Delays to accessing healthcare and rehabilitation following trauma in Madagascar - a qualitative study.

PURPOSE: To explore the factors affecting access to timely trauma care and rehabilitation in Madagascar. MATERIALS AND METHODS: A qualitative study based in the outpatient departments of two large rehabilitation centres. Semi-structured interviews and focus groups were conducted with 12 patients or family members and 11 healthcare professionals. Interviews and focus groups were conducted with a local interpreter and were audio-recorded and transcribed. The data were analysed deductively with thematic content analysis, utilising the Health Care Access Barriers model. RESULTS: Participants experienced delays in deciding to seek treatment, accessing healthcare facilities and in receiving appropriate treatment. Cognitive barriers included understanding and awareness of healthcare, structural barriers included distance and transportation to health facilities, financial barriers included affordability of healthcare and difficulty accessing funds. CONCLUSIONS: Delays to accessing healthcare may result in increased mortality and disability following trauma, as well as increased financial burden. Addressing the acceptability of services should be a focus for future service development, through training and education schemes. More importantly, improving both physical and financial accessibility of services must be a long-term priority. These findings may help to guide the ongoing development of trauma and rehabilitation pathways in Madagascar.IMPLICATIONS FOR REHABILITATIONDelays in accessing timely trauma care and rehabilitation can lead to complications such as pain, infection, malunion of fractures and loss of function, with devastating financial and social consequences for patients and their families.The acceptability of services is a key barrier to accessing hospital care and may be targeted through training schemes for healthcare professionals and education for the public.Improving the physical and financial accessibility of services in the long-term is paramount.Consideration should be given to these issues in the future development of co-ordinated trauma care and rehabilitation pathways in Madagascar.

Southern Hemisphere westerlies as a driver of the early deglacial atmospheric CO2 rise.

The early part of the last deglaciation is characterised by a ~40 ppm atmospheric CO2 rise occurring in two abrupt phases. The underlying mechanisms driving these increases remain a subject of intense debate. Here, we successfully reproduce changes in CO2, δ13C and Δ14C as recorded by paleo-records during Heinrich stadial 1 (HS1). We show that HS1 CO2 increase can be explained by enhanced Southern Ocean upwelling of carbon-rich Pacific deep and intermediate waters, resulting from intensified Southern Ocean convection and Southern Hemisphere (SH) westerlies. While enhanced Antarctic Bottom Water formation leads to a millennial CO2 outgassing, intensified SH westerlies induce a multi-decadal atmospheric CO2 rise. A strengthening of SH westerlies in a global eddy-permitting ocean model further supports a multi-decadal CO2 outgassing from the Southern Ocean. Our results highlight the crucial role of SH westerlies in the global climate and carbon cycle system with important implications for future climate projections.

Work in inflammatory and degenerative joint diseases.

This article focuses on work disability and sick leave and their cost; it also discusses the value of vocational rehabilitation programmes in rheumatic conditions such as rheumatoid arthritis, ankylosing spondylitis, hip and knee osteoarthritis. It acknowledges the importance of work not only for the worker who has one of these diseases but also for the public purse. Much can be done to improve the health of the persons and reduce their disability and its impact in the workplace which will have an important effect on their and their family's quality of life. It is important that neither rehabilitation nor vocational rehabilitation are regarded as bolt-on activities after drug treatment but are seen as an integral part of effective management. Publications dealing with return to work are relatively common in rheumatoid arthritis, less common in ankylosing spondylitis and relatively rare in osteoarthritis. Vocational rehabilitation programmes should aim to facilitate job retention or, failing that, to improve the ability to return to work. The process must be started with in the health arena and it has to be recognised that slow or poor practice in the health service can jeopardise the patient's work potential.

Vocational rehabilitation: a multidisciplinary intervention.

