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1.  The Effects Of Dental Anxiety And Irregular Attendance On Referral For Dental Treatment Under Sedation Within The National Health Service In London 
To investigate whether the relationship between dental anxiety and referral for treatment under sedation is explained by attendance patterns and oral health.
Structural Equation Modeling was used on the covariance matrix of the covariates to test hypothesized inter-relationships. Subsequently, we modeled the probability of referral for treatment under sedation with a multiple logistic regression taking into account inter-relationships between the independent variables.
A direct significant association of referral with dental anxiety and attendance patterns was detected but not with oral health status. However, oral health and anxiety were highly correlated. Also signaled were correlations between age and education and between gender and bad past experience.
Referral for treatment under sedation appears to be motivated by both fear and irregular patterns of attendance. Coupled with behavioral treatments to address dental fear and attendance, sedation can part of comprehensive care where curative treatments are long or unpleasant for patients.
PMCID: PMC2945617  PMID: 20545723
dental anxiety; structural equation modeling; logistic regression; utilization; sedation
2.  Sleeping position, oxygen saturation and lung volume in convalescent, prematurely born infants 
To determine whether the effects of sleeping position on lung volume and oxygenation are influenced by postmenstrual age (PMA) and oxygen dependency in convalescent prematurely born infants.
Prospective study.
Tertiary neonatal unit.
41 infants (21 oxygen dependent), median gestational age 28 weeks (range 24–31 weeks) and birth weight 1120 g (range 556–1780 g).
Infants were studied both supine and prone at two‐weekly intervals from 32 weeks' PMA until discharge. Each posture was maintained for 1 h.
Main outcome measures
Pulse oximeter oxygen saturation (Spo2) was monitored continuously, and at the end of each hourly period functional residual capacity (FRC) was measured.
Overall, lung volumes were higher in the prone position throughout the study period; there was no significant effect of PMA on lung volumes. Overall, Spo2 was higher in the prone position (p = 0.02), and the effect was significant in the oxygen‐dependent infants (p = 0.03) (mean difference in Spo2 between prone and supine was 1.02%, 95% CI 0.11% to 1.92%), but not in the non‐oxygen‐dependent infants. There was no significant influence of PMA on Spo2.
In the present study, prone sleeping did not improve oxygenation in prematurely born infants, 32 weeks' PMA or older and with no ongoing respiratory problems. However, the infants were monitored in each position for an hour, thus it is recommended that oxygen saturation should continue to be monitored after 32 weeks' PMA to be certain that longer periods of supine sleeping are not associated with loss of lung volume and hypoxaemia.
PMCID: PMC2675354  PMID: 17012305
preterm; oxygen saturation; lung volume; bronchopulmonary dysplasia
3.  Use of the out-of-hours emergency dental service at two south-east London hospitals 
BMC Oral Health  2009;9:19.
Prior to the introduction of the 2006 NHS dental contract in England and Wales, general dental practitioners (GDPs) were responsible for the provision of out-of-hours (OOH) emergency dental services (EDS); however there was great national variation in service provision. Under the contractual arrangements introduced 1st April 2006, local commissioning agencies became formally responsible for the provision of out-of-hours emergency dental services. This study aimed to examine patients' use of an out-of-hours emergency dental service and to determine whether the introduction of the 2006 national NHS dental contract had resulted in a change in service use, with a view to informing future planning and commissioning of care.
A questionnaire was administered to people attending the out-of-hours emergency dental service at two inner city London hospitals over two time periods; four weeks before and six months after the introduction of the dental contract in April 2006. The questionnaire explored: reasons for attending; dental registration status and attendance; method of access; knowledge and use of NHS Direct; satisfaction with the service; future preferences for access and use of out-of-hours dental services. Data were compared to determine any impact of the new contract on how and why people accessed the emergency dental service.
The response rate was 73% of attendees with 981 respondents for the first time period and 546 for the second. There were no significant differences between the two time periods in the gender, age, ethnic distribution or main language of service users accessing the service. Overall, the main dental problem was toothache (72%) and the main reason for choosing this service was due to the inability to access another emergency dental service (42%). Significantly fewer service users attended the out-of-hours emergency dental service during the second period because they could not get an appointment with their own dentist (p = 0.002 from 28% to 20%) and significantly more service users in the second period felt the emergency dental service was easier to get to than their own dentist (P = 0.003 from 8% to 14%). Service users found out about the service from multiple sources, of which family and friends were the most common source (30%). In the second period fewer service users were obtaining information about the service from dental receptionists (P = 0.002 from 14% to 9%) and increased use of NHS Direct for a dental problem was reported (P = 0.002 from 16% to 22%) along with more service users being referred to the service by NHS Direct (P = 0.02 from 19% to 24%). The most common preference for future emergency dental care was face-to-face with a dentist (79%).
This study has provided an insight into how and why people use an out-of-hours emergency dental service and has helped to guide future commissioning of these services. Overall, the service was being used in much the same way both before and after the 2006 dental contract. Significantly more use was being made of NHS Direct after April 2006; however, informal information networks such as friends and family remain an important source of information about accessing emergency dental services.
