Apolipoprotein E4 and traumatic brain injury.
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Apolipoprotein E4↗
Biomedical subjects
R Greenwood
Publications and source records attributed to R Greenwood.
Effect of an extended scope physiotherapy service on patient satisfaction and the outcome of soft tissue injuries in an adult emergency department.
OBJECTIVES: To evaluate the effect of introducing an extended scope physiotherapy (ESP) service on patient satisfaction, and to measure the functional outcome of patients with soft tissue injuries attending an adult emergency department (ED), comparing management by ESPs, emergency nurse practitioners (ENPs), and all grades of ED doctor. METHODS: The ESP service operated on four days out of every seven in a week in an urban adult ED. A satisfaction questionnaire was sent to all patients with a peripheral soft tissue injury and fractures (not related to the ankle) within one week of attending the ED. Patients with a unilateral soft tissue ankle injury were sent the acute Short Form 36 (SF-36) functional outcome questionnaire, with additional visual analogue scales for pain, at 4 and 16 weeks after their ED attendance. Waiting times and time spent with individual practitioners was also measured. RESULTS: The ESP service achieved patient satisfaction that was superior to either ENPs or doctors. Overall 55% of patients seen by the ESP service strongly agreed that they were satisfied with the treatment they received, compared with 39% for ENPs and 36% for doctors (p = 0.048). Assessment of long-term outcome from ankle injury was undermined by poor questionnaire return rates. There was a trend towards improved outcomes at four weeks in those patients treated by an ESP, but this did not achieve statistical significance. CONCLUSION: Adding an ESP service to the interdisciplinary team achieves higher levels of patient satisfaction than for either doctors or ENPs. Further outcomes research, conducted in a wider range of emergency departments and integrated with an economic analysis, is recommended.
Adult↗
Incontinence after brain injury: prevalence, outcome and multidisciplinary management on a neurological rehabilitation unit.
OBJECTIVE: To investigate the prevalence, outcome and multidisciplinary management of incontinence in patients with acquired brain injury. DESIGN: Retrospective case notes review. SETTING: Regional neurological rehabilitation unit. SUBJECTS: Two hundred and thirty-eight patients with acquired brain injury. MAIN MEASURES: Bladder and bowel subscores of the Barthel Index and Functional Independence Measure; number of multidisciplinary goals addressing bladder and bowel function. RESULTS: Fifty per cent of patients (n=112) had impaired bladder or bowel subscores on admission. Significant improvement was seen at discharge but 36% of patients (n=77) still had some degree of impairment. Over 90% of patients were set multidisciplinary goals addressing self-care (n=213) and mobility (n=205) but only 3.5% (n=8) were set multidisciplinary goals addressing bladder and bowel function. CONCLUSIONS: Incontinence was common in patients with brain injury on a neurological rehabilitation unit. Significant improvement was seen following rehabilitation. Bladder and bowel management was not well incorporated into the multidisciplinary management process.
Adolescent↗
Infliximab for the treatment of pyoderma gangrenosum: a randomised, double blind, placebo controlled trial.
BACKGROUND: Pyoderma gangrenosum (PG) is a chronic ulcerating skin condition that often occurs in association with inflammatory bowel disease. There have been a number of reports of PG responding to infliximab, a monoclonal antibody against tumour necrosis factor alpha. AIM: In the first randomised placebo controlled trial of any drug for the treatment of PG, we have studied the role of infliximab in this disorder. SUBJECTS: Patients 18 years of age or older with a clinical diagnosis of PG were invited to take part. METHODS: Patients were randomised to receive an infusion of infliximab at 5 mg/kg or placebo at week 0. Patients were then assessed at week 2 and non-responders were offered open labelled infliximab. The primary end point was clinical improvement at week 2, with secondary end points being remission and improvement at week 6. RESULTS: Thirty patients were entered into the study. After randomisation, 13 patients received infliximab and 17 patients received placebo. At week 2, significantly more patients in the infliximab group had improved (46% (6/13)) compared with the placebo group (6% (1/17); p = 0.025). Overall, 29 patients received infliximab with 69% (20/29) demonstrating a beneficial clinical response. Remission rate at week 6 was 21% (6/29). There was no response in 31% (9/29) of patients. CONCLUSIONS: This study has demonstrated that infliximab at a dose of 5 mg/kg is superior to placebo in the treatment of PG. Open label treatment with infliximab also produced promising results. Infliximab treatment should be considered in patients with PG.
