Physical assessment as a predictor of mortality in people with Parkinson's disease: a study over 7 years.

The primary aim of this study was to ascertain whether a battery of physical function measures in a Parkinson's disease (PD) patient cohort predicted mortality status at 7-year follow-up. Secondary aims were establishing which specific tests were the most useful, and whether PD phenotype was a predictor. A retrospective correlation design was used in this study. A cohort of 109 PD patients underwent baseline physiotherapy assessment of gait, balance, posture, muscle strength, and ability to change postural set. We compared mortality status at 7-year follow-up and baseline physical assessment tests. Tinetti gait and balance scores, UPDRS score, 10-m walk test (time, velocity, and number of strides), posture in standing, lying to sitting, sitting to standing, getting up from floor assessments, and time to ascend and descend four steps were found to be statistically significant physical predictors of mortality at 7-year follow-up. In addition, age, sex, and mini-mental state examination were significant nonphysical predictors of mortality. Using Cox regression, a survival model was constructed with age, sex, and Tinetti gait score as independent predictors of mortality. The results of this study suggest that there is a link between reduced physical function and an increased mortality risk in PD populations.

A questionnaire study of the approach to the anorexia-cachexia syndrome in patients with cancer by staff in a district general hospital.

GOALS OF WORK: This questionnaire study was designed to investigate understanding, assessment and management of cancer-related anorexia-cachexia syndrome (ACS) amongst hospital staff. METHODS: Qualified nurses and doctors on general medical and surgical wards within a district general hospital were asked to complete a questionnaire enquiring about understanding of the term cachexia, routine assessment of commonly associated symptoms and approaches to management of three commonly associated symptoms (poor appetite, early satiety and dry mouth). MAIN RESULTS: One hundred seventeen questionnaires were distributed with 100 returned (86% response rate). Cachexia was most frequently described as weight loss (79%) and anorexia (49%). Some symptoms (including altered appetite, constipation, nausea and vomiting) were routinely assessed during admission or review of these patients. Some common symptoms (including mouth problems, early satiety) were much less likely to be enquired about. Management of the three key symptoms demonstrated a range of approaches with little consistency. Early satiety was particularly poorly managed, with 29% of staff being unable to recognise or treat it. CONCLUSIONS: The study highlights the variable understanding of ACS and the lack of standardised assessment and management tools amongst staff in an acute hospital setting. This is likely to lead to inconsistent, and perhaps inadequate, care of patients with palliative care needs. Greater awareness and basic pathways of care may help to improve the experience of ACS for patients with cancer.

Quantifying the impact of standardized assessment and symptom management tools on symptoms associated with cancer-induced anorexia cachexia syndrome.

The objective of this study was to quantify the impact of standardized assessment and management tools on patient symptom scores in cancer-induced anorexia cachexia syndrome (ACS) using a within-group study design. Baseline assessments included the Patient Generated Subjective Global Assessment (PG-SGA) tool and an amended Symptoms and Concerns Checklist (SCC). Symptom management strategies, written for this project, were instigated. Follow-up SCC scores were collected at 2 and 4 weeks. Forty out of 79 patients referred were recruited; 29/79 (36.7%) were too unwell or had died prior to consent. At baseline, the PG-SGA tool revealed 250 active symptoms associated with ACS. Total PG-SGA score was above 9 for all patients. Predominant interventions involved simple dietary advice and prescription of artificial saliva, mouthwash and prokinetic antiemetics. Median total SCC score improved sequentially from 11 at baseline, to 7 and 4 at first and second review, respectively (visit 1 to 2, p = 0.001; visit 1 to 3, p < 0.001; and visit 2 to 3, p = 0.02). We conclude that patients with ACS are recognised late in their disease and have a considerable burden of active symptoms. A structured approach to assessment and management has a significant impact on symptom burden.

Efficacy of intracameral and subconjunctival cefuroxime in preventing endophthalmitis after cataract surgery.

