Orthognathic returns to theatre

The objectives of this retrospective study were to determine the unexpected return-to-theatre rate for orthognathic surgery at James Cook University Hospital and describe the reasons for return. A total of 357 consecutive orthognathic cases under two consultants over a 13-year period were included. Patients who had an unexpected return to theatre were identified and their notes analysed for data including preoperative dentofacial discrepancy, surgical movement, and reason for return. Returns to theatre for the removal of plates and planned procedures such as removal of a distractor or delayed genioplasty, were excluded. Thirteen patients required reoperation (3.6%). The commonest reason for return was malocclusion, and the majority returned within four weeks of the initial procedure. Proportionally more men returned to theatre than women, and revision was more likely to involve the mandible than the maxilla.

The changing case-mix of hip fractures in Scotland - evidence from the Scottish Hip Fracture Audit

Until discontinued in 2008, the Scottish Hip Fracture Audit collected and reported on data relating to the quality of care of hip fracture patients in Scotland. In 2013, the audit was recommenced under the umbrella of the MSK Audit group, which audits high volume orthopaedic pathways across Scotland. Our aim is to report on the changes in the demographics of hip fracture patients in Scotland between 2003 and 2013. There was an increase in the proportion of male patients from 2003 to 2013 (22.4% to 29.5%; p < 0.0001). An increased percentage of hip fracture patients were admitted from their own home (63.9% to 73.1%; p < 0.0001). Both these factors have deleterious effects on the outcome, and use of necessary resources, following hip fracture. There was also an increase in the percentage of patients who were American Society of Anesthesiologists Grade 3 (52.9% to 56.4%). Over the last decade, there has been a shift in the demographics of Scotland's hip fracture patients. If hip fracture incidence increases as predicted, this potentially more-challenging case-mix will likely impact on multiple health resources.

Acute kidney injury following primary hip and knee arthroplasty surgery

Acute kidney injury (AKI) is a recognised postoperative complication following primary hip/knee arthroplasty surgery. The aim of this study was to determine causative and potentially modifiable risk factors associated with postoperative AKI. Standard data were collected for 413 consecutive arthroplasty patients, both retrospectively and prospectively. Univariate and multivariate analyses were performed to identify any potential causative factors. Eight percent of patients developed postoperative AKI. Univariate analysis found increasing age, history of previous chronic kidney disease and requirement for postoperative intravenous fluids to be risk factors for AKI. The multivariate regression analysis model identified age and volume of postoperative fluid prescription as predictive of postoperative AKI. Antibiotic regime and prescription of non-steroidal anti-inflammatory drugs had no significant effect on the risk of AKI. No patients required dialysis but length of stay increased by 50% in the AKI group. Postoperative AKI may result in significant postoperative morbidity and increased length of stay, and may necessitate invasive therapies such as dialysis. Episodes of AKI could also predispose to future similar episodes and are associated with a long-term decrease in baseline renal function. This study has demonstrated that the identified risk factors are generally non-modifiable. Further work is suggested to determine whether targeted interventions in high risk patients would reduce the incidence of AKI.

Human Skeletal Allograft Collection — Room for Improvement?

Aim: To assess the efficiency of skeletal allograft collection from patients undergoing primary joint arthroplasty at a District General Orthopaedic Unit. Methods: A two cycle audit was performed. Between cycles procedural changes were implemented to improve the efficiency of allograft collection. The discard rate of donated allograft was also assessed during each cycle. Results: Initially 80 patients were identified. Eight (8/80) did not donate allograft due to medical contraindications. Two (2/80) patients underwent intra-operative autologous born grafting. Allograft was not collected from 22 (22/70) suitable patients. As such only 68.6% of suitable bone was collected by the West of Scotland Blood Transfusion Service (WSBTS). Subsequently 100 patients were studied. Twenty-eight (28/100) patients did not donate allograft due to medical contra-indications. Two (2/100) patients underwent intra-operative autologous bone grafting. Eight (8/70) allografts were discarded as a result of logistical problems. As such 88.9% of suitable allograft was collected. Initially 29% of all allograft donated was rejected due to poor patient selection. This subsequently fell to 9.4%. Conclusion: By auditing the collection process a significant improvement (c2 = 7.17 df = 1 p = 0.001) in the efficiency of allograft collection was achieved. This was complemented by a significant reduction(c2 = 6.09 df= 1 p=0.05) in the proportion of unsuitable allograft donated to the WSBTS.