Vocational rehabilitation is by definition a multidisciplinary intervention in a process linked to the facilitation of return to work or to the prevention of loss of the work. Clinical staff in contact with a person who has lost his job (general practitioner, specialized physician) must promote vocational rehabilitation. Medical rehabilitation for those with disabilities, whether new or old, has to be followed without delay by vocational rehabilitation. It is even better if these two intertwined processes are overlapping. They involve many professionals including physiotherapists, occupational therapists, psychologists, vocational trainers, job counsellors, teachers, case-managers, job placement agencies. Vocational rehabilitation has a financial cost, borne by many state organizations (security, social system, social affairs) as well as by employers and private insurances, which are in case of accident, concerned by this process. However, the evidence suggests that this is recouped 2- to 10-fold as suggested by the British Society of Rehabilitation Medicine.

Living with thalidomide: health status and quality of life at 40 years.

Thalidomide was first synthesized in 1953 and was subsequently marketed as a mild hypnotic and sedative in more than 20 countries. By 2001 it was estimated that there were 5,000 survivors from the 10,000 - 12,000 babies who were, as a result, born with severe abnormalities. For these survivors, recent concerns have emerged about their physical state, in particular their levels of pain and their ability to maintain independence. It was therefore wished to ascertain health status and current concerns amongst a sample of survivors living in the UK. A combination of qualitative and quantitative methodologies was employed. Qualitative interviews were undertaken with a sample drawn from the population affected by thalidomide known to the Thalidomide Trust. Selection of participants was based upon a theoretical sample frame. Postal questionnaires to examine health status and various psychosocial aspects concerned with living with the consequences of thalidomide were sent subsequently to these same participants and to a random sample of those not originally drawn for the qualitative interviews. For the qualitative interviews, 28 agreed to take part; two refused and the remainder did not respond. Those agreeing to interview were representative of the original compensation bands (Chi-Square = 3.929; p = 0.416). Several themes emerged from these interviews, including the effects on work and career; coping in terms of attitude to life, self-image, confidence, self-esteem, stress and emotion; relationships, independent living issues and emergent problems such as pain, quality of life, and anxiety about the future. A postal questionnaire was then sent to those who had agreed to interview (28), plus a random sample of the remaining group who were not initially chosen for the qualitative interviews. In total 82 people were sent the questionnaire, of whom 41 (50%) responded. Two-thirds of responders were female. Seven out of ten lived with a partner, and over half (56%) had children. Almost half (46%) were in work, but 32% reported they were permanently unable to work because of disability. Current levels of impairment were found to be similar across groups defined by the original compensation band. In contrast, the activity limitation measures showed a steep gradient across bands but only 37% considered themselves disabled. Nevertheless, despite the restriction in activities for some, levels of participation were similar across bands; likewise simple summary items on health status and quality of life were similar and 70% reported their quality of life (QoL) was good or better than good. Yet nine in ten believed that their body was less flexible than in the past. Almost as many reported they were less able to carry things. It turns out that when compensation bands were grouped (1 - 3, 4 - 5) to highlight those most severely affected according to the original assessment, then those in the higher band grouping reported significantly more musculoskeletal problems, high levels of fatigue and increasing dependency and feelings of vulnerability. It is clear that the original ranking of disability severity, as expressed through the compensation, bands (allocated in early childhood in most cases), is consistent with current ranking of limitations in activity and participation. Nevertheless, despite high levels of disability amongst some survivors, lifelong adjustments to the original impairments have resulted in more than two thirds reporting at least a good quality of life. However, survivors expressed increasing concern about emerging musculoskeletal and other problems which may compromise hard-won independence.

The needs of young people with disabilities in transition from paediatric to adult services.