PURPOSE: To compare the efficacy of intracameral cefuroxime versus subconjunctival cefuroxime in reducing the rate of endophthalmitis after cataract surgery. SETTING: Single-specialty eye hospital, Sunderland, United Kingdom. METHODS: A retrospective analysis of all presumed infectious endophthalmitis cases from January 1,2000, to December 31,2006 was performed. The rate of presumed infectious endophthalmitis in patients receiving subconjunctival cefuroxime was compared with those receiving intracameral cefuroxime at the end of surgery. RESULTS: This study included 36743 phacoemulsification cataract procedures. The mean rate of presumed infectious endophthalmitis was 0.95 per 1000 cases. The incidence of endophthalmitis was higher in the subconjunctival cefuroxime group than in the intracameral cefuroxime group; the difference was statistically significant with an odds ratio of 3.01 (95% confidence interval, 1.37-6.63). CONCLUSION: Intracameral cefuroxime was a safe alternative to subconjunctival cefuroxime and led to a lower rate of endophthalmitis.

Refractive change following pseudophakic vitrectomy.

BACKGROUND: To assess the occurrence and magnitude of refractive change in pseudophakic eyes undergoing 20 gauge pars plana vitrectomy without scleral buckling and to investigate possible aetiological factors. METHODS: Retrospective case note review of 87 pseudophakic eyes undergoing 20 gauge pars plana vitrectomy for a variety of vitreo-retinal conditions over a three-year period. Anterior chamber depth (ACD) was measured before and after vitrectomy surgery in 32 eyes. Forty-three pseudophakic fellow eyes were used as controls. RESULTS: Eighty-seven eyes (84 patients) were included in the study. Mean spherical equivalent refraction prior to vitrectomy was -0.20 dioptres, which changed to a mean of -0.65 dioptres postoperatively (standard deviation of refractive change 0.59, range-2.13 to 0.75 dioptres) (p < 0.001). Sixty-one of the 87(70%) eyes experienced a myopic shift and 45(52%) eyes had a myopic shift of -0.5 dioptres or more. Mean fellow eye refraction was -0.19 dioptres preoperatively and -0.17 dioptres postoperatively (p = 0.14)(n = 37)Mean ACD preoperatively was 3.29 mm and postoperatively 3.27 mm (p = 0.53) (n = 32) and there was no significant change in ACD with tamponade use. Regression analysis revealed no statistically significant association between changes in anterior chamber depth, as well as a wide variety of other pre-, intra and postoperative factors examined, and the refractive change observed. CONCLUSION: Significant refractive changes occur in some pseudophakic patients undergoing 20 g pars plana vitrectomy. The mean change observed was a small myopic shift but the range was large. The aetiology of the refractive change is uncertain.

Assessment of stereoscopic optic disc images using an autostereoscopic screen - experimental study.

BACKGROUND: Stereoscopic assessment of the optic disc morphology is an important part of the care of patients with glaucoma. The aim of this study was to assess stereoviewing of stereoscopic optic disc images using an example of the new technology of autostereoscopic screens compared to the liquid shutter goggles. METHODS: Independent assessment of glaucomatous disc characteristics and measurement of optic disc and cup parameters whilst using either an autostereoscopic screen or liquid crystal shutter goggles synchronized with a view switching display. The main outcome measures were inter-modality agreements between the two used modalities as evaluated by the weighted kappa test and Bland Altman plots. RESULTS: Inter-modality agreement for measuring optic disc parameters was good [Average kappa coefficient for vertical Cup/Disc ratio was 0.78 (95% CI 0.62-0.91) and 0.81 (95% CI 0.6-0.92) for observer 1 and 2 respectively]. Agreement between modalities for assessing optic disc characteristics for glaucoma on a five-point scale was very good with a kappa value of 0.97. CONCLUSION: This study compared two different methods of stereo viewing. The results of assessment of the different optic disc and cup parameters were comparable using an example of the newly developing autostereoscopic display technologies as compared to the shutter goggles system used. The Inter-modality agreement was high. This new technology carries potential clinical usability benefits in different areas of ophthalmic practice.

Towards a Formative Assessment of Classroom Competencies (FACCs) for postgraduate medical trainees.