Microbiology: lessons from a first attempt at Lake Ellsworth

During the attempt to directly access, measure and sample Subglacial Lake Ellsworth in 2012-2013, we conducted microbiological analyses of the drilling equipment, scientific instrumentation, field camp and natural surroundings. From these studies, a number of lessons can be learned about the cleanliness of deep Antarctic subglacial lake access leading to, in particular, knowledge of the limitations of some of the most basic relevant microbiological principles. Here, we focus on five of the core challenges faced and describe how cleanliness and sterilization were implemented in the field. In the light of our field experiences, we consider how effective these actions were, and what can be learnt for future subglacial exploration missions. The five areas covered are: (i) field camp environment and activities, (ii) the engineering processes surrounding the hot water drilling, (iii) sample handling, including recovery, stability and preservation, (iv) clean access methodologies and removal of sample material, and (v) the biodiversity and distribution of bacteria around the Antarctic. Comparisons are made between the microbiology of the Lake Ellsworth field site and other Antarctic systems, including the lakes on Signy Island, and on the Antarctic Peninsula at Lake Hodgson. Ongoing research to better define and characterize the behaviour of natural and introduced microbial populations in response to deep-ice drilling is also discussed. We recommend that future access programmes: (i) assess each specific local environment in enhanced detail due to the potential for local contamination, (ii) consider the sterility of the access in more detail, specifically focusing on single cell colonization and the introduction of new species through contamination of pre-existing microbial communities, (iii) consider experimental bias in methodological approaches, (iv) undertake in situ biodiversity detection to mitigate risk of non-sample return and post-sample contamination, and (v) address the critical question of how important these microbes are in the functioning of Antarctic ecosystems.

The Exeter technique can lead to a lower incidence of leg-length discrepancy after total hip arthroplasty

We evaluated an operative technique, described by the Exeter Hip Unit, to assist accurate introduction of the femoral component. We assessed whether it led to a reduction in the rate of leg-length discrepancy after total hip arthroplasty (THA). A total of 100 patients undergoing THA were studied retrospectively; 50 were undertaken using the test method and 50 using conventional methods as a control group. The groups were matched with respect to patient demographics and the grade of surgeon. Three observers measured the depth of placement of the femoral component on post-operative radiographs and measured the length of the legs. There was a strong correlation between the depth of insertion of the femoral component and the templated depth in the test group (R = 0.92), suggesting accuracy of the technique. The mean leg-length discrepancy was 5.1 mm (0.6 to 21.4) pre-operatively and 1.3 mm (0.2 to 9.3) post-operatively. There was no difference between Consultants and Registrars as primary surgeons. Agreement between the templated and post-operative depth of insertion was associated with reduced post-operative leg-length discrepancy. The intra-class coefficient was R ≥ 0.88 for all measurements, indicating high observer agreement. The post-operative leg-length discrepancy was significantly lower in the test group (1.3 mm) compared with the control group (6.3 mm, p < 0.001). The Exeter technique is reproducible and leads to a lower incidence of leg-length discrepancy after THA.

Peri-operative mortality after hemiarthroplasty for fracture of the hip: does cement make a difference?

We aimed to determine whether cemented hemiarthroplasty is associated with a higher post-operative mortality and rate of re-operation when compared with uncemented hemiarthroplasty. Data on 19 669 patients, who were treated with a hemiarthroplasty following a fracture of the hip in a nine-year period from 2002 to 2011, were extracted from NHS Scotland's acute admission database (Scottish Morbidity Record, SMR01). We investigated the rate of mortality at day 0, 1, 7, 30, 120 and one-year post-operatively using 12 case-mix variables to determine the independent effect of the method of fixation. At day 0, those with a cemented hemiarthroplasty had a higher rate of mortality (p < 0.001) compared with those with an uncemented hemiarthroplasty, equivalent to one extra death per 424 procedures. By day one this had become one extra death per 338 procedures. Increasing age and the five-year co-morbidity score were noted as independent risk factors. By day seven, the cumulative rate of mortality was less for cemented hemiarthroplasty though this did not reach significance until day 120. The rate of re-operation was significantly higher for uncemented hemiarthroplasty. Despite adjusting for 12 confounding variables, these only accounted for 15% of the observed variability. The debate about the choice of the method of fixation for a hemiarthroplasty with respect to the rate of mortality or the risk of re-operation may be largely superfluous. Our results suggest that uncemented hemiarthroplasties may have a role to play in elderly patients with significant co-morbid disease.

