Effect of general practitioner hospitals on district general hospital bed use in the Highlands of Scotland

OBJECTIVE

To examine hospital bed use by General Practices with and without access to General Practitioner beds.

DESIGN

Information from the Contract Management System for General Medicine and Surgery, and from SMR returns for Geriatric Medicine and GP beds was used to compare hospital bed use in District General Hospitals (DGHs) and in General Practitioner beds for practices with and without access to GP beds. Age adjusted rates were calculated for overall use of each specialty.

SETTING

All General Practices in the Highland Health Board area for December 1995-April 1997.

RESULTS

Compared to practices with no access to GP beds, practices with access used 39.4% fewer bed days per 1000 patients for medical specialties; 18% fewer bed days for surgical specialties; 34.5% fewer bed days for geriatric medicine, and 4.9% fewer bed days for other DGH specialties. Taking into account GP bed day use, practices with access to GP beds used 6.1% more hospital bed days per 1000 patients than did practices with no access.

CONCLUSION

These findings largely replicate work in England that found substantial decreases in General Medical and Geriatric Medicine bed use in Practices with access to GP beds, combined with an overall increase in occupied bed day use of 6-8% per 1000 patients. The lower use of surgical beds was unexpected, and may reflect more flexible use of GP beds in the Highlands for observation or rehabilitation, possibly related to the far greater distances involved than in the English studies.

Anti-psychotic drug prescribing trends in primary care in Scotland 1994-97

OBJECTIVE

To describe trends in the use of anti-psychotic drugs prescribed in Primary Care in Scotland.

DESIGN

Information on prescription numbers and costs were obtained from the Pharmacy Prescribing Division.

SETTING

Scotland 1994-1997. Results Prescriptions for anti-psychotic drugs in Primary Care in Scotland increased by 28% in the period April 1994-December 97. In the same period, quarterly costs increased from 523,971 Pounds to 1,339,215 Pounds, an increase of 155%. Ninety per cent of the increase is accounted for by use of the five drugs risperidone, sertindole, olanzapine, clozapine and quetiapine. Health Board areas vary markedly in their uptake of the new drugs.

CONCLUSION

The use of new anti-psychotic drugs in Scotland represents a substantial additional investment in mental health care. This has happened with little discussion or debate. Scotland needs to make explicit decisions on the place of newer anti-psychotics in treatment, and on the balance between investing in these drugs and investing in other aspects of mental health services.

Drug action team strategies in Scotland

OBJECTIVE

To compare the Strategic Plans of Scottish Drug Action Teams (DATs) to the recommendations of the Scottish Office Ministerial Task Force Report.

DESIGN

Extraction of information from the strategic plans of DATs.

SETTING

All 15 Scottish DATs 1995-96.

RESULTS

Five DATs did not include a membership list in their Strategy, and two stated the organisations represented, but not the identity of individual members. Where individuals were identified, Health Boards, Social Work departments, Education and Police were always members. The median number of members was 12 (range 4-16). Most areas had plans to improve information on drug misuse. Every plan mentioned preventive work with young people. In Criminal Justice settings, use of Children's Hearings (20% of plans), substitute prescribing linked to probation (13%) and prison aftercare schemes (33%) were mentioned less commonly. Substitute prescribing (87% of DATs), the role of General Practitioners (100%) and monitoring mechanisms (87%) were the service issues mentioned most often. Of other service issues in the Ministerial Report, those mentioned least by DATs were childcare linked to services (20%); services for people from ethnic minorities (33%); education on dangers of injecting to existing drug users (33%); women--only residential services (33%); services for women (46%) and role of pharmacists (53%).

CONCLUSION

Membership was from a core of statutory agencies. Young people were the priority of most DATs. Criminal Justice arrangements and services for special groups of people were not well developed in many plans. DATs should review their focus on these groups.

Changes in the pattern of work in a rural community hospital 1987-1997

OBJECTIVES

To examine time trends in clinical activity at a rural community hospital, and to assess associated changes in the complexity of the care received by inpatients.

DESIGN

Descriptive study utilising routine Scottish Morbidity Records data (SMRO1) and locally collected data, along with a retrospective review of admission case notes to quantify clinical inputs to patient care.

SETTING

Portree community hospital on the island of Skye.