Transition to adulthood requires consolidation of identity, achievement of independence establishment of adult relationships and finding vocation. Those with disabilities and health problems experience difficulty in this through lack of social opportunity. There are 340,000 affected UK individuals of 16-29 years. Most, having survived childhood disability, may experience later deterioration in functional level. Most will require long term monitoring. Health needs include treatment for the complications and progression of their condition, appropriate treatment for everyday, and unrelated diseases, and health maintenance knowledge. Leaving a cohesive paediatric service and entering the uncoordinated adult health services has been described as hurtling into a void''. Therefore, number of health service models have been proposed, including the person-focussed model, a disease-focussed model, a hospital-based model, a team-based outside the health service, a named person, a voluntary organisation and a primary care model. For those with complex disabilities an interdisciplinary team comprising a consultant in Rehabilitation Medicine, (who will facilitate referral to other medical consultants) occupational therapy, speech therapy, psychology and social work input with support from physiotherapy and nursing addresses all these needs. Young Adult Teams can both teach skills, and facilitate health and other service usage. This whole area of work is under-researched. The outcomes for disabling childhood conditions must be investigated, and planning for adulthood must influence the pattern of care in childhood. The most urgent need is to set up effective services for young adults, which will help to ensure that their 50 years of adulthood have quality of life.

Coagulation and fibrinolytic activity in Behçet's disease.

Coagulation and fibrinolytic activities were studied in 18 subjects with Behçet's disease and compared with results from 14 matched control patients suffering from sero-negative arthritis. Significantly higher plasma concentrations (median and range) were found in Behçet's patients for the following variables: fibrinogen 3.7 (1.7-6.9) vs 3.0 (2.0-5.1) g/l, p less than 0.05; von Willebrand factor antigen, 115 (72-344) vs 74 (60-119)%, p less than 0.002; plasminogen activator activity (10(6)/ECLT2) 219 (94-329) vs 137 (78-197) units, p less than 0.002; tissue plasminogen activator inhibitor (t-PA-I) activity, 9.1 (5.5-19.3) vs 5.1 (1.8-12.0) IU/ml, p less than 0.002; and PAI-1 antigen, 13.9 (4.5-20.9) vs 6.4 (2.4-11.1) ng/ml, p less than 0.002. Protein C antigen was significiantly lower: 97 (70-183) vs 126 (96-220)%, p less than 0.02. No differences were observed in antithrombin III activity or antigen, factor VIII coagulant activity, fibrinopeptides A and B beta 15-42, plasminogen, alpha-2-antiplasmin, functional and immunological tissue-plasminogen activator, thrombin-antithrombin complexes and D-dimer. Levels of tissue plasminogen activator inhibitor (activity and antigen) correlated with disease activity while fibrinogen and von Willebrand factor concentrations did not. Seven of the 18 subjects with Behçet's disease had suffered thrombotic events but it was not possible to distinguish these from the 11 patients without thrombosis using the assays performed. The results suggest the abnormal fibrinolytic activity in Behçet's disease is due to increased inhibition of tissue plasminogen activator. No abnormality of coagulation or fibrinolytic activity specific to Behçet's disease was detected.

A team approach to hospital formulary replacement.

A multidisciplinary antibiotic review team (MART) was implemented to improve patient care and reduce antimicrobial expenditures. MART consists of pharmacists and infectious disease (ID) physicians reviewing patients three times weekly. Antibiotic expenditures were reduced by recommending conversions to therapeutically equivalent antibiotics, conversion to an oral agent, and completion of treatment with home infusion therapy. In addition, MART proposed therapeutic interchanges from ceftriaxone to cefotaxime to the P and T committee. ID physician or pharmacist offered recommendations and initiated order changes if the attending physician agreed. Annualized savings was $74,371, with 40% of the recommendations resulting in an improved antimicrobial therapy.

Prevalence of low back pain in the community: implications for service provision in Bradford, UK.

