Left Hospital Research Articles

Survivors and victims of hospital restructuring and downsizing: who are the real victims?

This study reports the results of a longitudinal study of the effects of hospital restructuring and downsizing on nursing staff satisfaction and psychological well-being. Participants completed questionnaires in November 1996 and November 1999. All were employed as hospital-based nurses in 1996 but some had left hospital nursing for other jobs by 1999. Nurses still employed in hospital settings ( N=744) were compared with nurses now employed elsewhere ( N=74). Hospital-based nursing staff reported less job satisfaction, more absenteeism, greater psychological burnout and poorer psychological well-being than nurses now employed elsewhere.

Cirurgia Endoscópica Subfascial de veias Perfurantes Insuficientes (CESPI): experiência inicial

OBJETIVO: Estudar os resultados imediatos e a médio prazo da cirurgia endoscópica subfascial de perfurantes. MÉTODO: Estudo clínico, prospectivo e descritivo. Critérios de inclusão: insuficiência venosa crônica primária ou secundária, sistema venoso profundo pérvio e índice tornozelo/braço maior que 0,8. Critérios de exclusão: ocorrência da trombose venosa profunda, ou trauma ou cirurgia ortopédica e cirurgia sobre o sistema venoso profundo durante o período de seguimento pós-operatório. Todos doentes foram examinados pelo ecodoppler colorido antes da operação. RESULTADOS: Foram operados 43 membros a partir de junho/1997. Eram 27 doentes com média de idade 56,5 anos. A insuficiência venosa crônica era secundária à trombose venosa em dois membros. Três membros foram classificados como C3, 15 como C4, 11 como C5 e 14 como C6. A retirada das veias safena interna, safena externa e tributárias foi associada em 35 membros. Foram ligadas três a cinco perfurantes por membro; não houve óbitos no pós-operatório imediato; houve três infecções e as úlceras cicatrizaram em períodos variáveis de duas a 15 semanas. Dezenove doentes obtiveram alta hospitalar no primeiro dia de pós-operatório, seis no segundo e dois no terceiro. Houve uma recidiva de úlcera (4,0%) durante o período de seguimento de 25 meses (média) por causa de perfurante não-ligada. CONCLUSÕES: A cirurgia endoscópica subfascial de veias perfurantes insuficientes associada à cirurgia radical de varizes é segura, acompanha-se de baixo índice de complicações, pode ser adaptada aos instrumentos comuns da cirurgia laparoscópica, indicada para doentes classificados como C4, C5 e C6 e se acompanha de bons resultados imediatos e a médio prazo.

Deliveries, mothers and newborn infants in Sweden, 1973–2000

The aim of this report is to present descriptive data from the Swedish Medical Birth Register (MBR) reflecting trends in obstetric and neonatal practices over three decades. Since 1973 the MBR at the Swedish National Board of Health and Welfare receives information on all pregnancies in Sweden--around 95,000 annually--that have lead to delivery regarding the pregnancy, delivery and the newborn infant. In this study selected data from the MBR are presented as they have developed between 1973 and 2000. There was a shift in age distribution of childbearing women towards older women. Cigarette smoking in early pregnancy decreased from 30% to 12%. In-hospital time after both vaginal and cesarean (CS) delivery decreased and more than 50% of all women with a vaginal singleton delivery left hospital within 48 hours in 2000. The proportion of CS increased from 5 to 15% at singleton deliveries. The CS rate for breech deliveries increased and was nearly 80% in 2000. The mean birth weight increased, particularly the proportion of heavy infants. The proportion of early neonatal deaths decreased continuously, both for term infants and infants born after short gestational length, whereas no such downward trends was found for stillbirth during the last 10-15 years. Although several of the changes regarding pregnancy and delivery that occurred between 1973 and 2000 could be expected to influence pregnancy outcome negatively, the trends described here generally suggest improvement in maternal and child health.