SUBJECTS

Patients admitted to Portree community hospital in 1987, 1992 and 1997.

RESULTS

We found an 80 per cent rise in total annual admissions between 1987 and 1997 and a 34 per cent rise in annual casualty attendance between 1992 and 1997. There was a significant reduction in the median duration of in-patient stay, from 8.5 days in 1987 to 6.0 days in 1997. The case-mix of admissions altered significantly between 1992 and 1997. We also demonstrated significant changes in the proportion of patients receiving blood transfusions or intravenous (i.v.) fluids during this time period.

CONCLUSIONS

There have been significant changes in the pattern of use of this community hospital over the past 12 years. The rise in total admissions and casualty attendances, combined with the fall in duration of stay reveal an overall increase in activity at the hospital. This has been associated with changes in the clinical spectrum of admissions. Taken together with the results of the workload analysis, it seems likely that the complexity of the clinical input required at the hospital has increased, and that the role of this community hospital is increasingly the provision of intermediate care to acute cases.

Effect of femoral head surface roughness on the wear of ultrahigh molecular weight polyethylene acetabular cups

We studied the effect of femoral head surface roughness on the wear of ultrahigh molecular weight polyethylene (UHMWPE) acetabular cups using a hip joint simulator and a reciprocating wear tester. Compared with the hip simulator, the reciprocating wear tester severely exaggerates the effect of counterface roughness on UHMWPE wear and drastically underestimates the wear rate of the UHMWPE against smooth undamaged counterfaces. According to the hip simulator test results, the wear rate of the UHMWPE cups is approximately proportional to the square root of the femoral head roughness Ra (center-line-average roughness) rather than to Ra raised to a power greater than one as predicted by pin-on-disk studies. Roughening of the femoral heads by an order of magnitude results in a 2- to 3-fold increase in the wear rate. Therefore, the much wider clinical variations of wear cannot be fully explained by variations in surface roughness of the femoral heads.

Efficacy of oral iron supplementation is not enhanced by additional intravenous iron during autologous blood donation

BACKGROUND

The study compared the efficacy of oral iron combined with intravenous iron supplementation to that of oral iron supplementation alone in increasing the preoperative production of hemoglobin (Hb) in autologous blood donors with normal iron stores.

STUDY DESIGN AND METHODS

One hundred eight iron-replete patients who were scheduled for donation of 3 units of autologous blood at weekly intervals were randomly assigned to receive, in a double-blind fashion, no iron supplementation (placebo, Group 1), oral iron supplementation (285.6 mg of elemental iron/day, Group 2), or oral iron plus intravenous iron supplementation (285.6 mg of elemental iron/day orally plus 102.5 mg of elemental iron/week intravenously, Group 3). The amount of Hb produced during the 21-day study period was determined by the total amount of Hb donated minus the change in the amount of circulating Hb between the first donation (Day 0) and the poststudy examination (Day 21).

RESULTS

Hb production did not differ significantly in the two iron-supplemented groups (oral iron, 85 +/- 36 g; oral plus intravenous iron, 74 +/- 43 g). The patients in the oral iron group produced a significantly greater amount of Hb than those in the placebo group (85 +/- 36 g vs. 52 +/- 41 g, p < 0.01).

CONCLUSION

Oral iron supplementation increased the production of Hb in autologous blood donors more than placebo did. Additional intravenous iron did not lead to a further increase in preoperative Hb production.

Thirteen-year follow-up of deliberate self-harm, using linked data

BACKGROUND

We describe a national cohort of individuals surviving an episode of deliberate self-harm (DSH). Subsequent admissions for DSH and mortality over the following 13 years were studied.

METHOD

In 1981, 8304 individuals were discharged from Scottish general hospitals with a diagnosis of attempted suicide (E950-959). They were followed-up to the end of 1994 using the Scottish Linked Data Set. Mortality was compared to the Scottish population using person-years analysis.

RESULTS

2624 people (31.6%) were readmitted with further episodes of DSH. The median number of readmissions was 1, range 1-137. The observed:expected ratio for all-cause mortality was 2.26 (95% CI 2.13-2.26). One hundred and sixty-eight people (2%) died from suicide, and 46 (0.6%) from undetermined causes. The observed:expected ratio for suicide plus undetermined deaths was 12.17 (95% CI 10.64-13.91). Accidental deaths in men and homicide deaths in men and women were elevated. The pattern of deaths from other causes suggested that alcohol misuse was a contributory factor.

