidity, mean peak flow as a percentage of the predicted value was 91% (SD = 21%); for 91 responders with medium morbidity, the percentage was 77% (SD = 21%); and for 90 responders with high morbidity, it was 63% (SD = 29%). Fifty-seven per cent of the morbidity index categories remained unchanged after 12 months. The relative risks of high morbidity for having any acute asthma attacks, more than four attacks, and needing oral steroids during a one year period were 2.88 (CI = 1.87 to 4.43), 2.52 (CI = 1.84 to 3.44) and 2.38 (CI = 1.70 to 3.33) respectively. CONCLUSION: The revised morbidity index is a simple and valid tool for the opportunistic surveillance of asthma in primary care.

Asthma↗
PubMed1998

The fit of cast and premachined implant abutments.

STATEMENT OF PROBLEM: There is insufficient information regarding the adaptation of abutments to implants. PURPOSE: This study assessed the adaptation of premachined, cast, and laboratory modified premachined abutments to implants at two sites: abutment/implant interface and screw to screw seat. MATERIAL AND METHODS: Six combinations of abutments and implants were studied: CeraOne abutments joined to Nobel Biocare implants; STR (Implant Innovations Inc.) abutments joined to 31 implants; Cast UCLA (31) abutments subjected to porcelain firing cycles and joined to 31 implants; Cast UCLA abutments subjected to porcelain firing cycles and joined to Nobel Biocare implants; UCLA premachined abutments cast with gold palladium alloy and subjected to porcelain firing cycles (later joined to 31 implants); and UCLA premachined abutments joined to 31 implants. Each group contained five assemblies. RESULTS: The adaptation of abutments to implants was closer and the amounts of contact larger for assemblies with premachined and laboratory modified premachined abutments than for those with cast abutments. CONCLUSION: The finishing of custom-made abutments requires further refinement.

Analysis of Variance↗
PubMed1996

The standard primipara as a basis for inter-unit comparisons of maternity care.

OBJECTIVE: To assess the suitability of the standard primipara (a subset of the obstetric population that has relatively low risk or intervention and of adverse outcome) for making inter-unit comparisons of indicators of the process and outcome of maternity care. DESIGN: Inter-unit comparison of 10 indicators of obstetric intervention and adverse outcome derived from routinely collected computerised data held on the St Mary's Maternity Information System. SETTING: Fifteen maternity units in the former North West Thames Region. PARTICIPANTS: 15,463 primiparae who were delivered in 1992. MAIN OUTCOME MEASURES: Proportion of primiparae within the standard definition; degree to which standard primiparae are associated with lower rates of intervention and adverse outcome, as compared to other primiparae. RESULTS: Within the database, 42.6% of all primiparae were found to be standard, with rates varying between units from 25.9% to 57.7%. As expected, the standard primiparous woman is at less risk of intervention or adverse outcome than other primiparae. All but one component variable of the standard definition is a significant risk factor for at least four of the 10 indicators. Statistically significant differences in indicator rates are seen between standard and nonstandard primiparae within units. Within the standard group, significant differences in rates of intervention and adverse outcome are seen between units. Units with relatively high levels of intervention within the higher risk nonstandard group also have relatively high levels of intervention within the standard group. CONCLUSIONS: Use of the standard primipara, rather than the whole obstetric population, as the basis for inter-unit comparisons of maternity care will control for the substantial difference in case mix seen in different units, thereby increasing the validity of those comparisons. The technique has the additional benefit of clarifying the relationship between everyday clinical decision making and a unit's performance in comparative indicator reports. The approach must be combined with a separate study of the other groups in the case mix, such as multiparae and high risk primiparae. Additional nonoverlapping groups, homogeneous in terms of risk factors, should be defined and used to extend the basis on which comparisons may be made.

Adult↗
PubMed1995

Nottingham health profile measurement in the assessment of clinical outcome after prostatectomy. Northern Regional Prostate Audit Group.