COAGULATION MANAGEMENT IN PATIENTS WITH THE AXIAL FLOW PUMP BERLIN HEART INCOR

Purpose: We present the first results of our coagulation management in patients with the new axial flow pump Berlin Heart Incor. Methods: Between June and December 2002 the new axial flow pump was implanted in six patients. The diagnosis in three patients was dilatative cardiomyopathy (CMP) and in three ischemic CMP. The group was treated with a new anticoagulation concept consisting of anti-aggregation, anti-adhesion and anti-coagulation drugs and of rheologica. The mean support time was 110 days. Results: After the first two postoperative days the mean platelet count was 155.000/μl and results in platelet aggregation tests were normal, so that early anti-aggregation therapy with aspirin was necessary. Nevertheless one patient suffered a transient ischemic attack (TIA) on the eighth postoperative day. In total, four TIAs occurred in three patients (50%). In all these cases platelet anti-aggregation therapy was insufficient. No patient presented apoplexia and no patient died. None of the patients had to be reopened and none had gastrointestinal bleeding. In two patients transient epistaxis was seen. Four patients have left hospital; two are in the early postoperative stage. In one patient myocardial recovery occurred and the pump could be explanted. With the new axial flow pump Berlin Heart Incor early postoperative platelet recovery was seen, requiring early anti-aggregation therapy. Our coagulation protocol minimized the incidence of bleeding and embolic complications. It ensures the survival of the patients on MCS, is easy to perform, is not expensive and enables patients to be discharged home.

頚部動静脈奇形例

We herein report our findings in a 4-year-old male with arteriovenous malformation of the neck. The chief complaint was a neck mass which had progressed in size slowly from 2 months before. Physical examination revealed a non-pulsatile, painless and soft mass approximately 4cm in diameter under the left submandibular area. The diagnosis of lymphangioma cysticum was made based on imaging findings of polycystic lesion on ultrasonography and magnetic resonance imaging (MRI). Since the mass adhered to the submandibular gland very strongly, we performed en-block resection of the mass with the submandibular gland. The mass showed no adherence to the adjacent tissue without submandibular gland. The framework was filled with numerous arterial and venous structures, and the histopathological diagnosis was arteriovenous malformation. He left hospital without any problem on postoperative day 7. The treatment for subclinical arteriovenous malformation is regarded as to watch and see. Although the curative treatment is surgical resection, the resection of a bulky mass which may cause dyspnea is very difficult. Our patient could not be diagnosed preoperatively because he did not undergo gadolinium enhanced MRI.

Prosthetic Replacement For Femoral Neck Fractures

Prosthetic replacement of the femoral head was performed in series of five selected patients at Shanta Bhawan Hospital, Kathmandu. Although prosthetic replacement surgery is common place in most parts of the globe, this was the first time we had undertaken this type of treatment at our hospital. We used fenestrated stem Austin Moore prosthesis in all our patients. Bone cement (methyl-methacrylate) is not readily available to us at the present and we have not yet used prosthesis with cement at our hospital. One of our patients expired in the immediate post operative period. The remaining four patients were rapidly rehabilitated and left hospital on their feet after an average in-hospital stay of about three weeks. Although it is too early right now to draw conclusions, we feel that given the selected patient, there are definite indications for this type of procedure even in the Nepalese socio-economic context. TABLE 1.Case Age Sex Side Associated conditions 1 63 M (R) ASHD, Diabetes mellitus. 2 63 M (R) ---- 3 65 M (R) ---- 4 72 F (R) Duodenal ulcer disease. 5 70 M (R)

Pneumonectomy in children.

