Publications by authors named "Jonathan Robin"

16 Publications

  • Page 1 of 1

Association of risk of malnutrition with adverse outcomes and early support on discharge in acute stroke patients without prestroke disability: A multicenter, registry-based cohort study.

Nutr Clin Pract 2021 Oct 19. Epub 2021 Oct 19.

Institute of Cardiovascular Research, Royal Holloway University of London, Egham, UK.

Background: Malnutrition in hospitals remains highly prevalent. As part of quality improvement initiatives, the Royal College of Physicians recommends nutrition screening for all patients admitted with acute stroke. We aimed to examine the associations of patients at risk of malnutrition with poststroke outcomes.

Methods: We analyzed prospectively collected data from four hyperacute stroke units (HASUs) (2014-2016). Nutrition status was screened in 2962 acute stroke patients without prestroke disability (1515 men, [mean ± SD] 73.5 years ± 13.1; 1447 women, 79.2 ± 13.0 years). The risk of malnutrition was tested against stroke outcomes and adjusted for age, sex, and comorbidities.

Results: Risk of malnutrition was identified in 25.8% of patients). Compared with well-nourished patients, those at risk of malnutrition had, within 7 days of admission, increased risk of stay on the HASU of >14 days (odds ratio [OR]: 9.9 [7.3-11.5]), disability on discharge (OR: 8.1 [6.6-10.0]), worst level of consciousness in the first 7 days (score ≥ 1) (OR: 7.5 [6.1-9.3]), mortality (OR: 5.2 [4.0-6.6], pneumonia (OR: 5.1 [3.9-6.7]), and urinary tract infection (OR: 1.5 [1.1-2.0]). They also required palliative care (OR: 12.3 [8.5-17.8]), discharge to new care home (OR: 3.07 [2.18-4.3]), activities of daily living support (OR: 1.8 [1.5-2.3]), planned joint care (OR: 1.5 [1.2-1.8]), and weekly visits (OR: 1.4 [1.1-1.8]).

Conclusion: Patients at risk of malnutrition more commonly have multiple adverse outcomes after acute stroke and greater need for early support on discharge.
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http://dx.doi.org/10.1002/ncp.10790DOI Listing
October 2021

Comparison of characteristics and outcomes of patients admitted to hospital with COVID-19 during wave 1 and wave 2 of the current pandemic.

Intern Emerg Med 2021 Oct 12. Epub 2021 Oct 12.

Department of Endocrinology, Ashford and St Peter's Hospitals NHS Foundation Trust, Guildford Road, Chertsey, Surrey, KT16 0PZ, UK.

In this study of patients admitted with COVID-19, we examined differences between the two waves in patient characteristics and outcomes. Data were collected from the first COVID-19 admission to the end of study (01/03/2020-31/03/2021). Data were adjusted for age and sex and presented as odds ratios (OR) with 95% confidence intervals (CI). Among 12,471 admissions, 1452 (11.6%) patients were diagnosed with COVID-19. On admission, the mean (± SD) age of patients with other causes was 68.3 years (± 19.8) and those with COVID-19 in wave 1 was 69.4 years (± 18.0) and wave 2 was 66.2 years (± 18.4). Corresponding ages at discharge were 67.5 years (± 19.7), 63.9 years (± 18.0) and 62.4 years (± 18.0). The highest proportion of total admissions was among the oldest group (≥ 80 years) in wave 1 (35.0%). When compared with patients admitted with other causes, those admitted with COVID-19 in wave 1 and in wave 2 were more frequent in the 40-59 year band: 20.8, 24.6 and 30.0%; consisted of more male patients: 47.5, 57.6 and 58.8%; and a high LACE (Length of stay, Acuity of admission, Comorbidity and Emergency department visits) index (score ≥ 10): 39.4, 61.3 and 50.3%. Compared to wave-2 patients, those admitted in wave 1 had greater risk of death in hospital: OR = 1.58 (1.18-2.12) and within 30 days of discharge: OR = 2.91 (1.40-6.04). Survivors of COVID-19 in wave 1 stayed longer in hospital (median = 6.5 days; interquartile range = 2.9-12.0) as compared to survivors from wave 2 (4.5 days; interquartile range = 1.9-8.7). Patient characteristics differed significantly between the two waves of COVID-19 pandemic. There was an improvement in outcomes in wave 2, including shorter length of stay in hospital and reduction of mortality.
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http://dx.doi.org/10.1007/s11739-021-02842-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8505475PMC
October 2021

Changes in Characteristics and Outcomes of Patients Undergoing Surgery for Hip Fractures Following the Initiation of Orthogeriatric Service: Temporal Trend Analysis.

