Prevalence and Impact of Chronic Edema in Bariatric Patients: A LIMPRINT Study.

Background: Chronic edema (CO) is a complex condition, arising from different factors, including immobility and obesity. Edema and obesity can have a significant impact on quality of life of patients and their families. Understanding how to manage edema in obese patients is an increasing challenge for both patients and clinicians. As effective treatment options are limited for this population, it is more cost-effective for patients to lose weight before starting treatment. When patients cannot maintain weight loss, one option is to have bariatric surgery. This study was part of LIMPRINT: Lymphedema IMpact and PRevalence INTernational, a study with the aim of identifying the prevalence and impact of CO in different countries and health care settings. Study Purpose: To evaluate the prevalence and impact of CO among patients in a United Kingdom bariatric surgical service. Methods and Results: The gold standard pitting test assessed the presence of edema. General (EuroQOL-5 Dimensions [EQ-5D], RAND 36-Item Short Form Health Survey, Version 1.0 [SF-36], Generalized Anxiety Disorder 7-Item Scale [GAD-7] and Patient Health Questionnaire-9 [PHQ-9]), and edema-specific (Lymphedema Quality of Life [LYMQOL]) quality-of-life questionnaires were used to evaluate impact of edema. The prevalence of edema was 52.1% (25 of 48 participants had edema), potentially linked to obesity, immobility, and medications. Most participants had International Society of Lymphology (ISL) Stage I edema. There were no statistically significant differences between the quality of life of participants with and without edema. However, comparing SF-36 results and normative population data indicated that quality of life was much lower than those in the normative population. Conclusions: This study highlights the high prevalence of edema and low quality of life of this bariatric population. ClinicalTrials.gov ID: NCT03154593.

Prevalence of unmet needs for spasticity management in care home residents in the East Midlands, United Kingdom: a cross-sectional observational study.

OBJECTIVE: To establish the prevalence of unmet need for spasticity management in care home residents in two counties of the United Kingdom. DESIGN: Cross-sectional observational study with a six-month follow-up arm for participants with identified unmet needs. SETTING: 22 care homes in Derbyshire and Nottinghamshire. SUBJECTS: 60 care home residents with upper motor neuron syndrome-related spasticity. INTERVENTIONS: No intervention. When unmet needs around spasticity management were identified, the participant's general practitioner was advised of these in writing. MAIN MEASURES: Resistance to Passive Movement Scale to assess spasticity; recording of (a) the presence of factors which may aggravate spasticity, (b) potential complications of spasticity, (c) spasticity-related needs and (d) current interventions to manage spasticity. Two assessors judged the presence or absence of needs for spasticity management and whether these needs were met by current care. RESULTS: Out of 60 participants, 14 had no spasticity-related needs; 46 had spasticity-related needs; 11 had needs which were being met by current care and 35 participants had spasticity-related needs at baseline which were not being met by their current care. These were most frequently related to the risk of contracture development or problems with skin hygiene or integrity in the upper limb. In total, 6 participants had one or more pressure sores and 35 participants had one or more established joint contractures. A total of 31 participants were available for follow-up. Informing general practitioners of unmet needs resulted in no change to spasticity management in 23/31 cases. CONCLUSION: Care home residents in this study had high levels of unmet need for spasticity management.

Prevalence and Risk Factors for Chronic Edema in U.K. Community Nursing Services.

Background and Study Design: Chronic edema (CO) is believed to be a major clinical problem within community nursing services in the United Kingdom. This study was undertaken as part of the LIMPRINT international study to determine the number of people with CO and its impact on health services. Methods and Results: Three urban-based community nursing services participated in the United Kingdom with prospective evaluation for 4 weeks of all patients receiving nursing care using a questionnaire-based interview and clinical assessment using the LIMPRINT tools. Of the total 2541 patients assessed, 1440 (56.7%) were considered to have CO, comprising Leicester City [768/1298 (59.2%)], Nottingham West [124/181 (68.5%)], and Nottingham City [548/1062 (51.6%)]. The mean age for women with CO was 78.6 (standard deviation [SD] 12.8) years and that for men with CO was 72.9 (SD 14.5). More patients with CO suffered from diabetes (32.1% vs. 27.9%, p = 0.027), heart failure/ischemic heart disease (27.3% vs. 14.0%, p < 0.001), and peripheral arterial occlusive disease (5.5% vs. 1.9%, p < 0.001). By far the greatest association was with the presence of a wound (73.6% vs. 37.9%, p < 0.001). Cellulitis affected 628 patients (24.7%) and 688 patients (47.8%) had a concurrent leg ulcer. Rates of reduced mobility (71.6% vs. 61.9%) and obesity were higher in those with CO. Six independent factors associated with CO were service location, age, ethnicity, obesity, heart failure, and the presence of a wound. Conclusion: CO is a major and growing health care problem within primary care that has been previously unrecognized and requires effective service provision.