CONCLUSIONS

People admitted to general hospitals in Scotland after attempted suicide are at high risk of readmission for further episodes of DSH. Long-term follow-up of such large cohorts is impractical, but services should review the scope for intervention in alcohol misuse following DSH.

Vignettes of a pulmonary rehabilitation team

A successful comprehensive pulmonary rehabilitation program depends on these key pieces: thorough planning, an experienced coordinator who is a patient advocate, a dedicated and supportive medical director, enthusiastic and committed team members, the use of program graduates as volunteers, and providing the essential components of pulmonary rehabilitation, which consist of assessment, patient training, exercise, psychosocial intervention, and follow-up. The patients are the most important members of the team. Their courage, dedication, and determination to make their quality of life the best it can be is truly an inspiration to all of us.

Immunohistochemical visualization of wild-type p53 protein in paraffin-embedded rat liver using tyramide amplification: zonal hepatic distribution of p53 protein after N-hydroxy-2-acetylaminofluorene administration

P53 protein plays an important role in regulation of the cell cycle. Recently, a role in tumour genesis has also been suggested. The protein is induced after various forms of DNA damage. Immunohistochemical detection of p53 protein showed positive cells in human skin after UV-irradiation, in mouse skin after benzo[a]pyrene treatment and in mouse spleen, thymus and bone after gamma-irradiation. However, no staining was found in mouse and rat liver with traditional immunohistochemical staining methods due to the low amount of p53 present. This seriously hampered studies on the role of p53 in hepatocarcinogenesis. We have developed a more sensitive immunohistochemical method for staining of p53 in paraffin-embedded sections of rat liver using microwave irradiation for antigen retrieval, avidin-biotin complexing and tyramide amplification. A strong, specific fluorescence signal for p53 was found in hepatocytes of rats that had received the hepatocarcinogen N-hydroxy-2-acetylaminofluorene; in control liver no such p53 staining was observed. The fluorescence was located in the nucleus of hepatocytes in zone 1 of the liver. This agrees with the fact that N-hydroxy-2-acetylaminofluorene causes cytotoxicity in this zone.

Psychological reactions after multifetal pregnancy reduction: a 2-year follow-up study

This study had two objectives. Firstly we assessed the effects of multifetal pregnancy reduction on the mothers' emotional well-being and the relationship with the children during the 2 years following intervention. Secondly at 2 years we compared mothers who had a reduction with mothers who had not and had delivered triplets. The comparisons focused on the mothers' health and their relationship with the children. Women having had a reduction in two hospitals in Paris, between May 1992 and June 1993, were contacted just after intervention for a prospective study. In all, 18 women were included. At 1 and 2 years, 10 women participated. At 2 years, 10 additional women were included. The answers of these 20 mothers were compared to those of 11 consecutive mothers of 2 year old triplets, assessed by the same psychologist in a previous prospective study. Semi-structured interviews were conducted at home. The mothers' social characteristics, their parity, the children's condition at birth and 4 months were very similar between the reduction and triplet groups. One year after birth one-third of the women in the reduction group reported persistent depressive symptoms related to the reduction, mainly sadness and guilt. The others made medical and rational comments expressing no emotion. At 2 years all but two women seemed to have overcome the emotional pain associated with the reduction. The comparison with mothers of triplets indicated that the mothers' anxiety and depression, and difficult relationship with the children were less acute in the reduction group. These results presented some limitations, since a high number of women who miscarried or refused to participate in the follow-up were not assessed at 1 and 2 years. However, a majority of women who participated in the study 2 years after intervention seemed able to accept a multifetal pregnancy reduction to achieve parental goals.

