The Birmingham Hip Resurfacing: 5-year clinical and radiographic results from a District General Hospital

We prospectively examined the functional and radiographic outcomes of a serial cohort of 104 Birmingham Hip Resurfacings in an independent centre. Final follow-up was to a mean of 61 months, and six cases were lost to follow-up. Excellent results were obtained in 91%, but obese patients had significantly (p < 0.03) poorer post-operative outcomes. Whilst there were no cases of neck fracture neck narrowing of up to 20 mm was noted. Radiolucent lines were present in a single zone in 9.4% (9/96) acetabular and 3.1% (3/96) femoral components. However, no components were definitely loose and there were no revisions for any reason during the period of the study. This independent series confirms that the Birmingham Hip Resurfacing gives excellent early clinical results and little early evidence of radiographic failure. The high rate of neck narrowing gives us cause for concern and we would recommend regular radiographic follow-up.

The use of the cemented Exeter Universal femoral stem in a District General Hospital

We describe the survivorship of the Exeter femoral component in a District General Hospital. Between 1994 and 1996, 230 Exeter Universal cemented femoral components were implanted in 215 patients who were reviewed at a mean of 11.2 years (10 to 13). We used one acetabular implant, the Elite Ogee component, in 218 of the 230 hips.

During the period of this study 76 patients (79 hips) died. Of the remaining 139 patients (151 hips), 121 were able to attend for radiological analysis at a minimum of ten years. One patient was lost to follow-up.

No femoral component was revised for aseptic loosening. Three hips were revised for deep infection and six acetabular components required revision, four for loosening and two for recurrent dislocation. Taking the ‘worst-case scenario’ including the one patient lost to follow-up, the overall survival rate was 94.4% at 13 years.

Our results confirm excellent medium-term results for the Exeter Universal femoral component, implanted in a general setting. The excellent survival of this femoral component, when used in combination with the Ogee acetabular component, suggests that this is a successful pairing.

Hospital outpatient and emergency services in rural Victoria

Outpatient and emergency services in rural hospitals have rarely been studied. This paper analyses routinely collected data, together with data from a survey of hospitals, to provide a picture of these services in Victorian public hospitals. The larger rural hospitals provide the bulk of rural outpatients and emergency services, particularly so for medical outpatients. Cost per service varies with the size of the hospital, possibly reflecting differences in complexity. Funding policies for rural hospital outpatient and emergency services should be sufficiently flexible to take into account the differences between rural hospitals.

The Australian health workforce: facts and futures

The quality of care received by a patient or consumer critically depends on the knowledge, skills and attitudes of the health workforce; the structure and functioning of the health workforce is critical to the structure and functioning of the health system overall. To a very large extent, diagnosis and treatment decisions call on the training and experience of the health professional. The quality of the interaction between a patient or consumer depends on the interpersonal and technical skills of health professionals. In a sense, health workers are important to defining the very nature of health care services. The importance of the health workforce is further highlighted by the fact that, as is typical of most service industries, labour accounts for a large proportion of health costs (around 80%). This paper provides an overview of the size and composition of the health workforce in Australia. It then reviews three segments of the workforce in more detail (medical, nursing and other health professionals) and reviews contemporary policy issues affecting those groups.

Establishing minimum recommended standards for post-acute brain injury rehabilitation

Brain injury is the biggest cause of disability for men under the age of 60 in the UK, and yet there are no nationally set minimum standards of care. This article describes the process undertaken by the South Thames Brain Injury Association (STBIRA) in setting out minimum standards for post-acute brain injury rehabilitation in inpatient facilities. These standards cover just one aspect of the patient's journey from coma to community. It is hoped that other groups will take up the challenge to set standards for other parts of the integrated care pathway, in order to ensure appropriate treatment for individuals with acquired brain injury.

Does it matter who owns health facilities?

The rhetoric of governments 'steering not rowing' and of purchaser-provider splits is still part of the language of public sector reform throughout the world, despite some retreat in the National Health Service in the UK. Implementation of separation of purchaser and provider roles has often been associated with suggestions that the private sector is better able to manage hospitals. The evidence for this assertion is mixed, especially when possible quality differences are also considered. This essay suggests that the ownership question is a second-order issue and that policy-makers should ensure that existing public hospitals are funded in a way that encourages efficiency.

Clinical standards for inpatient specialist rehabilitation services in the UK

OBJECTIVE

To develop a set of clinical standards for specialist inpatient rehabilitation services in the UK and to undertake a preliminary survey of consultants who provide those services.

DESIGN

The proposed set of standards was developed by group consensus followed by an iterative consultation process. A postal survey was conducted on behalf of the British Society for Rehabilitation Medicine (BSRM) amongst its consultant members in the UK (n = 163), who were asked to assess their services in relation to these standards, and to comment on the standards themselves, their usefulness and applicability.