Adult↗
Memory function after resolution of post-traumatic amnesia.
PRIMARY OBJECTIVES: The aims of this pilot study were (1) to examine neuropsychological, particularly memory functions immediately after post-traumatic amnesia (PTA) resolution according to the Galveston Orientation and Amnesia Test (GOAT), and (2) to provide a preliminary exploration of pattern of performance on GOAT items across PTA duration. METHODS AND PROCEDURES: Thirty-seven head injured patients were administered the Recognition Memory Tests on the day that PTA resolved. Formal neuropsychological assessment was conducted on average 10 days after PTA resolution. MAIN OUTCOMES AND RESULTS: All the patients in the series showed memory impairment which varied in severity but was typically characterized as global and severe. Deficits in executive and speed and attention functions were common. GOAT items relating to orientation were typically passed, while items concerning anterograde and retrograde recall were most commonly failed across all stages of PTA duration. CONCLUSIONS: These findings suggest that reliance on memory performance as a measure of PTA is not ideal and highlight the need for further research of this issue.
Adult↗
Physiotherapy after stroke: define, divide and conquer.
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Humans↗
An evaluation of the costs, effectiveness and quality of renal replacement therapy provision in renal satellite units in England and Wales.
OBJECTIVES: To survey of the structure, processes and organisation of renal satellite units (RSUs) in England and Wales (Phase 1), and to compare the effectiveness, acceptability, accessibility and economic impact of chronic haemodialysis performed in RSUs compared to main renal units (MRUs) (Phase 2). DATA SOURCES: Phase 1: all renal satellite units in England and Wales. Phase 2: haemodialysis patients in a representative sample (based on geography, site, private--public ownership, medical input) of 12 RSUs and their MRUs. REVIEW METHODS: Phase 1 consisted of a questionnaire survey. Semi-structured interviews were held in a representative sample of 24 RSUs with the senior clinician, senior nurse and manager. Phase 2 consisted of a cross-sectional comparison of patients in these RSUs and patients in the parent MRUs deemed suitable for satellite care by senior staff. Clinical information was obtained from medical notes and unit computer systems. Generic and disease specific health-related quality of life (HRQoL) measures were used. Co-morbidity was assessed by the Wright/Khan Index, the Lister/Chandna score, the Modified Charlson Index, and the Karnofsky Performance Score. Statistical analyses compared RSU versus MRU patients and took account of the paired and clustered nature of the data. RESULTS: In Phase 1, responses were received from 74/80 (93%) of RSUs; 2600 patients were being treated in these RSUs. The interviews were generally positive about the impact of RSUs in terms of improved accessibility and a better environment for chronic haemodialysis (HD) patients, and in expanding renal replacement therapy patients (RRT) capacity. In Phase 2, some 82% of eligible patients took part, 394 patients in the 12 RSUs and 342 in the parent MRUs. The response rate was similar in both groups. There were no significant differences in clinical processes of care. Most clinical outcomes were similar, especially after pooled analysis, although a few parameters were statistically significantly different -- notably the proportion achieving Renal Association Standards for adequacy of dialysis as measured by the urea reduction ratio (URR) was higher in the RSU patients. Patient-specific quality of life did not differ except on the patient satisfaction questions from the KDQOL, which were scored higher by the RSU sample. Strength of preference for health status on and off dialysis was very similar between the groups, as were EQ-5D utilities. Major adverse events were not common in the RSU patients, although there were many hypotensive episodes on HD, a proportion of which affected the duration of the HD session. Of the costs measured, the only difference that was statistically significant was for District Nurse visits. Of particular note was that despite the MRU group having a higher proportion of patients hospitalised, this did not translate into a statistically significant budgetary impact in terms of the total cost per patient of hospitalisations or mean cost per patient per hospitalisation. CONCLUSIONS: This study has shown that RSUs are an effective alternative to MRU HD for a wide spectrum of patients. They improve geographic access for more dispersed areas and reduce patients' travel time, and are generally more acceptable to patients on several criteria. There does not seem to be an adverse impact of care in the RSUs although comparative long-term prospective data are lacking. The evidence suggests that satellite development could be successfully expanded; not all MRUs have any satellites and many have only a few. No single RSU model can be recommended but key factors would include local geography, the likely catchment population and the type of patients to be treated. There is a need for more basic budgetary information linking activity and expenditure to be available and more transparent, to perform at least an insightful top-down costing of the two care settings. Other areas suggested for further research include: a comparison of adverse events occurring in MRUs and RSUs with longer duration and larger numbers to identify more severe events, along with the more research into the scope for preventing such events, and a study into the patients deemed ineligible for satellite care. International comparisons of satellite care would also be useful.