Registered Replication Report: Schooler and Engstler-Schooler (1990)

Trying to remember something now typically improves your ability to remember it later. However, after watching a video of a simulated bank robbery, participants who verbally described the robber were 25% worse at identifying the robber in a lineup than were participants who instead listed U.S. states and capitals-this has been termed the "verbal overshadowing" effect (Schooler & Engstler-Schooler, 1990). More recent studies suggested that this effect might be substantially smaller than first reported. Given uncertainty about the effect size, the influence of this finding in the memory literature, and its practical importance for police procedures, we conducted two collections of preregistered direct replications (RRR1 and RRR2) that differed only in the order of the description task and a filler task. In RRR1, when the description task immediately followed the robbery, participants who provided a description were 4% less likely to select the robber than were those in the control condition. In RRR2, when the description was delayed by 20 min, they were 16% less likely to select the robber. These findings reveal a robust verbal overshadowing effect that is strongly influenced by the relative timing of the tasks. The discussion considers further implications of these replications for our understanding of verbal overshadowing.

The large-scale immobilization of Penicillium chrysogenum: batch and continuous operation in an air-lift reactor

A temperature-sensitive cell division cycle mutant of Penicillium chrysogenum P2 has been immobilized on Celite and grown in a 250-320-L working volume air-lift fermenter. The ability to uncouple growth and penicillin synthesis by raising the temperature to 30 degrees C also overcame the problem of the free cell mass which appeared after 300 h operation with the parent organism. After 500 h operation, penicillin and ACV dimer were still being synthesized.

Does delay to theatre for medical reasons affect the peri-operative mortality in patients with a fracture of the hip?

We have investigated how medical postponement, the time to surgery and the correction of medical abnormalities, according to McLaughlin criteria, before operation affected peri-operative mortality after fracture of the hip. From February to December 2007, in addition to core data, the Scottish Hip Fracture Audit collected information relating to surgical delay. Data were available for 4284 patients which allowed 30-day survival analysis to be performed. Multivariable logistic regression models were used to control for differences in case-mix.

Patients with major clinical abnormalities were more likely to have a postponement and had a lower unadjusted 30-day survival. The time to operation and postponement were not associated with higher mortality after adjustment for case-mix. Correction of major clinical abnormalities before surgery improved the adjusted survival, but this improvement was not significant (p = 0.10). Postponement without correction of a medical abnormality before surgery was associated with a significantly lower (p = 0.006) 30-day adjusted survival. The possible benefits of postponement need to be weighed against prolonged discomfort for the patient and the possibility of the development of other complications.

Locked intramedullary nailing of symptomatic metastases in the humerus

The humerus is a common site for skeletal metastases in the adult. Surgical stabilisation of such lesions is often necessary to relieve pain and restore function. These procedures are essentially palliative and should therefore provide effective relief from pain for the remainder of the patient’s life without the need for further surgical intervention.

We report a retrospective analysis of 35 patients (37 nails) with symptomatic metastases in the shaft of the humerus which were treated by locked, antegrade nailing. There were 27 true fractures (73.0%) and ten painful deposits (27.0%). Relief from pain was excellent in four (11.4%), good in 29 (82.9%) and fair in two (5.7%) on discharge. Function was improved in all but one patient. One case of palsy of the radial nerve was noted. The mean postoperative survival was 7.1 months (0.2 to 45.5) which emphasises the poor prognosis in this group of patients. There were no failures of fixation and no case in which further surgery was required.

Antegrade intramedullary nailing is an effective means of stabilising the humerus for the palliative treatment of metastases. It relieves pain and restores function to the upper limb with low attendant morbidity.

Changes in population demographics and the future incidence of hip fracture

BACKGROUND

During the first three decades of the 21st century the combination of increasing life expectancy and falling birth rates will result in substantial demographic changes within the population of the United Kingdom. A large increase in the elderly population is likely to have significant effects on the number of patients who sustain a hip fracture.

AIM

To predict future changes in hip fracture burden in Scotland.

MATERIALS AND METHODS

Data was obtained from the Scottish Hip Fracture Audit database for a 12 month period between April 2004 and March 2005. All orthopaedic units in Scotland participated in the audit during this period. This data was used to calculate the incidence of hip fracture by 5 year age/gender cohorts. Outcome data was analysed in a similar manner. Population prediction data obtained from the Registrar General's Office was then used to predict hip fracture numbers for the year 2031. Two separate prediction models were used. The first model assumed that the age/gender specific incidence of hip fracture observed in 2004 would remain constant. Between 1999 and 2004, a 9.6% decrease in the population incidence of hip fracture was observed. Therefore a second prediction model was used which assumed a continuation in the fall in population incidence of hip fracture between 2004 and 2031.

RESULTS

The population aged 50 years and above is predicted to increase 28% by 2031, with the most significant increases occurring in the over 1980s. The number of hip fractures is predicted to rise by 45% to 75% (from 6164 to 8829-10756 cases per annum) requiring an additional 287-474 hospital beds. By 2031 approximately 45% of fractures will occur in those aged 85 years and above, compared to 34% in 2004. Predicted changes in population demographics are highly variable by region and so local planning of resource provision will be essential.