RESULTS

The response rate was 61%, of which 81 respondents ran an inpatient rehabilitation service. Overall, the standards appeared to be acceptable to most, and mainly struck the right level, being attained by the majority of services. Specific suggestions were incorporated into the revised standards. Further work is required to establish agreed outcomes that are systematically measured and recorded: only half the respondents (50%) routinely recorded a standardized outcome measure, and only a quarter (26%) routinely reviewed patients to record long-term outcome.

CONCLUSIONS

Clinical standards have been developed for specialist inpatient rehabilitation services in the UK. The BSRM proposes to adopt these standards for a test period of 2-3 years in the first instance. It is likely that they will require further refinement with time, and modification is required to adapt them to different subspecialities and settings.

The pathogenesis of beryllium-induced pulmonary granulomatosis. A scanning secondary ion analytical microscopy study

Chronic granulomatous pneumonitis was induced in rats with beryllium to study the pathogenesis of that disease, by identifying and localizing the beryllium in histological sections of the pulmonary tissues. This was done with scanning secondary ion mass spectrometry (SIMS). Thus, our observations suggest that the route of the Be from the site of injection into the lung, passes first by the blood, through the vascular wall and into the surrounding pulmonary tissues where Be was phagocytized by macrophages. There resulted in acute vasculitis throughout the lung. It was noted that the granuloma were focal inflammatory sites, solely observed within the vascular wall, distributed along the course of the affected vessel. These findings raise the question as to whether pulmonary granulomatous lesions of other origins are also localized within the vascular wall.

Policy challenges for the Australian health care system

In contrast to the regular media reports decrying the so-called crisis in the health system, a number of academic commentators have identified areas in which the Australian health care system could improve. George Palmer has been one of those, and over the years has published a body of work identifying areas for improvement. This paper reviews the performance of the Australian health care system against the criteria of equity, efficiency and acceptability, and explicates the contemporary problem areas associated with each criterion.

Origins of the Creutzfeldt and Jakob concept

A review of the publications of Hans Creutzfeldt and Alfons Jakob pertaining to the concept which bears their name (CJD) reveals that they described a neuropathological syndrome and were opposed to its classification as a neurological disease. The evidence on which Creutzfeldt and Jakob based their view is reevaluated, and studies by other workers are cited in which a range of environmental and genetic factors generated the CJ syndrome, challenging the proposition that CJD is a disease with a single cause.

Pulmonary response to inhaled antigen: neuroimmune interactions promote the recruitment of dendritic cells to the lung and the cellular immune response to inhaled antigen

Dendritic cells (DCs) play a critical role in capturing and presenting inhaled antigens to T lymphocytes. We report that pulmonary DCs in the Lewis rat are normally located in the lung in immediate proximity to nerve fibers that contain immunoreactive substance P (SP). Functionally, pulmonary DCs bound 125I-SP and displayed increased motility in vitro in response to graded concentrations of SP. However, SP had no effect on the accessory cell activities of DCs. To examine the role of neural influences on the pulmonary immune response to inhaled antigen, Lewis rats were pretreated with capsaicin (CAP), which damages small nerves and depletes neuropeptide stores, and then challenged intratracheally (i.t.) with hen egg lysozyme (HEL). The number and antigen-presenting cell activities of pulmonary DCs in the CAP-treated rats were comparable to those of controls up to day 14. T lymphocytes harvested from the regional lymph nodes draining the lung were effectively sensitized to HEL in both groups. However, when CAP-treated rats sensitized to HEL i.t. at day 0 were rechallenged with HEL i.t. at day 14, the lungs showed decreased numbers of OX-6+ DCs and diminished pulmonary lymphoid infiltrates compared with controls. We suggest that CAP interferes with a neural-mediated response that contributes to the accumulation of inflammatory cells during the efferent limb of the pulmonary-cell-mediated immune response in vivo.

Are waiting lists inevitable?

Waiting lists are a common phenomenon in markets in which non-price allocation of goods and services occurs. To the extent that waiting lists for in-patient health services are perceived to ration imperfectly, many propose policies which focus on reducing demand or increasing supply. Strategies aimed at increasing supply often create perverse incentives in that they reward hospitals with long waiting lists through the provision of additional resources. This paper describes how supply has been addressed in Victoria by changing the financial incentives relating to waiting lists. The success of this payment policy in reducing waiting lists to public hospitals is reported.

The new market in health care: prospects for managed care in Australia

Most developed countries are experimenting or moving at full speed to implement new forms of health delivery based in part on capitation arrangements and stronger accountability of health service providers. Proposals for introduction of capitation or managed care have been advanced in Australia but have attracted strong opposition from the medical profession. This paper reviews the policy issues surrounding the introduction of managed care, including how Australia's current institutional forms may evolve into managed care provision.