STUDY OBJECTIVE: To assist a purchasing district in the planning of services for low back pain by assessing the prevalence of symptoms and the current involvement of primary, secondary, and complementary care in the treatment of low back pain. In the light of these findings, to assess further the potential impact of a new system of open access to physical therapy, as recommended by the British Clinical Standards Advisory Group (CSAG). DESIGN: A two-stage cross sectional survey approach using postal questionnaires. SUBJECTS: Altogether 1437 men and 1747 women aged 25-64 years, randomly selected from the family health services association register in Bradford. MAIN RESULTS: An annual incidence of 4.7% for low back pain was found, with lifetime, 12 month period, and point prevalences of 59%, 39%, and 19% respectively. Over a one year period, 50.3% of episodes were acute (< 2 weeks), 21% were subacute (2 weeks-3 months), and 26% were chronic (over 3 months) in duration. Altogether 17.8% of the population in this age range experienced referred pain, numbness, or tingling, and 6.4% took time off work as a result of low back pain. In the same year, 20% of the population in the same age range consulted no-one about their pain, 13.7% were treated at the primary care level, 4% received secondary care, and 3% visited a complementary therapist. One fifth of those who did not consult a professional experienced severe pain during episodes. Prevalence estimates indicate that an emphasis on early intervention and primary care management of simple low back pain as recommended by the CSAG could generate a 131% surge in demand for physical therapy. CONCLUSIONS: Local prevalence estimates may allow purchasers to estimate the potential effects of a shift in management policy for low back pain and to highlight areas of unmet need in terms of resources and patient education.

Prevalence of self reported stroke in a population in northern England.

STUDY OBJECTIVE: The aim of this study was to determine the prevalence of stroke survivors in a health district population aged 55 years and over. DESIGN: This was a point prevalence study using two-stage postal questionnaires sent to an age stratified random sample of the population. SETTING: A district health authority in northern England with a resident population of 723,000. SUBJECTS: Altogether 18,827 residents aged 55 years or over. MAIN RESULTS: Prevalence was found to increase with age and, apart from the very elderly, males had a higher prevalence than females. Overall prevalence was found to be 46.8/1,000 (95% CI 42.5, 51.6). 23% of respondents reported full recovery from stroke. Cognitive impairments (33%), problems with lower limbs (33% for right leg; 27% for left leg) and speech difficulties (27%) were the most common residual impairments. CONCLUSIONS: Current guidelines to purchasers on the provision of services to those who have had a stroke may under-estimate prevalence rates by as much as 50%. This could lead to a shortfall in provision of services designed to support people in the months and years following their stroke.

The vertically integrated pharmacy department.

Pharmacy's challenges and opportunities during a transition from a traditional hospital to an integrated health system are discussed with reference to the experience of a medical center in Vancouver, Washington. When a traditional hospital makes the transition to an integrated health system, pharmacy directors must consider how the core business will be affected, how pharmacy can add value, and how to best apply the skills of the pharmacy department. A well-trained staff that shares a view of the new organization and that can think outside the traditional hospital paradigm is required. New health systems will focus on quality-related outcomes at low cost and on disease management. Partnerships between providers and health care staff will be beneficial. To compete for capitated contracts, health systems will need to deliver services other than acute care to a broad geographic area, and primary care will be more prominent. There will be a shift toward outpatient services, and pharmacy departments will be under increasing pressure to develop outpatient pharmaceutical services. Pharmacy departments will also need to develop treatment guidelines for outpatients and to better manage drug costs by working with new business clients, improving continuity of care, increasing patients' access to care, having pharmacists provide hospice care, and implementing remote prescription-order entry. New health systems will need to have a clear understanding of how their core business is changing; the organizational strategy of a health system must include effective communication of change to staff members with the goal of overcoming traditional thinking.

The Leeds Assessment Scale of Handicap: its operationalisation, reliability, validity and responsiveness in in-patient rehabilitation.

PURPOSE: This paper describes the application of the handicap dimension of the International Classification of Impairments, Disabilities and Handicaps. METHOD: A method of assessing four of the six roles (or areas of expected competency) was developed and applied to an in-patient population, aged 16 to 65 years, receiving specialist rehabilitation following neurological damage. Handicap assessment was a collaborative process by a multidisciplinary team. Difficulties were experienced in measuring inter-rate reliability in the busy, clinical setting. RESULTS: We conclude that handicap assessment in an in-patient rehabilitation unit which uses a multidisciplinary approach to treating patients with complex physical, sensory and cognitive problems is both feasible and useful. CONCLUSION: The developed scale, The Leeds Assessment Scale of Handicap, provides a valid and valuable summary of human disadvantage, complementing the common disability assessments.