CONCLUSION

Changes in population demographics will have significant implications for health care provision for the care of hip fracture patients. An increase in the capacity of acute orthopaedic care and a review of care models will be required to ensure adequate resource provision.

Early mortality after surgical fixation of hip fractures in the elderly

We investigated the relationship between a number of patient and management variables and mortality after surgery for fracture of the hip. Data relating to 18 817 patients were obtained from the Scottish Hip Fracture Audit database. We divided variables into two categories, depending on whether they were case-mix (age; gender; fracture type; pre-fracture residence; pre-fracture mobility and ASA scores) or management variables (time from fracture to surgery; time from admission to surgery; grade of surgical and anaesthetic staff undertaking the procedure and anaesthetic technique).

Multivariate logistic regression analysis showed that all case-mix variables were strongly associated with post-operative mortality, even when controlling for the effects of the remaining variables. Inclusion of the management variables into the case-mix base regression model provided no significant improvement to the model. Patient case-mix variables have the most significant effect on post-operative mortality and unfortunately such variables cannot be modified by pre-operative medical interventions.

Outcome after surgery for the treatment of hip fracture in the extremely elderly

BACKGROUND

As a consequence of changes in population demographics, the extremely elderly represent one of the fastest growing groups in Western society. Previous studies have associated advanced age with increased mortality after hip fracture; however, this finding has not been consistent.

METHODS

The Scottish Hip Fracture Audit is a prospective, national, multicenter study that collects data on patients over the age of fifty years who are admitted to the hospital with a hip fracture. For the present study, we used data collected from twenty-two acute-care orthopaedic units between January 1998 and December 2005. The extremely elderly cohort consisted of 919 individuals with an age of ninety-five years or more. Case-mix variables and outcomes were compared with those for a modal control group of 15,461 individuals who were seventy-five to eighty-nine years of age. Outcome measures included thirty and 120-day mortality rates, the length of the hospital stay, the place of residence, and mobility. A multivariable logistic regression model was used to compare outcomes between groups while controlling for significant case-mix variables.

RESULTS

The extremely elderly presented with poorer indicators of health status as demonstrated by higher American Society of Anesthesiologists scores. In addition, this group was less likely to be independently mobile and more likely to be in institutional care at the time of the fracture (p < 0.001). Mortality at thirty and 120 days was higher in the extremely elderly even after adjusting for case-mix variables. The extremely elderly also were less likely to return home or to return to previous levels of mobility.

CONCLUSIONS

Although the extremely elderly exhibited a higher prevalence of prefracture indicators of poor outcome, statistical control for these case-mix variables showed further age-related deterioration in survival and outcomes after surgery for the treatment of a hip fracture.

Gender differences in epidemiology and outcome after hip fracture: evidence from the Scottish Hip Fracture Audit

We report gender differences in the epidemiology and outcome after hip fracture from the Scottish Hip Fracture Audit, with data on admission and at 120 days follow-up from 22 orthopaedic units across the country between 1998 and 2005. Outcome measures included early mortality, length of hospital stay, 120-day residence and mobility. A multivariate logistic regression model compared outcomes between genders. The study comprised 25 649 patients of whom 5674 (22%) were men and 19 975 (78%) were women. The men were in poorer pre-operative health, despite being younger at presentation (mean 77 years (60 to 101) vs 81 years (50 to 106)). Pre-fracture residence and mobility were similar between genders. Multivariate analysis indicated that the men were less likely to return to their home or mobilise independently at the 120-day follow-up. Mortality at 30 and 120 days was higher for men, even after differences in case-mix variables between genders were considered.

Emergency brake response time after first metatarsal osteotomy

BACKGROUND

There is sparse information upon which to recommend a return to activity after foot surgery. The purpose of this study was to determine whether six weeks is sufficient time for the emergency brake response time to return to preoperative levels after a first metatarsal osteotomy for symptomatic hallux valgus.

METHODS

We conducted a prospective, observational study to assess the effect of surgery on emergency brake response time in a group of twenty-eight patients undergoing a unilateral first metatarsal osteotomy on the right side for symptomatic hallux valgus. A custom-made driving simulator was used to assess total brake response time, reaction time, and brake time. Patients were assessed preoperatively and at two and six weeks postoperatively. A control group of twenty-eight individuals matched for age, driving status, and sex was included for baseline comparison.

RESULTS

Total brake response time, reaction time, and brake time were significantly lower for the control cohort compared with the preoperative values recorded in the study cohort (p < 0.05). Only seven of the twenty-eight study patients were able to complete the assessment at two weeks; the remainder were not able to complete it because of postoperative pain. All patients were able to comfortably complete the study at six weeks. In the study cohort, the total brake response time, reaction time, and brake time had significantly improved compared with preoperative recordings (p < 0.05).