BACKGROUND: An assumption of clinical competency is no longer acceptable or feasible in routine clinical practice. We sought to determine the feasibility, practicability and efficacy of undertaking a formal assessment of clinical competency for all postgraduate medical trainees in a large NHS foundation trust. METHODS: FY1 doctors were asked to complete a questionnaire to determine prior experience and self reported confidence in performing the GMC core competencies. From this a consensus panel of key partners considered and developed an 8 station Objective Structured Clinical Examination (OSCE) circuit to assess clinical competencies in all training grade medical staff... The OSCE was then administered to all training grade doctors as part of their NHS trust induction process. RESULTS: 106 (87.6% of all trainees) participated in the assessment during the first 14 days of appointment. Candidates achieved high median raw percentage scores for the majority of stations however analysis of pre defined critical errors and omissions identified important areas for concern. Performance of newly qualified FY1 doctor was significantly better than other grades for the arterial blood gas estimation and nasogastric tube insertion stations. DISCUSSION: Delivering a formal classroom assessment of clinical competencies to all trainees as part of the induction process was both feasible and useful. The assessment identified areas of concern for future training and also served to reassure as to the proficiency of trainees in undertaking the majority of core competencies.

Glucose-potassium-insulin infusions in the management of post-stroke hyperglycaemia: the UK Glucose Insulin in Stroke Trial (GIST-UK).

BACKGROUND: Hyperglycaemia after acute stroke is a common finding that has been associated with an increased risk of death. We sought to determine whether treatment with glucose-potassium-insulin (GKI) infusions to maintain euglycaemia immediately after the acute event reduces death at 90 days. METHODS: Patients presenting within 24 h of stroke onset and with admission plasma glucose concentration between 6.0-17.0 mmol/L were randomly assigned to receive variable-dose-insulin GKI (intervention) or saline (control) as a continuous intravenous infusion for 24 h. The purpose of GKI infusion was to maintain capillary glucose at 4-7 mmol/L, with no glucose intervention in the control group. The primary outcome was death at 90 days, and the secondary endpoint was avoidance of death or severe disability at 90 days. Additional planned analyses were done to determine any differences in residual disability or neurological and functional recovery. The trial was powered to detect a mortality difference of 6% (sample size 2355), with 83% power, at the 5% two-sided significance level. This study is registered as an International Standard Randomised Controlled Trial (number ISRCTN 31118803) FINDINGS: The trial was stopped due to slow enrolment after 933 patients were recruited. For the intention-to-treat data, there was no significant reduction in mortality at 90 days (GKI vs control: odds ratio 1.14, 95% CI 0.86-1.51, p=0.37). There were no significant differences for secondary outcomes. In the GKI group, overall mean plasma glucose and mean systolic blood pressure were significantly lower than in the control group (mean difference in glucose 0.57 mmol/L, p<0.001; mean difference in blood pressure 9.0 mmHg, p<0.0001). INTERPRETATION: GKI infusions significantly reduced plasma glucose concentrations and blood pressure. Treatment within the trial protocol was not associated with significant clinical benefit, although the study was underpowered and alternative results cannot be excluded.

Prevalence and pattern of perceived intelligibility changes in Parkinson's disease.

BACKGROUND: Changes to spoken communication are inevitable in Parkinson's disease (PD). It remains unclear what consequences changes have for intelligibility of speech. AIMS: To establish the prevalence of impaired speech intelligibility in people with PD and the relationship of intelligibility decline to indicators of disease progression. METHODS: 125 speakers with PD and age matched unaffected controls completed a diagnostic intelligibility test and described how to carry out a common daily activity in an "off drug" state. Listeners unfamiliar with dysarthric speech evaluated responses. RESULTS: 69.6% (n = 87) of people with PD fell below the control mean of unaffected speakers (n = 40), 51.2% (n = 64) by more than -1 SD below. 48% (n = 60) were perceived as worse than the lowest unaffected speaker for how disordered speech sounded. 38% (n = 47) placed speech changes among their top four concerns regarding their PD. Intelligibility level did not correlate significantly with age or disease duration and only weakly with stage and severity of PD. There were no significant differences between participants with tremor dominant versus postural instability/gait disorder motor phenotypes of PD. CONCLUSIONS: Speech intelligibility is significantly reduced in PD; it can be among the main concerns of people with PD, but it is not dependent on disease severity, duration or motor phenotype. Patients' own perceptions of the extent of change do not necessarily reflect objective measures.