Adult↗
Rapid hip bone loss in active Crohn's disease patients receiving short-term corticosteroid therapy.
BACKGROUND: Uncertainty over whether corticosteroids cause bone loss in patients with Crohn's disease may reflect their short, intermittent use. AIM: We investigated whether a 2-month course of prednisolone is associated with detectable bone loss. METHODS: Fifteen patients with active Crohn's disease and 19 controls with inactive Crohn's disease were recruited. Bone mineral density of the lumbar spine and hip was measured at baseline and 2 and 8 months. RESULTS: At 2 months, significant bone loss was found in patients with active disease (femoral neck -2.7%, P < 0.002; Ward's triangle -3.9%, P < 0.01). Although bone mineral density was still lower at 8 months, these differences were no longer significant (-1.3% and -3.4%, femoral neck and Ward's triangle, respectively). No significant change in hip bone mineral density was observed in controls. Previous corticosteroid use was not significantly associated with baseline bone mineral density, although significant independent associations were observed between weight, site of disease and lumbar spine bone mineral density, and between dietary calcium deficiency and femoral neck and Ward's triangle bone mineral density. CONCLUSION: Significant bone loss at the hip can be detected in patients receiving corticosteroid treatment for 2 months for active Crohn's disease ; however, it remains unclear whether this is because of disease activity or its treatment. This rapid bone loss may represent a risk factor for fracture and justify bone protective therapy.
Adult↗
Acute rehabilitation after severe head injury.
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Craniocerebral Trauma↗
Psychosocial outcomes at 18 months after good neurological recovery from aneurysmal subarachnoid haemorrhage.
OBJECTIVES: To evaluate functioning, 18 months after surgery, of 49 patients with good neurological recovery following aneurysmal subarachnoid haemorrhage (SAH), and to determine the extent of any improvements in disturbances of mood, cognitive functioning, and levels of activity and participation previously observed at 9 month follow up. METHODS: SAH patients, matched for age, gender, and occupation with healthy control participants, completely quantitative measures of mood (HADS, FIES, BDI) and activity/participation (BICRO-39 scales), and a brief cognitive assessment battery (verbal fluency, digit span, prose recall). Controls completed the HADS and the BICRO-39. RESULTS: Patients showed some recovery of cognitive functioning, though impairments of prose recall persisted. Anxiety and depression symptoms were higher in patients than in controls, but fewer than 20% scored in the clinical range on any questionnaires except for RIES-Intrusive thoughts (22%); only three showed signs of full blown post-traumatic stress disorder. Almost half showed elevated dependence on others for domestic activities and organisation and abnormally low levels of employment. Very little variance in outcome was predicted by demographic variables, neurological or cognitive impairment, prior life stress, or mood. However, levels of social activity and self-organisation were related to persisting fatigue. CONCLUSIONS: The observed decline in intrusive thoughts and avoidance over time is consistent with that seen after life threatening illness or trauma. The persistent reductions in independence and levels of employment may in some cases reflect considered lifestyle adjustments rather than adverse and unwanted changes but in others indicate a need for focused rehabilitation.
Activities of Daily Living↗
Mapping rehabilitation resources for head injury.