CONCLUSIONS

By six weeks after surgery, emergency braking time in patients undergoing a first metatarsal osteotomy is similar to that of healthy individuals.

The outcome of computed tomography in patients with acute renal colic from a low-volume hospital

OBJECTIVE

To assess the interobserver variability of unenhanced helical computed tomography (UHCT) in patients with acute renal colic admitted into a low-volume hospital.

MATERIALS AND METHODS

All admissions with acute renal colic between August 2002 and February 2004 (18 months) were registered. A total of 133 CT scans were performed on patients suspected of having a stone in the urinary tract (< 24 h after admission). All records were subsequently evaluated, the acute CT scans were re-evaluated by a radiological specialist. Interobserver agreements were assessed by means of Kappa analysis.

RESULTS

A total of 133 consecutive patients met the criteria for inclusion, of whom 62 were women and 71 were men. A total of 67 stones in 53 patients were identified. The variability of the radiological diagnosis (doctors under training and one consultant) was calculated, and the Kappa values were +0.66 and +0.69 for stones on the right and left side, respectively. The Kappa values for stones in ureter and the kidney were +0.79 and +0.52, respectively. In addition to stone disease, there were additional diagnoses in 30 patients (23%), out of whom seven had a malignant tumor.

CONCLUSION

In a low-volume hospital with fewer than 100 procedures a year, we found the UHCT method to be safe and reliable with a good interobserver agreement and Kappa value.

Hallux metatarsophalangeal arthroplasty in the rheumatoid forefoot

Surgical options for treatment of the hallux valgus deformity in the rheumatoid forefoot are numerous, but long-term results of many of these procedures have been less than satisfactory. Controversy exists as to whether excision or fusion is preferred for the treatment of the hallux metatarsophalangeal (MTP) joint. The role of replacement arthroplasty needs to be evaluated. The available surgical options for treatment of the arthritic first MTP joint in rheumatoid arthritis include arthrodesis, excision of the metatarsal head with or without interposition of the soft tissues, excision of the proximal phalanx, and silicone hinge replacement. This article discusses the various types of arthroplasty of the first MTP joint and the reported outcomes in the rheumatoid forefoot.

The biology of aseptic osteolysis

Total hip arthroplasty is one of the most commonly performed and successful elective orthopaedic procedures. However, numerous failure mechanisms limit the long-term success including aseptic osteolysis, aseptic loosening, infection, and implant instability. Aseptic osteolysis and subsequent implant failure occur because of a chronic inflammatory response to implant-derived wear particles. To reduce particulate debris and their consequences, implants have had numerous design modifications including high-molecular-weight polyethylene sockets and noncemented implants that rely on bone ingrowth for fixation. Surgical techniques have improved cementation with the use of medullary plugs, cement guns, lavage of the canal, pressurization, centralization of the stem, and reduction in cement porosity. Despite these advances, aseptic osteolysis continues to limit implant longevity. Numerous proinflammatory cytokines, such as interleukin-1, interleukin-6, tumor necrosis factor-alpha, and prostaglandin E2, have proosteoclastogenic effects in response to implant-derived wear particles. However, none of these cytokines represents a final common pathway for the process of particle-induced osteoclast differentiation and maturation. Recent work has identified the fundamental role of the RANKL-RANK-NF-kappaB pathway not only in osteoclastogenesis but also in the development and function the immune system. Thus, the immune system and skeletal homeostasis may be linked in the process of osteoclastogenesis and osteolysis.

The differential diagnosis of foot lumps: 101 cases treated surgically in North Glasgow over 4 years

INTRODUCTION

There are a wide variety of different lesions which present as lumps of the foot. There have been very few studies which look at the presenting characteristics or the differential diagnosis of such lesions.

PATIENTS AND METHODS

All patients who underwent excision or biopsy of a foot lump over a period of 4 years were studied in order to determine patient demographics, presenting characteristics, diagnoses encountered and to assess the diagnostic accuracy of the surgeon.

RESULTS

In total, 101 patients were identified. Average age was 47.3 years (range, 14-79 years); there was a marked female preponderance with 73 females and 28 males. Thirty different histological types were identified; ganglion cysts were the most commonly encountered lesions and there was only one malignant lesion encountered in this study. Only 58 out of the 101 lumps were correctly diagnosed prior to surgery. Certain lesions were more commonly encountered in specific zones of the foot.

CONCLUSIONS

We have shown that there are a wide variety of potential diagnoses which have to be considered when examining a patient with a foot lump. There is a low diagnostic accuracy for foot lumps and, therefore, surgical excision and histological diagnosis should be sought if there is any uncertainty.