Chronic oedema: a prevalent health care problem for UK health services.

Chronic oedema (CO) is a major clinical problem worldwide, which has many important secondary consequences for health, activity and participation. Effective treatment planning and organisation of services is dependent on an understanding of the condition and its epidemiology. This cross-sectional study was designed to estimate the point prevalence of CO within the health services of one UK urban population and to determine the proportions that have concurrent leg ulceration. Patients with CO in all anatomic sites were ascertained by health care professionals in one acute and one community hospital, all relevant outpatient and community nursing services, general practices and all nursing/residential homes in one urban catchment area (Derby City). The presence and distribution of oedema was confirmed through a brief clinical examination. A battery of demographic and clinical details was recorded for each case. Within the study population of Derby City residents, 971 patients were identified with CO [estimated crude prevalence 3·93 per 1000, 95% confidence interval (CI) 3·69-4·19]. The prevalence was the highest among those aged 85 or above (28·75 per 1000) and was higher among women (5·37 per 1000) than men (2·48 per 1000). The prevalence among hospital inpatients was 28·5%. Only five (3%) patients in the community population had oedema related to cancer or cancer treatment. Of the 304 patients identified with oedema from the Derby hospitals or community health services, 121 (40%) had a concurrent leg ulcer. Prevalence statistics and current demographic trends indicate that CO is a major and growing health care problem.

A questionnaire survey comparing the educational priorities of patients and medical students in the management of multiple sclerosis.

OBJECTIVE: To compare the educational priorities patients and students raise concerning the management of multiple sclerosis (MS). DESIGN/SETTING: A single-centre comparative questionnaire survey conducted in a foundation trust hospital which provides teaching for one UK medical school. PARTICIPANTS: A total of 255 people with multiple sclerosis (pwMS) and 125 final year medical students attending a mandatory module were invited to participate. MAIN OUTCOME MEASUREMENTS: Questionnaires were developed and piloted for this study and analysed on the basis of the International Classification of Functioning, Disability and Health terminology. RESULTS: Questionnaires were returned by 125 (50%) pwMS (age range 36-86 years; median 58) and 96 (77%) medical students (age range 22-37 years; median 23). The most commonly reported priority listed by people with MS and students concerned 'environmental contextual factors' (95.5% and 99%, respectively). PwMS focused primarily on the 'social and attitudinal aspects' of the environment (53.6%), while students expressed greater interest in the use of medications (91.7%) and investigations (14.6%) (p < 0.001). People with greater psychological or physical impact of the condition were more likely to prioritise 'health condition' topics. CONCLUSIONS: PwMS and medical students identify different topics when asked to list aspects of management of MS which they deem to be important for medical student teaching. These differences in educational priorities should be taken into consideration when teaching students about MS. The findings may also apply to other long-term neurological conditions and warrant further investigation.

A qualitative examination of inappropriate hospital admissions and lengths of stay.

BACKGROUND: Research has shown that a number of patients, with a variety of diagnoses, are admitted to hospital when it is not essential and can remain in hospital unnecessarily. To date, research in this area has been primarily quantitative. The purpose of this study was to explore the perceived causes of inappropriate or prolonged lengths of stay and focuses on a specific population (i.e., patients with long term neurological conditions). We also wanted to identify interventions which might avoid admission or expedite discharge as periods of hospitalisation pose particular risks for this group. METHODS: Two focus groups were conducted with a convenience sample of eight primary and secondary care clinicians working in the Derbyshire area. Data were analysed using a thematic content approach. RESULTS: The participants identified a number of key causes of inappropriate admissions and lengths of stay, including: the limited capacity of health and social care resources; poor communication between primary and secondary care clinicians and the cautiousness of clinicians who manage patients in community settings. The participants also suggested a number of strategies that may prevent inappropriate admissions or reduce length of stay (LoS), including: the introduction of new sub-acute care facilities; the introduction of auxiliary nurses to support specialist nursing staff and patient held summaries of specialist consultations. CONCLUSION: Clinicians in both the secondary and primary care sectors acknowledged that some admissions were unnecessary and some patients remain in hospital for a prolonged period. These events were attributed to problems with the current capacity or structuring of services. It was noted, for example, that there is a shortage of appropriate therapeutic services and that the distribution of beds between community and sub-acute care should be reviewed.

Appropriateness of acute admissions and last in-patient day for patients with long term neurological conditions.