Randomised controlled trial comparing three methods of presenting risk of Down's syndrome.

OBJECTIVE: To compare three simple methods of presenting information to patients about the risk of Down's syndrome. STUDY DESIGN: Randomised controlled trial of 150 " low risk" women booking for antenatal care before 19 weeks gestation at Sunderland Royal Hospital. After informing the women about the purpose of the study and reassuring them that they were "low risk", each patient was given a questionnaire, which used one of three different methods (graphic, written and interactive) to present information about the risk of Down's syndrome. A visual analogue scale allowed us to assess their level of understanding and anxiety before and after the information about risk was given to them. RESULTS: All three methods significantly altered patients' perception and anxiety about the risk of Down's syndrome. The interactive method was found to be the most effective of the three. CONCLUSION: This pilot study suggests that discussing the patients' worries about fetal anomalies with medical staff can markedly reduce their degree of anxiety. The interactive method was most effective at putting information across to the patient. It significantly reduced their level of anxiety as well as their overall worry about pregnancy.

Measuring edema in irradiated head and neck cancer patients.

OBJECTIVES: Edema is a common side effect of radiotherapy for head and neck cancer. Systems have been developed to record and monitor changes that occur after radiotherapy. These lack the sensitivity to record edema in specific laryngo-pharyngeal structures. The aim of this study was to develop a rating scale to measure edema in the larynx and pharynx. METHODS: This was an exploratory study to develop a new measure, with the help of an expert panel, assessing interrater and intrarater reliability. A consensus group developed the rating scale. Eleven structures and 2 spaces were identified as areas sensitive to the development of edema. The terms no, mild, moderate, and severe were used to describe the degrees of edema. The scale was piloted and then tested for interrater and intrarater reliability on 5 speech and language therapists. They viewed 25 nasendolaryngoscopic images (23 patients who had had radiotherapy and 2 healthy volunteers). The images were rated with the scale. This process was repeated 1 week later. RESULTS: Images were taken from patients with oral, oropharyngeal, nasopharyngeal, or laryngeal cancer. All had had radiotherapy or chemoradiotherapy. All raters were experienced in viewing larynges via nasendolaryngoscopy. The interrater reliability for scoring the edema rating scale was moderate (weighted kappa, 0.54). Lower levels of agreement were found for the tongue base, valleculae, pharyngeal walls, and anterior commissure. The intrarater reliability was very good (weighted kappa, 0.84). CONCLUSIONS: The edema rating scale can be scored with very good test-retest reproducibility and moderate levels of agreement between clinicians. Modifications to the method are suggested to increase interrater reliability.

Migrants and HIV stigma: findings from the Stigma Index Study (UK).

This paper is based on data collected in 2009 for the international Stigma Index Study which measured the experiences of stigma among participants living with HIV in the UK. Data were collected using a self-completed survey questionnaire and focus group discussions. Quantitative data were analysed using SPSS, while qualitative data were subjected to thematic analysis. The Stigma Index attempts to establish a baseline for documenting the experience of stigma and discrimination by people living with HIV while also acting as an advocacy tool whose power lay in the involvement of people living with HIV in the design of study instruments and data collection. Participants were recruited through collaborations with a broad range of UK HIV support organisations. The ethics protocols used were those described in the Stigma Index guidebook. A total of 867 people living with HIV took part, of whom 276 described themselves as 'immigrants'. Most of this 'migrant' subsample (70%) was women. Nearly, all (91%) identified as heterosexual, while 9% were attracted to someone of the same sex as them. Socioeconomic deprivation was a key theme and they reported other stigmatised chronic conditions in addition to HIV. It is not possible to ascertain from the questionnaire, the migrants' countries of origin and length of stay in the UK. Control of information about HIV was critically managed, with respect to family and partners. Felt stigma increased anxieties about personal safety, particularly among men. Strategies for safeguarding against the negative impact of stigma included avoiding social gatherings, intimacy, and clinical and HIV social care settings. Most participants were unaware of policies and declarations that protected them as persons living with HIV. Specific recommendations include creating awareness about rights as enshrined in various legal frameworks that protect the right of people living with HIV, which has been reconfigured as a 'disability'.

