Better practical evaluation for lower limb amputees.

PURPOSE: To avoid wastage of prostheses and unfair selection methods for prosthetic prescription, we aimed to develop a practical assessment tool for amputees with doubtful potential, using refurbished second hand modular prostheses. METHOD: Thirty-seven primary amputees (33 transfemoral, 4 transtibial; 22 males, 15 females; median age 71 years, range 19-91) were considered to have doubtful potential for prosthetic use, due to single or multiple impairments. Amputees were assessed using custom-made socket and refurbished second-hand modular prostheses. Liability issues were fully covered. RESULTS: Two patients died before completing the assessment. Median duration of assessment was 4 weeks (range 1-31 weeks). Among the 35 amputees who completed the trial, 14 (38%) proceeded to final prosthesis successfully and 21 (58%) decided to abandon the prostheses. The main reasons for prostheses rejection identified by the team were: hip flexion deformity (4); frailty (4); bilateral amputations (4); COAD (6), stroke (4), stump pain (3) and contralateral leg problems (2) CONCLUSION: High prosthetic rejection rate was expected and confirmed in this group (58%), but considerable number did proceed to definitive prosthesis. The method is practical and fair for amputees of doubtful potential, with considerable cost saving.

Consultant rheumatology workforce in the UK: changing patterns of provision 1997-2001.

OBJECTIVES: To summarize the changes in rheumatology provision and working practice that have occurred on the basis of the results of the 1997, 1999 and 2001 surveys carried out to update the British Society for Rheumatology/Arthritis Research Campaign Rheumatology Workforce Register. METHODS: The Workforce Register includes all consultant rheumatologists in the UK who do at least one NHS clinical session per week. Questionnaires were sent to all consultants on the register at the beginning of 1997, 1999 and 2001. The questionnaires asked about clinical commitments and workload. RESULTS: The response rates for 1997, 1999 and 2001 surveys were 85, 86 and 92% respectively. Scotland, Wales and Northern Ireland all had fewer consultant rheumatologists per capita than any English region. Within England, the London region had 60% more rheumatologists per capita than any other English region. CONCLUSION: There are ongoing inequalities in the provision of rheumatology, especially between London and Scotland, Wales and Northern Ireland.

The painful shoulder: can consultants agree?

As a two-phase exercise in inter-district audit, with the emphasis on critical evaluation of routine clinical practice, three rheumatologists each examined the same 44 patients with shoulder pain, and recorded their diagnosis and the investigations and treatment they would carry out. In the first phase, 26 patients were seen by each rheumatologist separately; there was complete diagnostic agreement in only 46%, with wide variation in the frequency of requests for standard investigations, but all three rheumatologists recommended steroid injections for most patients. In the second phase, all three rheumatologists examined a further 18 patients together, discussed the symptoms and signs, and recorded their diagnoses separately. There was complete agreement in 78%. The presence of more than one lesion, and differences in the interpretation of certain physical signs, partly explain the lack of agreement in Phase 1. Treatment of specific shoulder lesions is highly concordant, with injection the major treatment modality, followed by physiotherapy. Perhaps the different diagnoses reached, and the fact that treatment might therefore be administered for the wrong diagnosis, may explain some treatment failures. Also, recruitment of patients for studies of the treatment of shoulder lesions requires care to avoid selection of a heterogeneous group.

The Macalister archive: records from the Queen's Hospital, Sidcup, 1917-1921.

The Queen's Hospital opened in 1917 to care for soldiers receiving facial injuries in Western Front trenches, usually as a result of a gunshot wound. Some 8000 patients were treated by the medical teams of the UK, the Dominions and the USA. The wartime records were removed by their respective sections in 1921, but Queen Mary's Hospital has recently reacquired those of the New Zealand section, rescued from imminent destruction by Professor A.D. Macalister, late Dean of the Dental School at Dunedin, and kindly donated by him. There are 282 sets of case-notes containing typescript summaries, clinical photographs and radiographs, drawings, 77 watercolor paintings and a life-size wax model of head and upper torso illustrating some of the surgical techniques. The archive is a fine example of medical illustration 75 years ago, and provides invaluable detail on the plastic surgery and dental reconstructive methods that were developed at Sidcup.

What do rheumatologists do? A pilot audit study.

Four consultant rheumatologists from different health districts compared their out-patient and in-patient workloads for 3 months. Data collection proved simple and valuable to each local unit. Inflammatory joint disease (particularly severe rheumatoid arthritis) dominated the workload in all centres. Large differences in the number of new referrals with osteoarthritis, soft tissue diseases and polymyalgia rheumatica were observed. Differences were also apparent in the organization of clinics, provision of follow-up appointments for different diagnostic groups, and usage of steroid injections. Although there may be a variety of explanations for these similarities and differences, the data emphasize the need for further audit of rheumatology practice in the UK.

Rheumatoid arthritis and chronic bronchial suppuration.

Twenty-two patients with rheumatoid arthritis and severe chronic bronchial suppuration are described. In 11 patients the respiratory symptoms appeared after the onset of arthritis at an unusually late age. We discuss causes for the disease association, in particular the possibility that disease modifying drugs in rheumatoid arthritis may predispose to the development of chronic bronchial suppuration; such a possibility requires prospective investigation.