Retention of the patella in total knee arthroplasty for rheumatoid arthritis

AIM

To determine whether retention of the native patella during total knee arthroplasty is appropriate in patients with rheumatoid arthritis.

METHODS

All patients undergoing total knee arthroplasty with a diagnosis of rheumatoid arthritis were identified between January 1997 and December 2000. Subsequently, each individual underwent both radiological and clinical assessments at a designated follow-up clinic.

RESULTS

A total of 30 total knee arthroplasties were studied in 28 patients. Twenty-six patients (93%) were female with a mean age of 74.7 years (range 60-83 years). The average post-operative interval was 59.4 months (range 46-82 months). All individuals were noted to have satisfactory patellar tracking and bone stock at the time of surgery. No patient subsequently underwent revision surgery during follow-up and no episodes of implant sepsis were identified. The mean Patellar Score at final follow-up was 26.2 (range 22-30) with an average anterior knee pain score of 14.2 (range 10-15). The mean Oxford Knee Score was 18.7 (range 16-23) with a mean pain score component of 5.9. Patients were finally assessed with respect to the Knee Society Score. The mean Knee Score was 83.8 (range 71-96) with a mean Function Score of 79.7 (range 40-90).

CONCLUSION

By retaining the native patella we were still able to obtain highly satisfactory medium-term results in terms of pain relief and function. In addition, the potential complications associated with prosthetic replacement of the patella were avoided.

Outcome after surgery for fracture of the hip in patients aged over 95 years

Despite the increase in numbers of the extreme elderly, little data is available regarding their outcome after surgery for fracture of the hip. We performed a prospective study of 50 patients aged 95 years and over who underwent this procedure. Outcome measures included morbidity, mortality, hospital stay, residential and walking status. Comparison was made with a control group of 200 consecutive patients aged less than 95 years who had a similar operation. The mortality at 28 and 120 days was higher (p = 0.005, p = 0.001) in the patients over 95 years. However, the one-year cumulative post-operative mortality was neither significantly different between the two groups (p = 0.229) nor from the standardised mortality rate for the age-matched population (p = 0.445). Predictors of mortality included the ASA grade, the number of comorbid medical conditions and active medical problems on admission. Patients over 95 were unlikely to recover their independence and at a mean follow-up of 29.3 months (12.1 to 48) 96% required permanent institutional care.

Psychiatric co-morbidity and gender differences in intellectual disability

BACKGROUND

Although gender differences in psychopathology among the general psychiatric population appear to be well documented, such differences have been either ignored or inconsistently investigated among people with intellectual disability (ID).

METHODS

The study examined psychiatric co- morbidity in 295 men and 295 women with ID and significant social impairments living in community settings. The sample was drawn from consecutive clinical referrals to a specialist mental heath service of South-East London. Psychiatric diagnoses were based on ICD-10 criteria.

RESULTS

Personality disorder was more common among men, although dementia and adjustment reaction were more common among women. There were also gender differences in marital status, with a larger percentage of women being either married or in a stable relationship. Gender differences in the source of referral were also observed, with more women being referred through primary care and more men being referred through generic mental health services.

CONCLUSIONS

Female patients seem to have at some extent different mental health needs from male patients. Such differences should be taken into account in the design and delivery of clinical service for people with ID.

An exploratory study of assertive community treatment for people with intellectual disability and psychiatric disorders: conceptual, clinical, and service issues

BACKGROUND

Assertive community treatment (ACT) has been applied to a number of disorders in the adult population, such as schizophrenia, with some degree of success; its use in the treatment of people with intellectual disability (ID) and mental illness has received little attention. Despite the high costs of ID in health and social care, there has been very little evidence-based practice for people with ID and mental illness, and it remains a neglected area of research. Aims The aims of this study were an exploratory comparison of the effectiveness of an ACT model for the treatment of mental illness in people with ID (ACT-ID) with a standard community treatment (SCT-ID) approach.

METHOD

A Randomized controlled trial design was adopted and allocation was made by stratified randomization by an independent statistician. The prognostic factors used in the randomization were gender and psychiatric diagnosis (psychosis vs. affective). Service users were randomly allocated to either ACT-ID or SCT-ID.

RESULTS

There were no statistically significant differences between ACT-ID and SCT-ID in terms of the level of unmet needs, carer burden, functioning and quality of life, but borderline evidence of a difference between treatment groups in quality of life in favour of SCT-ID. Both SCT-ID and ACT-ID groups decreased level of unmet needs and carer burden, and increased functioning. SCT-ID also led to a small increase in quality of life.