Calcif Tissue Int 2021 Aug 27. Epub 2021 Aug 27.

Institute of Cardiovascular Research, Royal Holloway, University of London, Egham, TW20 0EX, Surrey, UK.

The Blue Book published by the British Orthopaedic Association and British Geriatrics Society, together with the introduction of National Hip Fracture Database Audit and Best Practice Tariff, have been influential in improving hip fracture care. We examined ten-year (2009-2019) changes in hip fracture outcomes after establishing an orthogeriatric service based on these initiatives, in 1081 men and 2891 women (mean age = 83.5 ± 9.1 years). Temporal trends in the annual percentage change (APC) of outcomes were identified using the Joinpoint Regression Program v4.7.0.0. The proportions of patients operated beyond 36 h of admission fell sharply during the first two years: APC =  - 53.7% (95% CI - 68.3, - 5.2, P = 0.003), followed by a small rise thereafter: APC = 5.8% (95% CI 0.5, 11.3, P = 0.036). Hip surgery increased progressively in patients > 90 years old: APC = 3.3 (95% CI 1.0, 5.8, P = 0.011) and those with American Society of Anaesthesiologists grade ≥ 3: APC = 12.4 (95% CI 8.8, 16.1, P < 0.001). There was a significant decline in pressure ulcers amongst patients < 90 years old: APC =  - 17.9 (95% CI - 32.7, 0.0, P = 0.050) and also a significant decline in mortality amongst those > 90 years old: APC =  - 7.1 (95% CI - 12.6, - 1.3, P = 0.024). Prolonged length of stay (> 23 days) declined from 2013: APC =  - 24.6% (95% CI - 31.2, - 17.4, P < 0.001). New discharge to nursing care declined moderately over 2009-2016 (APC =  - 10.6, 95% CI - 17.2, - 2.7, P = 0.017) and sharply thereafter (APC =  - 47.5%, 95%CI - 71.7, - 2.7, P = 0.043). The rate of patients returning home was decreasing (APC =  - 2.9, 95% CI - 5.1, - 0.7, P = 0.016), whilst new discharge to rehabilitation was increasing (APC = 8.4, 95% CI 4.0, 13.0; P = 0.002). In conclusion, the establishment of an orthogeriatric service was associated with a reduction of elapsed time to hip surgery, a progressive increase in surgery carried out on high-risk adults and a decline in adverse outcomes.
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http://dx.doi.org/10.1007/s00223-021-00906-4DOI Listing
August 2021

Adverse consequences of immediate thrombolysis-related complications: a multi-centre registry-based cohort study of acute stroke.

J Thromb Thrombolysis 2021 Jul 13. Epub 2021 Jul 13.

Institute of Cardiovascular Research, Royal Holloway University of London, Egham, TW20 0EX, UK.