OBJECTIVE: To compare the changes in pre- and post-operative symptom scores with changes in Nottingham health profile (NHP) scoring, and thus determine whether NHP scoring offers a reliable assessment of outcome after transurethral resection of the prostate (TURP), and whether NHP scoring could usefully supplement the more traditional method of symptom scoring in this assessment. PATIENTS AND METHODS: An 8-month audit of 1396 TURPs, involving 12 hospital sites, was performed in the Northern region between April 1 and November 31, 1991. A cohort of 371 of these patients, for whom pre- and post-operative NHPs and irritative and obstructive voiding symptoms had been recorded, were investigated. RESULTS: There was a significant decrease in both obstructive and irritative voiding symptom scores 3 months after TURP and a significant fall in the NHP scores for all stations except social isolation. There were significantly higher irritative symptom scores both before and after operation in men with prostate cancer compared with those with benign prostatic hypertrophy, and significantly higher post-operative obstructive symptom scores in men with prostate cancer. However, there were no significant differences in the pre- and post-operative NHP scores for these two subgroups of patients. In patients who had a good outcome on symptom scoring, there was a significant reduction in NHP scores for all stations except social isolation. However, in those patients who had a poor outcome on symptom score, there was no correlation with changes in the NHP scores, with some NHP stations showing a significant reduction after operation. CONCLUSION: NHP quality-of-life scoring cannot replace symptom scoring in the assessment of outcome after TURP and when used alone, added little further information. However, for a comprehensive assessment of outcome, symptom scores and quality-of-life assessments should be used together.

Cohort Studies↗
PubMed1995

Comparison of short term outcomes of open and laparoscopic cholecystectomy.

OBJECTIVE: To compare the three month outcome of open and laparoscopic cholecystectomy. DESIGN: Prospective assessment of outcome for a series of patients encompassing the introduction of the laparoscopic technique. SETTING: One teaching hospital. PATIENTS: 269 patients admitted for open cholecystectomy between January 1989 and March 1992 and 122 admitted for laparoscopic cholecystectomy between January 1991 and March 1992. MAIN MEASURES: Patients' reported symptoms and self assessed scores with the Nottingham health profile before operation and at three month follow up. Incidence of complications and adverse events after discharge. RESULTS: Similar improvements in symptom rates and health scores were seen regardless of surgical technique. A lower rate of postoperative complications was seen in the patients given laparoscopic surgery (6/95(6%) v 45/235(19%)), and their mean length of stay was lower (4.5 v 9.8 days). Similar results were obtained when the analysis was restricted to a subset of fairly uncomplicated cases (patients aged 60 or less without other illnesses on admission who were not undergoing emergency or urgent surgery), which constituted a larger proportion of the group given laparoscopy (35/95(37%) v 40/235(17%)). Between these two groups no significant difference was seen in the frequency of relevant readmissions to hospital or visits to general practitioners or accident and emergency departments. CONCLUSION: Ideally, a new surgical technique would be evaluated in a randomised trial. In the absence of such a trial, this observational study provides some evidence that the switch from open to laparoscopic cholecystectomy has brought benefits, particularly in terms of reduced length of stay in hospital. A range of clinical and patient derived indicators suggests that these gains have not been associated with a reduction in the quality of the outcome at three months.

Cholecystectomy↗
PubMed1994

Establishing inter-hospital comparisons of outcomes.

This paper describes the ongoing development of a region-wide system for monitoring the short-term outcomes of total knee replacement surgery. The system aims to collect data from a dozen hospitals, and relies on a close collaboration with locally based surgeons and medical audit staff. The intention is to provide routine comparative information based on a broad conception of outcome, that includes both clinical/technical measures and patient-derived assessments of general health status. These data may be reported in the context of relatively detailed case mix information. To date, both data capture and clinical support for the project have been good. Example reports are presented together with a discussion of current limitations and possible future developments.

Activities of Daily Living↗
PubMed1994

Written consent about sexual function in men undergoing transurethral prostatectomy.