PMCID: PMC2729730  PMID: 19630986
4.  The emerging dental workforce: why dentistry? A quantitative study of final year dental students' views on their professional career 
BMC Oral Health  2007;7:7.
Dental graduates are joining a profession experiencing changes in systems of care, funding and skill mix. Research into the motivation and expectations of the emerging workforce is vital to inform professional and policy decisions. The objective of this research was to investigate final year dental students' perceived motivation for their choice of career in relation to sex, ethnicity and mode of entry.
Self-administered questionnaire survey of all final year dental students at King's College London. Data were entered into SPSS; statistical analysis included Chi Squared tests for linear association, multiple regression, factor analysis and logistic regression.
A response of 90% (n = 126) was achieved. The majority were aged 23 years (59%), female (58%) and Asian (70%). One in 10 were mature students. Eighty per cent identified 11 or more 'important' or 'very important' influences, the most common of which were related to features of the job: 'regular working hours' (91%), 'degree leading to recognised job' (90%) and 'job security' (90%). There were significant differences in important influences by sex (males > females: 'able to run own business'; females > males: 'a desire to work with people'), ethnic group (Asians > white: 'wish to provide public service', 'influence of friends', 'desire to work in healthcare', having 'tried an alternative career/course' and 'work experience') and mode of entry (mature > early entry: 'a desire to work with people'). Multivariate analysis suggested 61% of the variation in influences is explained by five factors: the 'professional job' (31%), 'healthcare-people' (11%), 'academic-scientific' (8%), 'careers-advising' (6%), and 'family/friends' (6%). The single major influence on choice of career was a 'desire to work with people'; Indian students were twice as likely to report this as white or other ethnic groups.
Final year dental students report a wide range of important influences on their choice of dentistry, with variation by sex, ethnicity and mode of entry in relation to individual influences. Features of the 'professional job', followed by 'healthcare and people' were the most important underlying factors influencing choice of career.
PMCID: PMC1929066  PMID: 17573967
5.  Relationship between three palliative care outcome scales 
Various scales have been used to assess palliative outcomes. But measurement can still be problematic and core components of measures have not been identified. This study aimed to determine the relationships between, and factorial structure of, three widely used scales among advanced cancer patients.
Patients were recruited who received home or hospital palliative care services in the south of England. Hope, quality of life and palliative outcomes were assessed by patients in face to face interviews, using three previously established scales – a generic measure (EQoL), a palliative care specific measure (POS) and a measure of hope (Herth Hope Index). Analysis comprised: exploratory factor analysis of each individual scale, and all scales combined, and confirmatory factor analysis for model building and validation.
Of 171 patients identified, 140 (81%) consented and completed first interviews; mean age was 71 years, 54% were women, 132 had cancer. In exploratory analysis of individual means, three out of the five factors in the EQoL explained 75% of its variability, four out of the 10 factors in POS explained 63% of its variability, and in the Hope Index, nine out of the 12 items explained 69% of its variability. When exploring the relative factorial structure of all three scales, five factors explained 56% of total combined variability. Confirmatory analysis reduced this to a model with four factors – self-sufficiency, positivity, symptoms and spiritual. Removal of the spiritual factor left a model with an improved goodness of fit and a measure with 11 items.
We identified three factors which are important outcomes and would be simple to measure in clinical practice and research.
PMCID: PMC539243  PMID: 15566627
palliative care; quality of life; assessment; hope; symptoms; hospice; day care
6.  Community pulmonary rehabilitation after hospitalisation for acute exacerbations of chronic obstructive pulmonary disease: randomised controlled study 
BMJ : British Medical Journal  2004;329(7476):1209.
Objective To evaluate the effects of an early community based pulmonary rehabilitation programme after hospitalisation for acute exacerbations of chronic obstructive pulmonary disease (COPD).
Design A single centre, randomised controlled trial.
Setting An inner city, secondary and tertiary care hospital in London.
Participants 42 patients admitted with an acute exacerbation of COPD.
Intervention An eight week, pulmonary rehabilitation programme for outpatients, started within 10 days of hospital discharge, or usual care.
Main outcome measures Incremental shuttle walk distance, disease specific health status (St George's respiratory questionnaire, SGRQ; chronic respiratory questionnaire, CRQ) and generic health status (medical outcomes short form 36 questionnaire, SF-36) at three months after hospital discharge.
Results Early pulmonary rehabilitation, compared with usual care, led to significant improvements in median incremental shuttle walk distance (60 metres, 95% confidence interval 26.6 metres to 93.4 metres, P = 0.0002), mean SGRQ total score (-12.7, -5.0 to -20.3, P = 0.002), all four domains of the CRQ (dyspnoea 5.5, 2.0 to 9.0, P = 0.003; fatigue 5.3, 1.9 to 8.8, P = 0.004; emotion 8.7, 2.4 to 15.0, P = 0.008; and mastery 7.5, 4.2 to 10.7, P < 0.001) and the mental component score of the SF-36 (20.1, 3.3 to 36.8, P = 0.02). Improvements in the physical component score of the SF-36 did not reach significance (10.6, -0.3 to 21.6, P = 0.057).