Recovery of visual and functional disability following cataract surgery in older people: Sunderland Cataract Study.

PURPOSE: To examine changes in visual, psychological, and functional disability in older people waiting for cataract extraction and 6 months after surgery. SETTING: Community-based study in Northeast England. METHODS: Participants were 92 patients (mean age 78.1 years +/- 6.5 [SD], 79% female) with age-related cataract. Questionnaires were administered at time of listing for cataract extraction, 2 weeks preoperatively, and 2 and 6 months after surgery to assess visual symptoms and function, anxiety and depression, perceived health status, cognition, and activities of daily living. RESULTS: Mean waiting time was 265 +/- 64.4 days. Forty-six patients had first-eye surgery, 39 had second-eye surgery, and 7 had sequential-eye surgery (both eyes operated on during follow-up). During the waiting period, there were no significant changes in visual symptoms, cognition, or functional abilities. However, perceived health status, anxiety, and depression improved significantly during this time. For first- and second-eye patients, surgery resulted in significant improvements in all questionnaire scores, except activities of daily living. CONCLUSIONS: Despite waiting 9 months for cataract surgery, patients did not decline in visual symptoms, social functioning, or cognition. In first- and second-eye patients, successful cataract extraction resulted in significant gains in visual function, cognition, and emotional and general well-being. The benefits of cataract surgery in older people extended beyond simple measures of visual acuity.

Poststroke hyperglycemia: natural history and immediate management.

BACKGROUND AND PURPOSE: Poststroke hyperglycemia (PSH) is a frequent finding for which there is currently no evidence to justify routine treatment. The United Kingdom Glucose Insulin in Stroke Trial (GIST-UK) is the only trial of glucose modulation in acute stroke from which evidence can be derived for the immediate management of PSH. Using safety-monitoring data from the trial we aimed to describe the immediate recovery of PSH in treated and control patients, thus providing evidence for the use of glucose/potassium/insulin (GKI) infusions as a means of maintaining euglycemia. METHODS: GIST-UK is a multicenter randomized controlled trial of GKI or saline infusions in acute stroke patients presenting with mild to moderate hyperglycemia (admission plasma glucose, 6.0 to 17 mmol). We analyzed the capillary BM and plasma glucose values in the 2 treatment groups to describe the recovery of PSH and the effectiveness of the GIST treatment regimen in maintaining euglycemia. RESULTS: The majority of patients have only moderate PSH (mean plasma glucose, 8.37+/-SD 2.13). Without specific intervention, mean plasma glucose levels decline spontaneously. Treatment with the GIST GKI regimen rapidly achieved euglycemia at significantly lower levels than with saline hydration alone. Euglycemia was achieved with a median of 2 changes to the GKI regimen and a low risk of hypoglycemia. CONCLUSIONS: GKI infusions as described in the GIST trial are a safe and effective means of correcting PSH and maintaining euglycemia in the acute phase of stroke. The clinical benefits of routine management of hyperglycemia remain to be determined.

Investigation into postoperative endophthalmitis and lessons learned.

PURPOSE: To describe an approach to the investigation of a series of endophthalmitis cases to determine whether there was a true outbreak. SETTING: Outpatient facility, Sunderland, England. METHODS: Different approaches to statistical analysis of the probability of infrequent events being due to chance occurrence are described. Potential factors leading to an outbreak were reviewed. RESULTS: Bayesian statistical analysis was shown to be appropriate in the determination of an endophthalmitis outbreak. The only factor found to account for the outbreak was the operating surgeon's recent abandonment of subconjunctival antibiotic prophylaxis. This decision was based on the absence of good evidence that subconjunctival antibiotic injection is effective in prophylaxis. These endophthalmitis cases demonstrate that the absence of evidence for effect is not the same as there being no effect. CONCLUSIONS: Bayesian statistical analysis has a place in determining whether an outbreak has occurred. Withdrawing treatment simply on the basis of a lack of good evidence can lead to undesirable outcomes.