Outcome following stroke.

A community study based on an age-stratified sample of those aged 55 years and older in a northern health district in the United Kingdom has been used to consider the implications for purchasing health-care services for those who have survived a stroke. The study showed that while almost a quarter of those reporting a stroke had made a full recovery, a wide range of impairments and disabilities persisted. Almost half reported needing help at least daily. A logistic regression model to predict this level of dependency found that impairments, disabilities and other factors, such as locality, were also predictive of dependency. A second model predicting mobility handicap (dwelling restricted) was found to have a similar mix of predictors. These results show how purchasers must consider the broad outcome in terms of a continuum of impairment, disability and handicap. The results also show that handicap is a distinct concept that draws together many influences which act upon the individual.

The disabled living centre: what does it do?

Seventy five consecutive users of the Leeds disabled living foundation were surveyed. Two thirds of these users were at least moderately severely disabled. Forty eight of the 65 people (74%) who completed the questionnaire were recommended aids, and 33 had received some at the end of the survey. Only 10 of 28 people had received recommended adaptations. Few referrals were made to the centre by doctors. It is important that they tell their patients of this useful service.

Prevalence of knee problems in the population aged 55 years and over: identifying the need for knee arthroplasty.

OBJECTIVE: To determine the prevalence of knee problems in people aged 55 years and over and identify those who should be considered for knee arthroplasty. DESIGN: Postal survey; questionnaires were sent to a multistage stratified probability sample of residents of North Yorkshire Health Authority aged 55 and over. SETTING: A health district with a population of 210,000 aged 55 and over. RESULTS: An initial four page postal questionnaire produced an 86% response rate among 18,827 eligible patients. A subsequent detailed questionnaire sent to 1277 patients with knee problems (with a response rate of 78%) then determined the prevalence of severe pain and severe disability. Pain and disability consistent with the need to consider arthroplasty was found in 20.4/1000 (95% confidence interval 18.0 to 23.1); of these, 4.1 (2.7 to 5.8)/1000 had extreme disability. Age and sex specific rates in men who might benefit from arthroplasty were, in those aged 55-64, 12.9 (8.4 to 19.0)/1000; aged 65-74, 12.1 (7.4 to 18.4)/1000; aged 75 and over, 20.3 (12.9 to 30.5)/1000. In women aged 55-64 the rates were 12.9 (8.6 to 18.7)/1000; aged 65-74, 19.6 (13.9 to 26.7)/1000; aged 75 years and over, 42.6 (34.3 to 52.4)/1000. CONCLUSIONS: Total knee replacement has until recently been considered unreliable and often seen as a last resort for many with severe knee problems. Advances in prosthesis design and surgical and anaesthetic techniques have transformed this procedure into a reliable option with a potential for reducing disability and dependency in a large number of people in the community. Understandably, the prevalence pool of those who may benefit is large; health authorities and, increasingly, general practitioners should consider purchasing more total knee replacement surgery to offer real choice to those in need.

Evaluation of an inpatient decentralized pharmacy team program in an HMO setting.

Decentralized drug distribution and clinical pharmacy services were implemented on two nursing units, orthopedics and oncology, of a health maintenance organization-owned hospital. The use of targeted high-cost drugs was assessed before and during the decentralized pharmacy services intervention on the experimental units and on a comparison unit. Other assessments included a survey of nurses from the experimental units and surveillance of telephone encounters between the central pharmacy and the experimental units. In the experimental units, there were significant changes in cefazolin therapy for prophylaxis, aminoglycoside therapy, and metoclopramide use from baseline to the intervention periods. Cefazolin use for prophylaxis essentially remained the same in the comparison unit. Telephone encounters decreased substantially from the before- to the during-program period. An increase in the proportion of inappropriately drawn aminoglycoside blood levels was also noted in the during-program period. Decentralized pharmacy services appeared to reduce the cost of targeted drugs and improve communications with the nursing units.