Schizophrenia-spectrum psychoses in people with and without intellectual disability

BACKGROUND

Although there is an increased risk of schizophrenia-spectrum psychoses (SSP) in people with intellectual disability (ID), there is a paucity of research evidence into clinical presentation of the disorder in comparison with research into SSP in people without ID.

AIMS

The aims of the study were to compare clinical, functional, and social factors in patients with mild ID (ICD-10: F70) and SSP (ICD-10: F20-9) attending a specialist mental health service for people with ID, with a control group of patients without ID but with SSP attending a generic adult mental health (GAMH) outpatient clinic.

METHOD

A total of 106 patients with SSP (53 with ID and 53 from GAMH) were assessed on psychopathological symptoms, functioning scales and quality of life. They were compared using chi-squared and regression analysis where appropriate.

RESULTS

People with ID and SSP appear to be more debilitated by the co-occurring disorder than those with the same disorder but without ID. Increases in observable psychopathology and "negative" schizophrenic symptoms, and decreased functional abilities were observed in the group with ID when compared to the GAMH group. The clinical implications of these findings are discussed.

Psychiatric inpatient care for adults with intellectual disabilities: generic or specialist units?

BACKGROUND

When adults with intellectual disabilities (ID) require a psychiatric admission, general adult mental health units are often used. Specialist units have emerged recently as a care option but there is only limited evidence of their effectiveness. Thus this study aims to describe and evaluate the effectiveness of a specialist inpatient unit and report on the utilization of generic and specialist inpatient services.

METHOD

All patients admitted to a specialist ID psychiatric unit were evaluated on admission and immediately after discharge on a number of outcome measures. In addition, they were compared with those admitted to general adult mental health units covering the same catchment area.

RESULTS

Significant improvements were demonstrated within the specialist unit cohort on measures including psychopathology, global level of functioning, behavioural impairment and severity of mental illness. The specialist unit patients had a longer length of inpatient stay but were less likely to be discharged to out-of-area residential placement.

CONCLUSIONS

Specialist units are an effective care option for this group of people.

Referral trends of people with intellectual disabilities and psychiatric disorders

BACKGROUND

The Specialist Mental Health Service for people with an intellectual disability (ID) and psychiatric disorder (referred to throughout this paper as 'the Service') has been in operation in south-east London for the last 18 years, during which time two local, long-stay institutions have closed.

AIMS

To measure the number of referrals to the Service from 1983 to 2001 and identify trends.

METHODS

Data were recorded on 752 new referrals using the assessment and information rating profile. Diagnoses according to the International Classification of Diseases (10th edition) were made by two psychiatrists. Referrals for a one off consultation or assessment, or with an IQ>70 were excluded from analysis.

RESULTS

Over time more non-white clients and more clients with mild ID were referred. More referrals were made in later years, and a greater proportion came from primary care. Later referrals were also more likely to have a psychiatric diagnosis than those in earlier years.

CONCLUSION

Significant trends in referrals were identified, which may be explained by various external factors.

Contextual risk factors for the common mental disorders in Britain: a multilevel investigation of the effects of place

STUDY OBJECTIVE

To test hypotheses about associations between area level exposures and the prevalence of the most common mental disorders (CMD) in Britain. A statistically significant urban-rural gradient was predicted, but not a socioeconomic gradient, in the prevalence of CMD after adjusting for characteristics of individual respondents. The study tested the hypothesis that the effects of area level exposures would be greatest among those not in paid employment.

DESIGN

Cross sectional survey, analysed using multilevel logistic and linear regression. CMD were assessed using the General Health Questionnaire (GHQ). Electoral wards were characterised using the Carstairs index, the Office of National Statistics (ONS) Classification of Wards, and population density.

SETTING

England, Wales, and Scotland.

PARTICIPANTS

Nearly 9000 adults aged 16-74 living in 4904 private households, nested in 642 electoral wards.

MAIN RESULTS

Little evidence was found of statistically significant variance in the prevalence of CMD between wards, which ranged from 18.8% to 29.5% (variance 0.035, SE 0.026) (p=0.11). Associations between CMD and characteristics of wards, such as the Carstairs index, only reached statistical significance among those who were economically inactive (adjusted odds ratio for top v bottom Carstairs score quintile 1.58, 95% CI 1.08 to 2.31) (p<0.05).

CONCLUSIONS

There may be multiple pathways linking socioeconomic inequalities and ill health. The effects of place of residence on mental health are greatest among those who are economically inactive and hence more likely to spend the time at home.