Several reports have pointed to the unevenness in the UK of services for rehabilitation after head injury. A study was conducted in the Eastern Region of England to define the key stages in recovery and rehabilitation, by an iterative process of questionnaire, interview and consensus conference. Findings were translated into a draft set of maps showing current availability of services which were revised after feedback. Working groups then developed a set of definitions and classification codes for each stage of rehabilitation which were likewise disseminated for feedback. The maps were then redrafted to correspond with the definitions together with a flowchart of potential head injury rehabilitation services. The definitions were piloted at a regional neurosurgery unit and a rehabilitation hospital. Core services for neurorehabilitation region-wide were found to be variable and uncoordinated with fragmented and inequitable allocation of resources. The definitions and mapping system that emerged from this study should facilitate the design of care pathways for patients and identify gaps in the services.
Craniocerebral Trauma↗
Adjustment of dry weight in hemodialysis patients using intradialytic continuous multifrequency bioimpedance of the calf.
BACKGROUND: Current concepts of dry weight (DW) prescription are largely based on clinical symptoms because of the difficulty in assessing extracellular fluid volume (ECV) during dialysis. Intradialytic changes in ECV can be recorded as changes in extracellular resistance [Re] by continuous regional calf multifrequency bioimpedance spectroscopy (BIS). We hypothesized that relative changes in calf Re (Re at time '0' over Re at time 't' [R(e-0)/R(e-t)]) will become very small when ECV is reduced towards normal and individual dry weight is reached. METHOD: Intradialytic continuous calf BIS was recorded repeatedly in 15 hemodialysis (HD) patients. The first measurement was performed at the prevailing clinical dry weight (CDW). Next measurements were made after post-HD body weight was gradually decreased by 0.2-0.3 kg per treatment. This procedure was iterated over several subsequent treatments until a treatment was observed where changes in R(e-0)/R(e-t) were < 1%. The weight at the end of this treatment was defined as "achieved dry weight (ADW)". Each R(e-0)/R(e-t) curve was fitted using a Matlab program (curve fitting toolbox) to obtain the exact weight at 20 min after beginning of the flattening of the R(e-0)/R(e-t) slope ('dry' weight estimated from BIS, DW-BIS). RESULTS: Both mean ADW (80.5 +/- 34.1 kg) and mean DW-BIS (80.6 +/- 34.1) were significantly lower than CDW (81.4 +/- 32.0 kg, p < 0.001), but there was no difference between ADW and DW-BIS. However, the average weight reduction from CDW to ADW (0.80 +/- 0.15 kg) was significantly higher than from CDW to DW-BIS (0.66 +/- 0.14 kg, p < 0.001, paired t-test). When ADW was achieved, pre-dialysis systolic blood pressure (SBP) was lower than at CDW (139.3 +/- 32.5 mmHg, vs. 129.4 +/- 33 mmHg, p < 0.05), post-HD SBP did not differ. The incidence of clinical symptoms of underhydration was similar at CDW (15%) and DW-BIS (15%), but higher at ADW (46%). CONCLUSION: Intradialytic continuous calf BIS allows the assessment of changes in extracellular calf resistance as an indicator of changes in extracellular fluid volume. Recording of a continuous R(e-0)/R(e-t) slope during dialysis appears to be a promising new tool for the prediction of dry weight in hemodialysis patients.
Analysis of Variance↗
Review of the measurement of zeta potentials in concentrated aqueous suspensions using electroacoustics.
This paper reviews the technique of electroacoustics as it has been applied to aqueous suspensions of inorganic particles. It starts by charting the development of the technique from its earliest beginnings in the 1930s to the present day. The technique has become well established in the last decade with the advent of the Acoustosizer and the Acoustosizer II. Illustrations of how the technique can be used are given based on the author's own experience, especially the measurement of iso electric points, the adsorption of polyelectrolytes, the effect of ionic strength, the effect of powder surface area and the dissolution of material from powders. Some new data on (a) the adsorption of different molecular weights of polyacrylic acid onto alumina and (b) titanium dioxide suspensions are also presented.
Journal Article↗
Prism adaptation can improve contralesional tactile perception in neglect.
The authors show that prismatic adaptation can reduce tactile inattention in stroke patients with unilateral neglect. Four patients with visuospatial neglect and tactile extinction underwent 10-minute application of 20 degrees right-shifting prismatic lenses during pointing. This improved contralesional tactile perception in all patients, even for a task requiring no exploration or spatial motor responses. This finding suggests a potential role for prismatic adaptation in the rehabilitation of multiple sensory modalities in patients with neglect.