OBJECTIVE: To review the written recording of consent about possible sexual dysfunction after transurethral resection of the prostate (TURP), and the incidence of sexual dysfunction in sexually active men after TURP, from a large scale audit of transurethral prostatectomy held in 12 hospital sites in the Northern Region. PATIENTS AND METHODS: Over an 8-month period data were collected from 12 separate hospital sites within the Northern Region by two independent nurse co-ordinators who travelled to each of the sites. Information was gathered from medical records, operation lists and theatre books using a standard proforma. The Nottingham Health Profile (NHP) was used as a quality of life instrument in a subgroup of patients who were asked about sexual function before and after operation. RESULTS: Advice about retrograde ejaculation was recorded infrequently, with only 30% of case notes including a statement about this (inter-site variations 0-78%). The mean age of patients in whom a written record was made was lower (70 [0.44 SEM] years) than those in whom there was no recording (72 [0.25] years; P < 0.001), but marital status did not appear to be a significant factor. No significant differences in NHP were found comparing men who did or who did not have written evidence about consent regarding retrograde ejaculation. In addition, in a subset of men who had been asked pre-operatively about sexual function, no significant differences were found in overall NHP measurements in those who did or who did not develop retrograde ejaculation. In men who were sexually active before operation, the incidence of major sexual problems, impotence and retrograde ejaculation were 12%, 11% and 24% respectively. CONCLUSION: The incidence of sexual dysfunction following TURP in this audit concurred with previously reported studies (4-40%), but despite this most urologists in our audit were not recording that they had advised their patients about this possible outcome.

Aged↗
PubMed1994

Deaths and complications following prostatectomy in 1400 men in the northern region of England. Northern Regional Prostate Audit Group.

OBJECTIVE: To determine the degree of variation in mortality and major morbidity following transurethral resection of the prostate (TURP), and to assess intersite variation for mortality and morbidity over 12 sites within the Northern Region. Further, to determine whether the previously observed effects on morbidity of unit size, patient through-put and emergency admission were borne out in contemporary urological practice in the Northern Region. PATIENTS AND METHODS: For an 8 month period, 1 April 1991-31 November 1991, an independent audit of TURP was performed on 12 different hospital sites throughout the Northern Region. A constant data set was designed which was collected on each patient before and 3 months after operation by two independent clinical co-ordinators who travelled to each of the sites. All case notes were reviewed at 3 months after operation by the co-ordinators using a standard proforma, rather than depending upon self reporting by medical staff. Data on factors potentially affecting mortality and morbidity were collected, including emergency admission, diagnosis of prostate cancer, American Society of Anesthesiologists' co-morbidity scores, and age and differences in throughput in the 12 sites. The effect of through-put or 'volume' on mortality and morbidity was assessed by comparing morbidity and the number of cases performed. RESULTS: The early mean death rate was 13 of 1396 patients (0.9%), with an inter-site variation ranging from 0% to 3.8%. A mean of 2.0% of men were returned to theatre after TURP, 2.4% of patients received a blood transfusion (> 2 units) after operation, and 8.0% of patients developed post-operative sepsis; these complications varied sixfold, sevenfold and 17-fold across the different sites respectively. Those units performing < or = 100 operations over the audit period (equivalent to < 150 operation per year) had a significantly increased rate of deaths and complications which was not related to population differences, though some low volume units had good results. Elderly men who were admitted as emergencies or with prostate cancer were particularly vulnerable to complications. CONCLUSIONS: The overall early mortality rate after TURP for benign prostatic hyperplasia across the Region compares well with other reported large series. The significant variation in morbidity rates found in this study suggests that careful attention needs to be paid by Urologists, Purchasers and Providers to morbidity rates after prostatectomy.

Age Factors↗
PubMed1994

The quality of routinely collected maternity data.

OBJECTIVE: To assess the validity of clinical information held on a regional maternity database, the St Mary's Maternity Information System (SMMIS). DESIGN: A retrospective review of 892 maternity case notes and matched SMMIS records, by a midwife trained in clinical coding techniques. SETTING: Three maternity units in the North West Thames Region. MAIN OUTCOME MEASURES: Percentage agreement for 17 directly recorded SMMIS data items and equivalent data abstracted from the notes. Frequencies of diagnosis codes abstracted from case notes, as compared with those generated by SMMIS on the basis of directly recorded data. RESULTS: A generally high level of agreement was observed between the abstracts of the notes and the SMMIS records. Of the 17 data items examined, 10 showed 95% agreement or better, and all but two exceeded 80% agreement. Little difference was found between the levels of agreement observed at the three sites. A greater number and range of diagnosis codes were abstracted from the notes than were generated by SMMIS. CONCLUSIONS: The directly recorded clinical data held on the SMMIS regional database is largely accurate and consistently recorded across a variety of units. The database can therefore be considered a valuable resource for the comparative audit of maternity practice. The SMMIS technique for deriving, on a semi-automatic basis, diagnosis codes from the directly recorded fields, appears to work moderately well. We suggest that the direct method of data collection used in SMMIS could provide a model for other specialties in the National Health Service.