Prevalence of osteoporotic bone mineral density at the hip in Britain differs substantially from the US over 50 years of age: implications for clinical densitometry

The purpose of this study was to compare hip bone mineral density (BMD) recorded in seven population based cohorts in Britain with the third National Health and Nutrition Examination Survey (NHANES III) US population-based reference data, in order to assess geographic variation in the prevalence of osteoporosis. Men and women aged 50-80+ years were randomly recruited from population and health registers. Dual X-ray absorptiometry (DXA) equipment was used to measure BMD at the hip, with the femoral neck and the trochanter regions studied. Prevalences of osteopenia and osteoporosis were estimated in accordance with World Health Organisation diagnostic criteria for women. Young normal data, used to establish cut-off criteria, was from NHANES III. Both male and female British subjects over 50-years-old were found to have significantly higher mean BMD at the femoral neck and trochanter than their US counterparts. Decline in BMD with age in British men appeared slower than in US men. Between British centres there were also statistically significant differences in BMD values in both sexes. British age-adjusted prevalences of osteopenia in women averaged 20% less than those of NHANES III, whereas the prevalence of osteoporosis was substantially lower in British subjects of both sexes (55% in women, 68% in men). Thus, applying the US NHANES III data as the referent, osteoporosis of the proximal femur in Britain appears to be less common than in the US, due primarily to differences in the lower tails of the BMD distributions. Providing that the relationship between fracture rates and BMD is the same in Britain and the US, it would still be appropriate to apply the reference data in fracture risk assessment in the UK.

The socioeconomic status of older adults: how should we measure it in studies of health inequalities?

STUDY OBJECTIVE

To identify which of seven indicators of socioeconomic status used singly or combined with one other would be most useful in studies of health inequalities in the older population.

DESIGN

Secondary analysis of socioeconomic and health data in a two wave survey.

SETTING

Great Britain. Participants were interviewed at home by a trained interviewer.

PARTICIPANTS

Nationally representative sample of 3543 adults aged 55-69 interviewed in 1988/9, 2243 of whom were interviewed again in 1994.

METHODS

Desirable features of socioeconomic measurement systems for identifying health inequalities in older populations were identified with reference to the literature. Logistic regression was used to examine variations in self reported health by seven indicators of socioeconomic status. The pair of indicators with the greatest explanatory power was identified.

MAIN RESULTS

All indicators were significantly associated with differences in self reported health. The best pair of variables, according to criteria used, was educational qualification or social class paired with a deprivation indicator.

DISCUSSION

For a range of reasons the measurement of socioeconomic status is particularly challenging in older age groups. Extending our knowledge of which indicators work well in analyses and are relatively easy to collect should help both further study of health inequalities in the older population and appropriate planning.

[Catheter-guided thrombolysis in peripheral arterial occlusion]

By catheter-directed, regional, intravascular thrombolysis a thrombus-dissolving enzyme is applied through a catheter placed at/in the occlusion. Non-fibrin-specific (streptokinase or urokinase) and fibrin-specific agents (tissue plasminogen activators) are available. The large randomised trials (TOPAS and STILE) have serious selection bias, which makes generalisation difficult. Other studies have incomparable data and thus meta-analysis is impossible. Consequently, a recent consensus document cannot recommend an agent or principle of infusion. Thrombolysis of late, but transitory (< 14 days), occlusions seems beneficial but long-term results are lacking and recurrences are common. Exclusion of preoperative thrombolysis in late and longer lasting occlusions (> 14 days) is debatable, because of a potential thrombolysis-caused improved run-off. Individual case selection is still needed, because thrombolysis is a promising, although experimental, treatment.

BIOMED-MEROPE project: service provision for adults with intellectual disability: a European comparison

The aim of the present paper is to describe and compare services for adults with intellectual disability (ID) and mental health needs in five European countries: Austria, England, Greece, Ireland and Spain. A framework and structure for collecting information about service provision was designed. This information was collected through a mixture of interviews with service providers, questionnaires and a review of the research literature within each country. Information was collected on historical context, policy, legislation, assessment, treatment and the structure of services for people with ID and mental health problems. Overall, the needs of those with additional mental health needs have not been specifically addressed at a national level with perhaps the exception of England and Ireland, although there are still gaps in services in these nations. Normalization has been adopted in each of the five countries, and there are moves toward deinstitutionalization, integration and inclusion. Families and self-advocacy groups have grown. The pace of this change varies between and even within countries. The main findings of the study include: unclear policy, trends for legislative changes, increased prevalence of mental health problems, inadequate generic service provision, a need for specialist mental health services, a need for improved interconnections of services, and a need for training developments. Policy and legislation in the five European countries under consideration tend to separate the disability aspects of people with ID from their mental health needs. Consequently, the service needs of this group remain largely invisible. This might be a direct reflection of policy clarity and legislation, or could be the result of a failure to implement existing guidelines. This has a detrimental effect on the lives of people with ID, and their families and carers.