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.

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.

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.

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.