Complications following thrombolysis for stroke are well documented, and mostly concentrated on haemorrhage. However, the consequences of patients who experience any immediate thrombolysis-related complications (TRC) compared to patients without immediate TRC have not been examined. Prospectively collected data from the Sentinel Stroke National Audit Programme were analysed. Thrombolysis was performed in 451 patients (52.1% men; 75.3 years ± 13.2) admitted with acute ischaemic stroke (AIS) in four UK centres between 2014 and 2016. Adverse consequences following immediate TRC were assessed using logistic regression, adjusted for age, sex and co-morbidities. Twenty-nine patients (6.4%) acquired immediate TRC. Compared to patients without, individuals with immediate TRC had greater adjusted risks of: moderately-severe or severe stroke (National Institutes of Health for Stroke Scale score ≥ 16) at 24-h (5.7% vs 24.7%, OR 3.9, 95% CI 1.4-11.1); worst level of consciousness (LOC) in the first 7 days (score ≥ 1; 25.0 vs 60.7, OR 4.6, 95% CI 2.1-10.2); urinary tract infection or pneumonia within 7-days of admission (13.5% vs 39.3%, OR 3.2, 95% CI 1.3-7.7); length of stay (LOS) on hyperacute stroke unit (HASU) ≥ 2 weeks (34.7% vs 66.7%, OR 5.2, 95% CI 1.5-18.4); mortality (13.0% vs 41.4%, OR 3.7, 95% CI 1.6-8.4); moderately-severe or severe disability (modified Rankin Scale  score ≥ 4) at discharge (26.8% vs 65.5%, OR 4.7, 95% CI 2.1-10.9); palliative care by discharge date (5.1% vs 24.1%, OR 5.1, 95% CI 1.7-15.7). The median LOS on the HASU was longer (7 days vs 30 days, Kruskal-Wallis test: χ = 8.9, p = 0.003) while stroke severity did not improve (NIHSS score at 24-h post-thrombolysis minus NIHSS score at arrival = - 4 vs 0, χ = 24.3, p < 0.001). In conclusion, the risk of nosocomial infections, worsening of stroke severity, longer HASU stay, disability and death is increased following immediate TRC. The management of patients following immediate TRC is more complex than previously thought and such complexity needs to be considered when planning an increased thrombolysis service.
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http://dx.doi.org/10.1007/s11239-021-02523-2DOI Listing
July 2021

SARS-CoV-2 antibody seroprevalence in NHS healthcare workers in a large double-sited UK hospital.

Clin Med (Lond) 2021 05 23;21(3):e290-e294. Epub 2021 Mar 23.

Institute of Cardiovascular Research, Royal Holloway University of London, and consultant neurologist, Imperial College Healthcare NHS Trust, London, UK

We determined the seroprevalence of SARS-CoV-2 antibodies in NHS healthcare workers (HCWs) in a cross-sectional study from a large general hospital located in a double-sited rural and semi-rural area. The sample size of 3,119 HCWs (mean age 43±13) consisted of 75.2% women, 61.1% White individuals and predominantly (62.4%) asymptomatic individuals. Seroprevalence of SARS-CoV-2 antibodies was 19.7%. Determinants of seropositivity were preceding symptomatic infection and non-White ethnicity. Regardless of staff role or sex, multivariate regression analysis revealed that non-White HCWs were three times (odds ratio [OR] 3.12, 95% confidence interval [CI] 2.53-3.86, P<0.001) more likely to have antibodies than White staff, and seven times (OR 7.10, 95% CI 5.72-8.87, P<0.001) more likely if there was a history of preceding symptoms. We report relatively high rates of seropositivity in all NHS healthcare workers. Non-White symptomatic HCWs were significantly more likely to be seropositive than their colleagues, independent of age, sex or staff role.
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http://dx.doi.org/10.7861/clinmed.2020-1096DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8140688PMC
May 2021

Early emergency readmission frequency as an indicator of short-, medium- and long-term mortality post-discharge from hospital.

Intern Emerg Med 2021 09 26;16(6):1497-1505. Epub 2020 Dec 26.

Department of Endocrinology, Ashford and St Peter's Hospitals NHS Foundation Trust, Guildford Road, Chertsey, Surrey, KT16 0PZ, UK.

