Modern Orthopedic Inpatient Care of the Orthopedic Patient With Diabetic Foot Disease.

In this article, we describe emergency and elective pathways within our orthopedic multidisciplinary inpatient care of patients with diabetic foot problems. We performed a retrospective cohort review of 19 complex patients requiring orthopedic surgical treatment of infected ulceration or Charcot feet or deformity at our institution. A total of 30 admissions (19 emergency, 11 elective) were included. The pathways were coordinated by a multidisciplinary team and comprised initial assessment and investigation and a series of key events, which consisted of emergency and elective surgery together with the introduction, and change of intravenous antibiotics when indicated. Patients had rigorous microbiological assessment, in the form of deep ulcer swabs, operative tissue specimens, joint aspirates, and blood cultures according to their clinical presentation as well as close clinical and biochemical surveillance, which expedited the prompt institution of key events. Outcomes were assessed using amputation rates and patient satisfaction. In the emergency group, there were 5.6 ± 3.0 (mean ± SD) key events per admission, including 4.2 ± 2.1 antibiotic changes. In the elective group, there were 4.8 ± 1.4 key events per inpatient episode, with 3.7 ± 1.3 antibiotic changes. Overall, there were 3 minor amputations, and no major amputations. The podiatric and surgical tissue specimens showed a wide array of Gram-positive, Gram-negative, aerobic and anaerobic isolates and 15% of blood cultures showed bacteremia. When 9 podiatric specimens were compared with 9 contemporaneous surgical samples, there was concordance in 2 out of 9 pairs. We have described the successful modern care of the orthopedic diabetic foot patient, which involves close clinical, microbiological, and biochemical surveillance by the multidisciplinary team directing patients through emergency and elective pathways. This has enabled successful surgical intervention involving debridement, pressure relief, and stabilization, with low rates of amputation.

Changes in household composition among the over sixties: a longitudinal analysis of the Health and Lifestyles Surveys.

Analyses of longitudinal data from the Health and Lifestyles Surveys (HALS) were carried out in order to examine the household changes of older people. Respondents who were interviewed at both the first HALS survey in 1984/85 (HALS1) and the second survey 7 years later (HALS2) and were aged 60 or over in HALS1 were selected (1156). Changes in household composition between the two surveys were examined and the relationship of these changes to socio-demographic factors and to both cross-sectional and longitudinal health factors investigated. Results of the analysis showed there was great diversity of experience and a considerable amount of change in what is often considered a fairly stable and homogeneous section of the population. Almost one-third of respondents changed household type, the majority changing to live alone and only a small proportion changing to live in households with their child/children or with others. Household changes were associated with poor and declining health (both physical and mental) and the rate of change was found to increase with age. In the case of ill health the first source of practical support and care is generally from within the household. Where this is not available it is sought from the wider community or the state. An increase in the proportion of the population aged over 60 and in the numbers of the oldest people, coupled with a rate of household change that increases with age, means that demand on health and community services can only be expected to increase.