Conclusion Early pulmonary rehabilitation after admission to hospital for acute exacerbations of COPD is safe and leads to statistically and clinically significant improvements in exercise capacity and health status at three months.
PMCID: PMC529363  PMID: 15504763
7.  Training carers of stroke patients: randomised controlled trial 
BMJ : British Medical Journal  2004;328(7448):1099.
Background Informal care givers support disabled stroke patients at home but receive little training for the caregiving role.
Objective To evaluate the effectiveness of training care givers in reducing burden of stroke in patients and their care givers.
Design A single, blind, randomised controlled trial.
Setting Stroke rehabilitation unit.
Subjects 300 stroke patients and their care givers.
Interventions Training care givers in basic nursing and facilitation of personal care techniques.
Main outcome measures Cost to health and social services, caregiving burden, patients' and care givers' functional status (Barthel index, Frenchay activities index), psychological state (hospital anxiety and depression score), quality of life (EuroQol visual analogue scale) and patients' institutionalisation or mortality at one year.
Results Patients were comparable for age (median 76 years; interquartile range 70-82 years), sex (53% men), and severity of stroke (median Barthel index 8; interquartile range 4-12). The costs of care over one year for patients whose care givers had received training were significantly lower (£10 133 v £13 794 ($18 087 v $24 619; €15 204 v €20 697); P = 0.001). Trained care givers experienced less caregiving burden (care giver burden score 32 v 41; P = 0.0001), anxiety (anxiety score 3 v 4; P = 0.0001) or depression (depression score 2 v 3; P = 0.0001) and had a higher quality of life (EuroQol score 80 v 70; P = 0.001). Patients' mortality, institutionalisation, and disability were not influenced by caregiver training. However, patients reported less anxiety (3 v 4.5; P < 0.0001) and depression (3 v 4; P < 0.0001) and better quality of life (65 v 60; P = 0.009) in the caregiver training group.
Conclusion Training care givers during patients' rehabilitation reduced costs and caregiver burden while improving psychosocial outcomes in care givers and patients at one year.
PMCID: PMC406319  PMID: 15130977
8.  Symptom severity in advanced cancer, assessed in two ethnic groups by interviews with bereaved family members and friends 
Little research has been reported on the experience of cancer among minority ethnic communities in the UK. As part of a wider survey in inner London we interviewed bereaved family members or close friends of 34 first-generation black Caribbeans and of 35 UK-born white patients about symptoms and symptom control in the year before death with cancer. They were drawn from population samples in which the response rates were equal at about 46%.
Symptoms in the two ethnic groups were similar. However, multivariate logistic regression indicated greater symptom-related distress in black Caribbeans for appetite loss, pain, dry mouth, vomiting and nausea, and mental confusion. Respondents were also more likely to say, in relation to black Caribbean patients, that general practitioners (though not hospital doctors) could have tried harder to manage symptoms.
The findings suggest a need for better assessment and management of cancer symptoms in first-generation Caribbean Londoners, guided by a deeper understanding of cultural influences on their responses to advanced illness.
PMCID: PMC539365  PMID: 12519796
9.  Prospective cohort study to determine if trial efficacy of anticoagulation for stroke prevention in atrial fibrillation translates into clinical effectiveness 
BMJ : British Medical Journal  2000;320(7244):1236-1239.
To determine whether trial efficacy of prophylaxis with warfarin for patients with atrial fibrillation at high risk of stroke translates into effectiveness in clinical practice.
Two year prospective cohort study.
District general hospital.
167 patients with atrial fibrillation and at high stroke risk who were eligible for anticoagulation.
Long term anticoagulation with warfarin at adjusted doses to maintain an international normalised ratio of 2.0-3.0.
Main outcome measures
Comparison of patient characteristics, comorbidity, anticoagulation control, stroke rate, and haemorrhagic complications with pooled data from five randomised controlled trials.
Patients in the study group were seven years older (95% confidence interval 4 to 10) and comprised 33% more women than patients in the pooled trials. The international normalised ratio was in the target range for 61% of the time (range 37%-85%), below for 26% of the time (range 8%-32%), and above for 13% of the time (range 6%-26%). The time that patients in the study group spent in the target range was significantly less than in the pooled analysis. The incidence of stroke in the study group (2.0% per year, 0.7% to 4.4%) was comparable to that of patients receiving warfarin in pooled studies (1.4%, 0.8% to 2.3%). Per year the incidence of major (1.7% v 1.6%) and minor (5.4% v 9.2%) bleeding complications was also similar.
Rates of stroke and major haemorrhage after anticoagulation in clinical practice were comparable to those obtained from pooled data from randomised controlled studies for patients with atrial fibrillation at high risk of stroke.
PMCID: PMC27364  PMID: 10797031

Results 1-9 (9)