Data Collection↗
PubMed1994

Comparative hospital databases: value for management and quality.

OBJECTIVES: To establish an accurate and reliable comparative database of discharge abstracts and to appraise its value for assessments of quality of care. DESIGN: Retrospective review of case notes by trained research abstractors and comparison with matched information as routinely collected by the hospitals' own information systems. SETTING: Three district general hospitals and two major London teaching hospitals. PATIENTS: The database included 3905 medical and surgical cases and 2082 obstetric cases from 1990 and 1991. MAIN MEASURES: Accessibility of case notes; measures of reliability between reviewers and of validity of case note content; application of high level quality indicators. RESULTS: The existing hospital systems extracted insufficient detail from case notes to conduct clinical comparative analyses for medical and surgical cases. The research abstractors at least doubled the diagnostic codes extracted. Interabstractor agreement of about 70% was obtained for primary diagnosis and assignment to diagnosis related group. These data were sufficient to create a comparative database and apply high level quality indicators designed to flag topics for further study. For obstetric-specific indicators the rates were comparable for abstractors and the hospital information systems, which in each case was a departmentally based system (SMMIS) producing more detailed and accessible data. CONCLUSIONS: Current methods of extracting and coding diagnostic and procedural data from case notes in this sample of hospitals is unsatisfactory: notes were difficult to access and recording is unacceptably incomplete. IMPLICATIONS: Improvements as piloted in this project, are readily available should the NHS, hospital managers, and clinicians see the value of these data in their clinical and managerial activities.

Data Collection↗
PubMed1992

Effects of colour substitutions upon motion detection in spatially random patterns.

To investigate the effects of colour upon motion detection, the short-range motion displacement limit (Dmax) was determined using two-frame kinematograms in which the two classes of square comprising the pattern differed both in luminance and in colour. In the second motion frame, the squares retained either the same luminance and colour as in the first frame, or they changed their colour while retaining their luminance. The experiment was repeated at three different viewing distances to investigate the effects of element angular size. Two of the four observers had normal trichromatic colour vision; the other two were dichromats (protanopes). For the trichromatic observers, the change of colour between frames made motion displacements harder to detect when the squares were large, but not when they were small. The result accords with an input of colour into motion detection at low but not at high spatial frequencies. For the dichromats, the colour change had little effect at any of the viewing distances, thus ruling out the possibility that the deleterious effects of colour substitution upon motion detection in trichromats was due to chromatic aberration or other artefacts.

Color Perception↗
PubMed1992

Ambiguous motion in a two-frame sequence.

We measured the ability of ten different observers to identify the direction of motion displacement of a 1.77 c/deg grating in a two-frame sequence. One subject showed virtually errorless performance, in agreement with Derrington and Cox [(1992) Vision Research, 32, 2191-2193], but most subjects found the task difficult and made many errors. One subject saw motion in the reverse of the actual direction of displacement. We conclude that the two-frame sequence contains motion signals in both directions, and that selective attention to the forward direction is necessary for errorless performance.

Attention↗
PubMed1992

Effects of contrast substitutions upon motion detection in spatially random patterns.

We report the effects of contrast changes between frames in a random-square kinematogram. When the contrasts of both frames are too low to permit directional discrimination, increasing the contrast of either the first or the second frame alone makes directional discrimination possible. However, at suprathreshold contrasts for motion detection, increasing the contrast of either the first or the second frame alone makes discrimination more difficult. We conclude that motion detection is a special case of contrast discrimination, in agreement with the Reichardt model of motion detection.

Contrast Sensitivity↗