School injuries in the west of Scotland: estimate of incidence and health service costs

Injuries are an important cause of morbidity and mortality in childhood. Injuries at school account for up to 30% of accident and emergency department attendances in school age children in England and Wales. Routine school reports are a possible source of information on these injuries, but work in other countries indicates that schools under-report injuries to children, making it difficult to estimate incidence. Over a four-week period, children attending an Accident and Emergency Department at a District General Hospital in the West of Scotland as a result of a school accident were compared to those included in routine school incident reports in the area for the same time period. One hundred and forty-eight children were identified as attending the Accident and Emergency Department after sustaining an injury which met the definition of a school accident. This would indicate a rate of injuries resulting in hospital treatment of 47 per 1,000 pupils per year. The prospective data collection identified school under-reporting of accidents requiring hospital treatment of 705%. This information obtained allowed estimation of hospital costs to the NHS. The cost of the Accident and Emergency Department attendances, out-patient treatment and in-patient costs for this group of children was estimated at Pounds 7,715. At this rate, the cost of hospital treatment for school accidents for Argyll and Clyde Health Board is estimated at Pounds 134,760 per year. Applied to the Scottish population, costs would be over Pounds 1.8 million per year. These figures supply the first UK estimates of health care costs of school accidents, and hence assist services in deciding the priority to accord school accident prevention.

Screening for Psychiatric Distress and Low Self-esteem in Patients Presenting for Excimer Laser Surgery for Myopia

BACKGROUND

Patients presenting for photorefractive keratectomy (PRK) may have unusual psychological profiles. Certain psychological variables may impact treatment outcome, making early identification crucial. We report a controlled questionnaire study of psychiatric "anxiety/distress" and self-esteem in myopic patients who presented for excimer laser treatment.

METHODS

Ninety consecutive myopic individuals (patients) who presented for excimer laser PRK and 50 consecutive myopic individuals who presented to an optometrist for contact lens fitting (controls) were assessed using two self-completion questionnaires-the GHQ30 and Hudson Index of Self-Esteem ISE. The questionnaires were distributed during assessment for treatment.

RESULTS

PRK patients had a 90% response rate for both questionnaires and control patients, 98% for GHQ30 and 100% for Hudson ISE. PRK patients were significantly older (p = 0.000003), had a greater myopic spherical equivalent refraction (p = 0.012) and had better spectacle-corrected visual acuity (p = 0.0096). No significant differences were demonstrated with regard to anxiety/distress in terms of absolute scores (p = 0.07), or the proportion of patients being positive or negative (p = 0.10). Similarly, self-esteem was not significantly different between the two groups (absolute scores p = 0.69; positive/negative p = 0.29). The high response rate shows that the GHQ30 and Hudson ISE are easy to use and well tolerated by myopes in a busy clinic setting. The fact that the patients were older, with a greater refractive error, may partly reflect the onset of contact lens intolerance.

CONCLUSION

The psychological findings suggest that PRK patients cannot be considered more distressed or anxious than other myopic individuals. There is no evidence that their decision to undergo surgery is driven by abnormally low self-esteem.

Psychological aspects of excimer laser surgery for myopia: reasons for seeking treatment and patient satisfaction

AIMS

To determine the reasons patients seek excimer laser treatment for myopia and to measure levels of patient satisfaction with each phase of this relatively new treatment.

METHODS

A unique 38 item visual analogue questionnaire was developed and applied to 100 consecutive patients (n = 100) who had undergone excimer laser photorefractive keratectomy for myopia or myopic astigmatism at a single centre. All subjects underwent extensive ophthalmic assessment and patient education before treatment.

RESULTS

A 90% response rate was achieved (n = 90). Improved unaided vision (85.6%), freedom from spectacles (83.3%), and difficulties with contact lens wear (72.7%) were the most common reasons for seeking treatment. The majority of patients felt that the quality of their life had improved (85.5%) and 82% felt that the quality of their unaided vision was as good as they had anticipated. overall, 95.5% of patients were pleased that they had undergone this procedure. The vast majority (98.9%) of patients felt that they fully understood the operation pretreatment but almost one quarter (23.9%) found the actual operation distressing. Only 15.7% found postoperative pain did not respond adequately to prescribed analgesia.

CONCLUSIONS

This study demonstrates a very high level of patient satisfaction after excimer laser treatment for myopia and myopic astigmatism. It suggests that most patients seek treatment to enjoy better vision free from optical aids and that a high level of patient education preoperatively may establish realistic expectations and satisfaction with overall outcome.