Adaptation, Physiological↗
Chest radiograph interpretation by medical students.
AIM: To assess the ability of final year medical students to interpret conventional chest radiographs. MATERIALS AND METHODS: Ten conventional chest radiographs were selected from a teaching hospital radiology department library that were good radiological examples of common conditions. All were conditions that a medical student should be expected to recognize by the end of their training. One normal radiograph was included. The radiographs were shown to 52 final year medical students who were asked to describe their findings. RESULTS: The median score achieved was 12.5 out of 20 (range 6-18). There was no difference between the median scores of male and female students (12.5 and 12.3, respectively, p=0.82) but male students were more likely to be certain of their answers than female students (median certainty scores 23.0 and 14.0, respectively). The overall degree of certainty was low. On no radiograph were more than 25% of students definite about their answer. Students had received little formal radiology teaching (2-42 h, median 21) and few expressed an interest in radiology as a career. Only two (3.8%) students thought they were good at interpreting chest radiographs, 17 (32.7%) thought they were bad or awful. CONCLUSION: Medical students reaching the end of their training do not perform well at interpreting simple chest radiographs. They lack confidence and have received little formal radiological tuition. Perhaps as a result, few are interested in radiology as a career, which is a matter for concern in view of the current shortage of radiologists in the UK.
Clinical Competence↗
Identification of T-cell epitopes in clotting factor IX and lack of tolerance in inbred mice.
Immune responses to the factor IX protein pose problems for hemophilia B patients who develop antibodies against factor IX and for potential future treatment with gene therapy. To better define the response to human factor IX, we analyzed T-cell responses to human factor IX in factor IX knockout mice on BALB/c and C57BL/6 (B6) backgrounds, both strains having CD4+ T cells that proliferate in response to human factor IX. Surprisingly, wild-type mice have similar factor IX-recognizing CD4+ T cells. We defined a dominant CD4+ epitope for each strain (CVETGVKITVVAGEH for BALB/c and LLELDEPLVLNSYVTPIC for B6) that was recognized by both factor IX knockout and wild-type mice. While human factor IX did not cross-react with the mouse homologs of these epitopes, immunization with peptides from murine factor IX stimulated proliferation in factor IX knockout mice and wild-type mice, demonstrating a failure to delete murine factor IX-specific T cells in normal mice.
Amino Acid Sequence↗
Treatment of oro-facial hypersensitivity following brain injury.
A 56 year old man who was 10 months post-severe traumatic brain injury was unable to tolerate oral hygiene. He had oro-facial hypersensitivity, oral dyspraxia and limited oral function. Poor oral hygiene with coating of oral structures and infection was present. An intensive systematic desensitization programme over 2 weeks, even at this late stage post-injury, increased oral tolerance and allowed full oral hygiene. Participation in oral hygiene and functional patterns of movement also improved, enabling some oral nutritional intake. This case study provides controlled evidence, very little of which exists in the literature, to demonstrate the effectiveness of these treatment techniques
Accidents↗
Population requirement for primary knee replacement surgery: a cross-sectional study.
OBJECTIVES: To determine the population requirement for total knee replacement (TKR) in England. METHODS: Population-based study using an age/sex-stratified random sample of 28 080 individuals aged 35 yr and over. Incident disease was estimated from prevalence by statistical modelling. The New Zealand priority criteria for major joint replacement were used for case selection. RESULTS: Patients with knee disease were less likely than those with equally severe hip disease to have been referred to a specialist, to have consulted an orthopaedic surgeon or to be on a waiting list for joint replacement. The estimated annual requirement of TKRs in England, based on New Zealand Scores alone, was 55,800 (95% CI 40 700-70,900), contrasting sharply with an annual provision of 29,300 actually observed. However, in contrast to previously reported hip replacement data, when patient willingness to undergo surgery was considered, this estimate decreased considerably. CONCLUSIONS: There appears to be an underprovision of TKR in England. This may be due in part to differences in perception of disease severity and likely response to surgery between patients and general practitioners on one hand, and rheumatologists and orthopaedic surgeons on the other.
Adult↗