Frequent emergency readmissions, an indicator of quality of care, has been rising in England but the underlying reasons remain unclear. We examined the association of early readmissions with subsequent mortality in adults, taking into account the underlying presenting diagnoses and hospital length of stay (LOS). Data of alive-discharge episodes were prospectively collected between 01/04/2017 and 31/03/2019 in an National Health Service hospital, comprising 32,270 patients (46.1% men) aged 18-107 years (mean = 64.0, ± SD = 20.5 years). The associations of readmission frequency within 28 days of discharge and mortality within 30 days and 6 months of hospital discharge, and over a 2-year period were evaluated, adjusted for presenting diagnoses, LOS, age and sex during the first admission. Analysis of all patients 18-107 years (reference: no readmission) showed mortality within 30 days was increased for 1 readmission: event rate = 9.2%, odds ratio (OR) = 3.4 (95% confidence interval (CI) = 2.9-4.0), and ≥ 2 readmissions: event rate = 10.0%, OR = 2.6 (95%CI = 2.0-3.3), and within 6 months for 1 readmission: event rate = 19.6%, OR = 3.0 (95%CI = 2.7-3.4), and ≥ 2 readmissions: event rate = 27.4%, OR = 3.4 (95%CI = 2.9-4.0), and over a 2-year period for 1 readmission: event rate = 25.5%, hazard ratio = 2.2 (95%CI = 2.0-2.4), and ≥ 2 readmissions: event rate = 36.1%, hazard ratio = 2.5 (95%CI = 2.2-2.8). Within the age groups 18-49, 50-59, 60-69, 70-79 and ≥ 80 years, readmissions were also associated with increased risk of mortality within 3 months and 6 months of discharge, and over 2-year period. In conclusion, early hospital readmission predicts short-, medium- and long-term mortality post-discharge from hospital in adults aged 18-107 years, independent of underlying presenting conditions, LOS, age and sex. Further research focussing on safe discharge and follow-up patient care may help reduce preventable readmissions and post-discharge mortality.
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http://dx.doi.org/10.1007/s11739-020-02599-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8354916PMC
September 2021

Clinical outcomes in patients admitted to hospital with cervical spine fractures or with hip fractures.

Intern Emerg Med 2021 Aug 26;16(5):1207-1213. Epub 2020 Nov 26.

Institute of Cardiovascular Research, Royal Holloway, University of London, Egham, TW20 0EX, Surrey, UK.

Patients admitted with a cervical fracture are twice as likely to die within 30 days of injury than those with a hip fracture. However, guidelines for the management of cervical fractures are less available than for hip fractures. We hypothesise that outcomes may differ between these types of fractures. We analysed 1359 patients (406 men, 953 women) with mean age of 83.8 years (standard deviation = 8.7) admitted to a National Health Service hospital in 2013-2019 with a cervical (7.5%) or hip fracture (92.5%) of similar age. The association of cervical fracture (hip fracture as reference), hospital length of stay (LOS), co-morbidities, age and sex with outcomes (acute delirium, new pressure ulcer, and discharge to residential/nursing care) was assessed by stepwise multivariate logistic regression. Acute delirium without history of dementia was increased with cervical fractures: odds ratio (OR) = 2.4, 95% confidence interval (CI) = 1.3-4.7, age ≥ 80 years: OR = 3.5 (95% CI = 1.9-6.4), history of stroke: OR = 1.8 (95% CI = 1.0-3.1) and ischaemic heart disease: OR = 1.9 (95% CI = 1.1-3.6); pressure ulcers was increased with cervical fractures: OR = 10.9 (95% CI = 5.3-22.7), LOS of 2-3 weeks: OR = 3.0 (95% CI = 1.2-7.5) and LOS of ≥ 3 weeks: OR = 4.9, 95% CI = 2.2-11.0; and discharge to residential/nursing care was increased with cervical fractures: OR = 3.2 (95% CI = 1.4-7.0), LOS of ≥ 3 weeks: OR = 4.4 (95% CI = 2.5-7.6), dementia: OR = 2.7 (95% CI = 1.6-4.7), Parkinson's disease: OR = 3.4 (95% CI = 1.3-8.8), and age ≥ 80 years: OR = 2.7 (95% CI = 1.3-5.6). In conclusion, compared with hip fracture, cervical fracture is more likely to associate with acute delirium and pressure ulcers, and for discharge to residency of high level of care, independent of established risk factors.
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http://dx.doi.org/10.1007/s11739-020-02567-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8310478PMC
August 2021

COVID-19 outcomes in UK centre within highest health and wealth band: a prospective cohort study.

BMJ Open 2020 11 16;10(11):e042090. Epub 2020 Nov 16.