BACKGROUND: To examine the appropriateness of admissions and in-patient stay for patients with long term neurological conditions (LTNCs). To identify variables predictive of appropriateness and explore management alternatives. METHODS: Adults admitted as acute patients to Derby Hospitals NHS Foundation Trust (England). Data were collected prospectively and examined by a multi-disciplinary expert panel to determine the appropriateness of admission and length of stay (LoS). Management alternatives were discussed. RESULTS: A total of 119 participants were recruited. 32 admissions were inappropriate and 83 were for an inappropriate duration. Whether a participant lived in their own home was predictive of an inappropriate admission. The number of LTNCs, number of presenting complaints and whether the participant lived alone in their own home were predictive of an inappropriate LoS. For admissions judged to be inappropriate, the panel suggested management alternatives. CONCLUSION: Patients with LTNCs are being admitted to hospital when other services, e.g. ambulatory care, are available which could meet their needs. Inefficiencies in hospital procedures, such as discharge planning and patient transfers, continue to exist. Recognition of the need to plan for discharge at admission and to ensure in-patient services are provided in a timely manner may contribute towards improved efficiency.

Reproducibility of swallowing over time in healthy elderly adults.

The purpose of this study was to evaluate the reproducibility of aspects of swallowing assessed over time by the Exeter Dysphagia Assessment Technique. Fourteen healthy elderly adults were assessed during the morning on four consecutive days. During day 1, the assessment was repeated ten times. During days 2, 3, and 4 the assessment was carried out once and at the same time of the day. This allowed the reproducibility of the data to be examined between sessions and between days. The results show that the reproducibility of data between sessions was moderate to very good for all of the items evaluated (median kappas = 0.56-0.82, ICCs = 0.7-0.8). Between-day reproducibility was also moderate to very good for nine of the variables measured (median kappas = 0.58-0.96, ICCs = 0.53-0.84) and poor for one (ICC = 0.15). We conclude that the majority of variables examined by the Exeter Dysphagia Assessment Technique are reliable when swallowing is assessed repeatedly and on different days.

Design features of portable wheelchair ramps and their implications for curb and vehicle access.

This study evaluated a range of portable wheelchair ramps to highlight the effect of different product features on ease of use when wheelchair users climb curbs or access vehicles. Twelve portable ramps were evaluated. Although all the ramps were designed to load powered wheelchairs into motor vehicles, they were manufactured in different designs. The ramps were based on a "singlewide" platform or "channel" design. Some ramps had fixed dimensions, whereas others could be reduced in size because they were telescopic or designed to allow folding. Overall, the ramps could be divided into four subgroups on the basis of their key features. These were horizontally and longitudinally folding ramps, telescopic ramps, and ramps with fixed dimensions. The telescopic ramps could be subdivided into "U"-shaped gutter ramps and reverse profile ramps. Product appraisals and trials involving wheelchair users and caregivers of wheelchair users were done to evaluate each of these ramp designs. Although wheelchair ramps are available in a wide range of designs and configurations, we found that no single ramp design successfully met the needs of all wheelchair users or their caregivers. The evaluation highlighted a number of specific problems and potential hazards. Some ramps were found to move during a maneuver, showed poor stability when used with some vehicles, or were too narrow to allow wheelchair castors to pass through the channel without jamming. Some features, such as handles and locking mechanisms, influenced the ease with which the caregivers could use the ramps. Wheelchair users preferred the wide platform ramps because they were able to drive up these with ease and little preparation. The caregivers preferred folding or telescopic channel ramps because these were easier to handle and store.

Aspiration with dysphagia: the interaction between oropharyngeal and respiratory impairments.

Individuals with neurodisability and dysphagia often aspirate food because of oropharyngeal impairments and poor control of respiration. This study explored the interaction between these factors in 32 participants aged 3-33 years. Each person underwent a modified barium swallow study, during which respiration was recorded and displayed simultaneously on the video screen, in terms of inspiration, expiration, and velocity of airflow (TV data). The duration of time that material remained in the pharynx before the swallow (either because of pharyngeal delay or residue from the previous swallow) was called the pharyngeal dwell time (PDT). The mean PDT of the 5 slowest swallows for each participant was calculated for both liquids and thick purees. The proportions of time spent in inspiration and expiration during the PDT in seconds and a score representing the abnormality of inspiration, including its frequency and velocity, were recorded. The volume of material in the pharynx prior to these swallows was also estimated. Twelve participants aspirated liquids and 3 of the 12 also aspirated thick purees. PDTs were longer among aspirators (6.2 s) than nonaspirators (2.4 s) when consuming liquids. Also, the percentage of the PDT spent in inspiration was greater among aspirators than nonaspirators when taking liquids (31% vs. 11%) or thick purees (35% vs. 14%). During the PDT, aspirators showed more abnormal respiratory patterns for liquids but not for purees. There were no differences in the volumes of liquid or puree in the pharynx before the swallow between aspirators and nonaspirators. A plot of the PDT against a combined respiratory impairment score (i.e., percentage of the PDT spent in inspiration and respiratory abnormality) predicted aspirators with a sensitivity of 83% and specificity of 95%. Aspiration results from oropharyngeal impairments with inadequate respiratory integration. Further research is needed to investigate whether intervention to improve respiratory control can reduce aspiration in people with dysphagia.