Comparative study of first-day postoperative cataract review methods.

PURPOSE: To assess whether telephone review on the first day after uneventful phacoemulsification is as effective as postoperative review in a hospital or the patients' home by nursing staff. SETTING: Sunderland Eye Infirmary, Sunderland, United Kingdom. METHOD: This prospective study comprised 3 arms, each of which consisted of 100 patients who had uneventful phacoemulsification with intraocular lens implantation. Patients received the same postoperative medications and were given a questionnaire regarding their opinions on the method of postoperative review. The method of review was different for each arm as follows: (1) home review by a nurse, (2) return to the hospital for review by a nurse, and (3) telephone review by a nurse. Statistical analysis of relative frequencies was done; exact testing was applied throughout to test for differences in proportions and, where applicable, to construct 95% confidence intervals. RESULTS: There were no significant differences between the 3 groups in the degree to which patients understood the instructions and questions. The telephone group was significantly less reassured than the home-visit group, but there was no significant difference in the degree of reassurance between the telephone and hospital-visit groups. Seventy percent of patients in the telephone group listed telephone review as their preferred method of postoperative review. CONCLUSION: In cases of uneventful phacoemulsification, telephone review is safe, effective, and acceptable and is a reasonable alternative to other first-day review methods.

Swallowing in the first year after chemoradiotherapy for head and neck cancer: clinician- and patient-reported outcomes.

BACKGROUND: This prospective study evaluated swallowing outcomes prechemoradiotherapy (pre-CRT) up to 1 year post-CRT, in a substantial cohort of patients with head and neck cancer and explored factors predicting outcome. METHODS: One hundred twelve patients were assessed pretreatment and at 3, 6, and 12 months posttreatment using a questionnaire, endoscopic assessment, water swallow test, and diet score. RESULTS: Seventy-one patients were retained, the majority had oropharyngeal (53%) or hypopharyngeal cancer (20%). A marked deterioration occurred between pretreatment and 3 months posttreatment (p ≤ .01). Significant improvement between 3 and 12 months was found on 2 swallowing measures, but not self reported. Three of the 4 pretreatment assessments predicted outcomes at 1 year. CONCLUSION: CRT results in a marked deterioration on different paradigms of swallowing measurements. Improvement occurs on some clinical measures, but limited change is observed in patients' perceptions. Pretreatment measures are important indicators of long-term dysphagia. Swallowing recovery is complex, taking different courses between clinical tests and perspectives.

Long term survival of patients with raised pulmonary arterial systolic pressure utilizing echocardiography-a five-year prospective study.

BACKGROUND: Pulmonary arterial systolic pressure (PASP) can be estimated with transthoracic echocardiography. However, the significance of raised PASP on routine echocardiography is uncertain. In this study, we evaluated the mortality and hospitalization rates of subjects with raised PASP in a cohort of patients referred directly by their general practitioners for routine outpatient (open access) echocardiography for further analysis of suspected heart failure. RESULTS: A total of 485 subjects were referred for open access echocardiography at our hospital in 2002. A cohort of 209/485 (43%) consecutive subjects with measurable tricuspid regurgitation were followed for a minimum of five years investigating hospitalization rates and survival. Some 62 of 209 (30%) subjects had pulmonary hypertension (PH). Subjects with PH were significantly more likely to have four or more hospital admissions (22% vs. 8%; P < 0.01) and > 30 days of cumulative hospital stay over five years (29% vs. 13%; P < 0.01). PH was significantly associated with mortality (P = 0.003), while moderate to severe PH was an independent predictor of mortality (hazard ratio: 4.31; 95% confidence interval (95% CI): 1.51-12.30). Records from the Office of National Statistics revealed that subjects with PH were more likely to have chronic lung diseases recorded as immediate or contributory causes of death (50% vs. 14%; P < 0.05). CONCLUSIONS: PASP ≥ 36 mmHg on routine echocardiography is associated with recurrent hospital admissions, prolonged hospitalizations and increased cause of mortality. Therefore, the diagnosis of PH on echocardiography deserves further clinical evaluation, with future studies designed at defining a suitable diagnostic strategy.