Institute of Cardiovascular Research, Royal Holloway University of London, Egham, UK

Objectives: To describe the characteristics and outcomes of hospitalised patients with COVID-19 from UK in the highest decile of health and gross regional products per capita.

Design: Prospective cohort study.

Setting: Recruited all adult inpatients with laboratory-confirmed COVID-19 symptoms admitted to a single Surrey centre between March and April 2020. Extensive demographic details were documented.

Outcome Measure: COVID-19 status of alive/dead and intensive care unit (ICU) status of yes/no.

Participants: Patients with COVID-19 from Surrey centre UK (n=429).

Results: 429 adult inpatients (mean age 70±18 years; men 56.4%) were included in this study, of whom, 19.1% required admission to ICU and 31.9% died. Adverse outcomes were associated with age (OR with each decade of years: 1.78, 95% CI 1.53 to 2.11, p<0.001 for mortality); male gender (OR=1.08, 95% CI 0.72 to 1.63, p=0.72, present in 70.7%, of admissions to ICU versus 53% of other cases, p=0.004); cardiac disease (OR=3.43, 95% CI 2.10 to 5.63, p<0.001), diabetes mellitus (OR=2.37, 95% CI 1.09 to 5.17, p=0.028) and dementia (OR=5.06, 95% CI 2.79 to 9.44, p<0.001). There was no significant impact of ethnicity or body mass index on disease outcome.

Conclusions: Despite reports of worse outcomes in deprived regions, we show similar complication and mortality rates due to COVID-19 in an affluent and high life expectancy region.
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http://dx.doi.org/10.1136/bmjopen-2020-042090DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7670555PMC
November 2020

LACE index predicts age-specific unplanned readmissions and mortality after hospital discharge.

Aging Clin Exp Res 2021 Apr 5;33(4):1041-1048. Epub 2020 Jun 5.

Department of Endocrinology, Ashford and St Peter's Hospitals NHS Foundation Trust, Guildford Road, Chertsey, KT16 0PZ, Surrey, UK.

Background: The LACE index scoring tool (Length of stay, Acuity of admission, Co-morbidities and Emergency department visits) has been designed to predict hospital readmissions. We evaluated the ability of the LACE index to predict age-specific frequent admissions and mortality.

Methods: Analysis of prospectively collected data of alive-discharge episodes between 01/04/2017 and 31/03/2019 in an NHS hospital. Data on 14,878 men and 17,392 women of mean age 64.0 years, SD = 20.5, range 18.0-106.7 years were analysed. The association of the LACE index with frequency of all-cause readmissions within 28 days of discharge and over a 2-year period, and with all-cause mortality within 30 days or within 6 months after discharge from hospital were evaluated.

Results: Within LACE index scores of 0-4, 5-9 or ≥ 10, the proportions of readmission ≥ 2 times within 28 days of discharge were 0.1, 1.3 and 9.2% (χ = 3070, p < 0.001) and over a 2-year period were 1.7, 4.8 and 19.1% (χ = 3364, p < 0.001). Compared with a LACE index score of 0-4, a score ≥ 10 increased the risk (adjusted for age, sex and frequency of admissions) of death within 6 months of discharge by 6.8-fold (5.1-9.0, p < 0.001) among all ages, and most strongly in youngest individuals (18.0-49.9 years): adjusted odds ratio = 16.1 (5.7-45.8, p < 0.001). For those aged 50-59.9, 60-69.9, 70-79.9 and ≥ 80 years, odds ratios reduced progressively to 9.6, 7.7, 5.1 and 2.3, respectively. Similar patterns were observed for the association of LACE index with mortality within 30 days of hospital discharge.

Conclusions: The LACE index predicts short-term and long-term frequent admissions and short-term and medium-term mortality, most pronounced among younger individuals, after hospital discharge.
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http://dx.doi.org/10.1007/s40520-020-01609-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8084827PMC
April 2021

Prestroke Disability Predicts Adverse Poststroke Outcome: A Registry-Based Prospective Cohort Study of Acute Stroke.

Stroke 2020 02 17;51(2):594-600. Epub 2019 Dec 17.