Simulation of titration curves indicated with two indicator electrodes (biamperometry)

A rigorous method to simulate titration curves with indication using two indicator electrodes (biamperometry) is presented. Computer simulations can be carried out for reversible as well as for irreversible systems. The different parameters like the area of the individual electrodes, applied potential difference, heterogeneous rate constant, and the kinetic parameter alpha were varied and investigated as to their influence upon the shape of the titration curves. The theoretically derived effects match with the effects obtained by experiment. Considering the effects described here, it is possible to tailor the shape of the titration curve by the experimental conditions for specific applications in order to get an optimum shape at the end point of the titration.

Bivoltametric titrations using electrodes with innovative geometry

Electrodes with different surface areas were investigated for the determination of reversible, quasireversible, irreversible or electroinactive substrates. Two kinds of electrodes were constructed, a helical electrode with a given asymmetry and a platinum array electrode with a variable area. These electrodes were applied for the cerimetry of ammonium iron(II) sulfate and for the bromatometry of various organic substances. The theoretically derived effects on the shape of the voltametric titration curve are verified experimentally. It is possible to sharpen one side of the peak and to broaden the other side, depending on the system and the side of the peak one is interested in. It is possible to improve the bivoltametric determination of hydroquinone, benzocaine and sulfaguanidine by bromatometry by the directed employment of electrodes of different areas. For the bromatometric determination of electrochemically irreversible substrates the use of the electrode geometries proposed is a way to obtain a sharp bend and a steep decrease of titration curves with low values of the constant current which is a basic requirement for the accuracy.

Mechanistic and morphological origins of ultra-high molecular weight polyethylene wear debris in total joint replacement prostheses

The mechanistic and morphological origins of microscopic wear debris generated from UHMWPE articular surfaces in total joint replacement prostheses are investigated in this study. It was found experimentally that the molecular chain structure at the articulating surface of UHMWPE undergoes a re-organization process due to strain accumulation caused by surface traction. This molecular re-organization process creates a fibre-like surface texture that exhibits an anisotropic behaviour similar to a unidirectionally reinforced polymer composite. This composite responds to stresses favourably if loaded along the fibre axis but unfavourably if loaded off axis. Due to the very complex multi-axial motion/loading nature at the articular surfaces in total joint replacements, the stress tensors applied to each localized asperity contact area continuously change their directions and magnitudes. These changes in the localized stress field create an off-axis loading situation at each localized contact zone with respect to the orientation of the molecular chains. Depending on the off-axis angle, failure of the molecular structure occurs in three different ways: tensile rupture at very small off-axis angles, shear rupture at intermediate off-axis angles and transverse splitting at large off-axis angles. These failure mechanisms all produce similar fibre-like wear debris. However, the failure stresses differ significantly among the three modes. According to this molecular wear theory, the preferred polymer microstructure for optimal wear resistance would be a three-dimensionally strong network connected by covalent bonds between molecular chains. For UHMWPE, a three-dimensional molecular network can be created by radiation induced cross-linking. Experiments conducted on both gamma irradiated and unirradiated UHMWPE specimens using a linear wear machine and multi-axial joint simulators confirmed the validity of the molecular wear theory.

Two years of school injuries in a Scottish education sub-division

Injuries sustained in schools account for 20-30% of all accident and emergency attendances in school age children. Little information has been available on the epidemiology of school accidents in the United Kingdom. Two years of routine school incident reports were analysed from Renfrew Sub-Region, an area with a school roll of 55,521 children attending 135 schools. Schools returned 1,660 report forms in the two year period, of which 1,440 referred to injuries to school children. The peak incidence of injuries was in the 10-12 year age group. The male:female ratio was 1.37:1. Cuts/ laceration and fractures were the commonest diagnoses reported for both Primary and Secondary Schools. Injuries to face and features were commonest in Primary, and upper limb injuries in Secondary Schools. Uncontrolled areas, e.g. playgrounds, stairways and corridors were the most frequent places of occurrence in Primary Schools (Relative Risk 5.24, 95% C.I. 3.28-8.35). Report accuracy was assessed by comparing one year of school reports in a Local Government District to records in the local District General Hospital. This identified 156 children who had attended hospital as the result of a school accident. Schools overestimated the number of fractures by 27%, but where schools had not provided a diagnosis, 15.4% were identified as fractures in hospital records. Each child seen at the hospital received an average of 2.1 X-rays. Nine children underwent manipulations under general anaesthetic. Seventeen children were admitted to hospital, and the group required 103 outpatient follow-up appointments.