From the Institute of Cardiovascular Research, Royal Holloway University of London, Egham, United Kingdom (T.S.H., S.S., P.S.).

Background and Purpose- Information on what effect disability before stroke can have on stroke outcome is lacking. We assessed prestroke disability in relation to poststroke hospital outcome. Methods- Analysis of prospectively collected data from the Sentinel Stroke National Audit Programme. A total of 1656 men (mean age ±SD =73.1±13.2 years) and 1653 women (79.3±13.0 years) were admitted to hyperacute stroke units with acute stroke in 4 major UK between 2014 and 2016. Prestroke disability, assessed by modified Rankin Scale (mRS), was tested against poststroke adverse outcomes, adjusted for age, sex, and coexisting morbidities. Results- Compared with patients with prestroke mRS score =0, individuals with prestroke mRS scores =3, 4, or 5 had greater adjusted risks of moderately severe or severe stroke on arrival (4.4% versus 16.7%; odds ratio [OR], 3.2 [95% CI, 2.3-4.6] <0.001); urinary tract infection or pneumonia within 7 days of admission (9.6% versus 35.9%; OR, 3.7 [95% CI, 2.8-4.8] <0.001); mortality (7.2% versus 37.1%; OR, 4.9 [95% CI, 3.7-6.5] <0.001); requiring help with activities of daily living on discharge (12.3% versus 26.7%; OR, 3.1 [95% CI, 2.3-4.1] <0.001); and transferred to new care home (2.4% versus 9.4%; OR, 2.1 [95% CI, 1.3-3.3] =0.002). Patients with mRS scores =1 or 2 had intermediate risk of adverse outcomes. Overall, those with a mRS score =1 or 2 had length of stay on hyperacute stroke units extended by 5.3 days (95% CI, 2.8-7.7; <0.001) and mRS score =3, 4 or 5 by 7.2 days (95% CI, 4.0-10.5; <0.001). Conclusions- Individuals with evidence of prestroke disability, assessed by mRS, had significantly increased risk of poststroke adverse outcomes and longer length of stay on hyperacute stroke units and higher level of care on discharge.
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http://dx.doi.org/10.1161/STROKEAHA.119.027740DOI Listing
February 2020

Associations of 4AT with mobility, length of stay and mortality in hospital and discharge destination among patients admitted with hip fractures.

Age Ageing 2020 04;49(3):411-417

Institute of Cardiovascular Research, Royal Holloway, University of London, Surrey TW20 0EX, UK.

Background: the 4AT (Alertness, Abbreviated Mental Test-4, Attention and Acute change or fluctuating course), a tool to screen cognitive impairment and delirium, has recently been recommended by the Scottish Intercollegiate Guidelines Network. We examined its ability to predict health outcomes among patients admitted with hip fractures to a single hospital between January 2018 and June 2019.

Methods: the 4AT was performed within 1 day after hip surgery. A 4AT score of 0 means unlikely delirium or severe cognitive impairment (reference group); a score of 1-3 suggests possible chronic cognitive impairment, without excluding possibility of delirium; a score ≥ 4 suggests delirium with or without chronic cognitive impairment. Logistic regression, adjusted for: age; sex; nutritional status; co-morbidities; polypharmacy; and anticholinergic burden, used the 4AT to predict mobility, length of stay (LOS), mortality and discharge destination, compared with the reference group.

Results: from 537 (392 women, 145 men: mean = 83.7 ± standard deviation [SD] = 8.8 years) consecutive patients, 522 completed the 4AT; 132 (25%) had prolonged LOS (>2 weeks) and 36 (6.8%) died in hospital. Risk of failure to mobilise within 1 day of surgery was increased with a 4AT score ≥ 4 (OR = 2.4, 95% confidence interval [CI] = 1.3-4.3). Prolonged LOS was increased with 4AT scores of 1-3 (OR = 2.4, 95%CI = 1.4-4.1) or ≥4 (OR = 3.1, 95%CI = 1.9-6.7). In-patient mortality was increased with a 4AT score ≥ 4 (OR = 3.1, 95%CI = 1.2-8.2) but not with a 4AT score of 1-3. Change of residence on discharge was increased with a 4AT score ≥ 4 (OR = 3.1, 95%CI = 1.4-6.8). These associations persisted after excluding patients with dementia. 4AT score = 1-3 and ≥ 4 associated with increased LOS by 3 and 6 days, respectively.

Conclusions: for older adults with hip fracture, the 4AT independently predicts immobility, prolonged LOS, death in hospital and change in residence on discharge.
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http://dx.doi.org/10.1093/ageing/afz161DOI Listing
April 2020

High tibial osteotomy in knee laxities: Concepts review and results.

EFORT Open Rev 2016 Jan 13;1(1):3-11. Epub 2017 Mar 13.

Lyon 1 University, France.

Patients with unstable, malaligned knees often present a challenging management scenario, and careful attention must be paid to the clinical history and examination to determine the priorities of treatment.Isolated knee instability treated with ligament reconstruction and isolated knee malalignment treated with periarticular osteotomy have both been well studied in the past. More recently, the effects of high tibial osteotomy on knee instability have been studied.Lateral closing-wedge high tibial osteotomy tends to reduce the posterior tibial slope, which has a stabilising effect on anterior tibial instability that occurs with ACL deficiency.Medial opening-wedge high tibial osteotomy tends to increase the posterior tibia slope, which has a stabilising effect in posterior tibial instability that occurs with PCL deficiency.Overall results from recent studies indicate that there is a role for combined ligament reconstruction and periarticular knee osteotomy.The use of high tibial osteotomy has been able to extend the indication for ligament reconstruction which, when combined, may ultimately halt the evolution of arthritis and preserve their natural knee joint for a longer period of time. Cite this article: Robin JG, Neyret P. High tibial osteotomy in knee laxities: Concepts review and results. 2016;1:3-11. doi: 10.1302/2058-5241.1.000001.
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http://dx.doi.org/10.1302/2058-5241.1.000001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5367616PMC
January 2016

The role of patelloplasty in total knee arthroplasty.

Arch Orthop Trauma Surg 2016 Nov 29;136(11):1607-1613. Epub 2016 Sep 29.

Albert Trillat Center, Lyon North University Hospital, 103 Grande Rue de la Croix-Rousse, 69004, Lyon, France.

Introduction: Anterior knee pain (AKP) is a frequent complication after total knee arthroplasty (TKA). Patelloplasty, defined as reshaping the patella for optimal tracking in the trochlea, has been proposed to reduce the rate of this complication in patellar retaining implants. Aim of this study was to analyze the available literature regarding the outcomes of patelloplasty and to assess its methodological quality.

Materials And Methods: A comprehensive review of the English literature was performed using the keywords "total knee arthroplasty", "patelloplasty" and "patellaplasty" with no limit regarding the year of publication. All the selected articles were evaluated with the Coleman score.

Results: Seven full text articles were retrieved. The initial cohort included 461 knees in the study groups and 465 in the control groups. At an average FU of 70.6 months 447 knees were reviewed in the study group and 447 in the control groups. The global rate of AKP after patelloplasty was 11.3 % which compared to 7.9 % in the patella resurfacing control group. No signs of specific patellar complications due to patelloplasty were reported. Average Coleman score was 66.9.

Conclusion: Most of the literature has barely sufficient methodological quality. Patelloplasty aims at reducing patellar thickness and improve its tracking with TKA. This procedure is a safe and easy option with no reported adverse effects. In the included studies, outcome seemed to be superior in comparison with isolated osteophyte removal and denervation with a lower rate of AKP. The included studies, however, report a lower rate of AKP following TKA with patellar resurfacing. Patelloplasty may have the potential to improve the outcome of patellar retaining implants.

Level Of Evidence: 4, systematic review.
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http://dx.doi.org/10.1007/s00402-016-2577-7DOI Listing
November 2016

A classification system for hip disease in cerebral palsy.

Dev Med Child Neurol 2009 Mar 3;51(3):183-92. Epub 2008 Dec 3.

Murdoch Childrens Research Institute, The University of Melbourne, Department of Orthopaedic Surgery, The Royal Children's Hospital, Parkville, Victoria, Australia.

In population-based studies, hip displacement affects approximately one-third of children with cerebral palsy (CP). Given the extreme range of clinical phenotypes in the CP spectrum, it is unsurprising that hip development varies from normality, to dislocation and degenerative arthritis. Numerous radiological indices are available to measure hip displacement in children with CP; however, there is no grading system for assessing hip status in broad categorical terms. This makes it difficult to audit the incidence of hip displacement, determine the relationship between hip displacement and CP subtypes, assess the outcome of intervention studies, and to communicate hip status between health care professionals. We developed a categorical, radiographic classification of hip morphology based on qualitative indices and measurement of the key continuous variable, the migration percentage of Reimers. One hundred and thirty-four radiographs were reviewed of 52 female and 82 male adolescents with CP who were at, or close to, skeletal maturity (mean age 16y 1mo [SD 1y 4mo] range 14y to 19y 1mo). Twenty-nine were classified at Gross Motor Function Classification System level I, 25 at level II, 27 at level III, 24 at level IV, and 29 at level V. A classification system was developed to encapsulate the full spectrum of hip morphology in CP, with and without intervention.
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http://dx.doi.org/10.1111/j.1469-8749.2008.03129.xDOI Listing
March 2009

A systematic review of measures of activity limitation for children with cerebral palsy.

Dev Med Child Neurol 2008 Mar 12;50(3):190-8. Epub 2008 Jan 12.

University of Melbourne, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.

This systematic review critically appraises the literature on the psychometric properties and clinical utility of evaluative activity limitation outcome measures used for children with cerebral palsy (CP). The search strategy yielded 29 articles for eight outcome measures that met the inclusion criteria for the review. The Gross Motor Function Measure and Activities Scale for Kids were found to have sound psychometric properties in most areas. Reliability was found to be adequate for all tools. For the CP population, further examination of some aspects of validity is required for the Child Health Questionnaire (CHQ), Functional Assessment Questionnaire (FAQ), Functional Mobility Scale (FMS), Pediatric Evaluation of Disability Inventory, Pediatric Outcomes Data Collection Instrument (PODCI), and the Functional Independence Measure for Children. The FAQ, CHQ, FMS, and PODCI were found to require further examination for responsiveness. Clinical utility of the measures varied. The FMS was the only one to differentiate between function in the home, school, and community and to consider different assistive devices. These findings suggest that a range of measures is required to evaluate activity, and assessment should be tailored to the individual needs of children with CP.
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http://dx.doi.org/10.1111/j.1469-8749.2008.02027.xDOI Listing
March 2008

Protease-activated receptor 2-mediated vasodilatation in humans in vivo: role of nitric oxide and prostanoids.

Circulation 2003 Feb;107(7):954-9

Centre for Clinical Pharmacology & Therapeutics, University College London, London, UK.

Background: Systemic hypotension as a consequence of vascular dysfunction is a well-recognized and important feature of critical illness. Although serine protease activation has been implicated as a cause of vascular dysfunction in systemic inflammation, the mechanism is unknown. Recently, a class of receptors with an entirely novel mechanism of action, protease-activated receptors (PARs), has been identified that would explain the link between protease activation and systemic hypotension. Our aim was to test the hypothesis that in vivo activation of protease-activated receptor 2 (PAR-2) in humans would mediate vasodilatation.

Methods And Results: For these first-in-human studies, an activating peptide for the human PAR-2 receptor was synthesized and administered to healthy volunteers. Using both the dorsal hand vein technique and forearm plethysmography, we studied the effects of PAR-2 activation in human blood vessels and investigated the mechanism of vasodilation. Activation of PAR-2 receptors in vivo dilated human blood vessels in a dose-dependent manner, and the effects were reduced by inhibition of both nitric oxide and prostanoid synthesis

Conclusions: These findings demonstrate that serine protease activity can cause human vasodilation and provide a possible explanation of why serine protease activation in critical illness is associated with vascular dysfunction.
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http://dx.doi.org/10.1161/01.cir.0000050620.37260.75DOI Listing
February 2003
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