Surgical literature carries relatively scant information on pneumonectomy in children. We reviewed our experience over 7 years, determined the risk/benefit ratio and compared our experience with reports from the literature. The records of children undergoing pneumonectomy, 14 years and younger, over a 7-year period from January 1991 to December 1997, are analysed, the techniques used to determine the need for and extent of surgery are studied, whilst the problems and outcome of surgery in this age group are determined. Fifty-nine children, 40 males, 19 females, aged 6 months to 14 years, average age of 7.5 years, underwent pneumonectomy. A history of pulmonary infection/s and a chest radiograph suggestive of lung destruction were indicators for investigation by bronchography and/or computerized axial tomography of the chest (HRCT scan). This determined the nature and extent of disease and the possibility and extent of surgery required. Bronchus blockers (22), five others in combination with the prone operating position, prone position (six) and a double lumen tube in one, were used to protect the healthy lung at surgery. Spill of pus was recognized once with a bronchus blocker and the prone position used in combination. Six intra-operative complications (10.1%) were recognized: bronchial spill (one) without consequence, conversion of bi-lobectomy to pneumonectomy due to pulmonary artery injury (one), cardiac arrest (with resuscitation, one), bradycardia with hypotension (one), excessive bleeding (one) and intra-pleural spill of debris (one), the last without consequence. Seven post-operative complications (11.8%) occurred: one empyema (sterilized), bleeding one, pulmonary infection two, suspected but unproven broncho-pleural fistulae two, prolonged antibiotics in one, reason unrecorded. One pneumonectomy through an empyema was uncomplicated. The main histological features were bronchiectasis (38), active tuberculosis (eight), end-stage lung (five), collapse and pulmonary haemorrhage (one), lobar emphysema (one). Histology unrecorded (one). No death occurred. All patients left hospital well. Careful preparation, often including anti-tuberculosis cover, and timing of pneumonectomy are essential. Meticulous anaesthetic and surgical technique and co-operation are critical. Bronchus blockers functioned well but are not without risk. Attention to detail makes pneumonectomy safe in childhood.

The Jarvik 2000 Heart. Clinical validation of the intraventricular position

Heart failure is now a public health epidemic. Donor hearts are severely restricted in availability. Permanent mechanical circulatory support or bridge to myocardial recovery are emerging alternatives. After extensive laboratory experience we sought to evaluate the intraventricular Jarvik 2000 Heart in patients with endstage heart failure. The Jarvik 2000 Heart is a novel thumb-sized left ventricular assist device (LVAD) which is fitted within the apex of the native left ventricle. A vascular graft off loads this to the descending thoracic aorta. The pump rotor spins at between 8000 and 12,000 rpm providing 5-6 litres blood flow per minute. We have used the device with skull-mounted power delivery for seven permanent implants and trans-abdominal drive line for ten bridge-to-transplant patients. All patients survived the operation. Three died from non-device related complications. Survivors had early resolution of heart failure with return to NYHA I/II. All had pulsatile circulation. The device was user-friendly and imperceptible to the patient. Both the pump and native left ventricle contributed to the cardiac output during exercise. Seven patients have been transplanted successfully. All explanted devices were free from thrombus formation. Two permanent implant patients left hospital as early as 3 weeks postoperatively. The Jarvik 2000 is an effective user-friendly LVAD which allows early discharge from hospital. The intraventricular position has distinct advantages especially through absence of an inflow cannula. Synergy develops between the LVAD and native left ventricle. Early experience suggests that this may be a realistic LVAD to treat heart failure routinely in the outpatient setting.

Quality of medical care and excess mortality in older patients with mental disorders.

This study investigated whether differences in quality of medical care might explain a portion of the excess mortality associated with mental disorders in the year after myocardial infarction. This study examined a national cohort of 88 241 Medicare patients 65 years and older who were hospitalized for clinically confirmed acute myocardial infarction. Proportional hazard models compared the association between mental disorders and mortality before and after adjusting 5 established quality indicators: reperfusion, aspirin, beta-blockers, angiotensin-converting enzyme inhibitors, and smoking cessation counseling. All models adjusted for eligibility for each procedure, demographic characteristics, cardiac risk factors and history, admission characteristics, left ventricular function, hospital characteristics, and regional factors. After adjusting for the potential confounding factors, presence of any mental disorder was associated with a 19% increase in 1-year risk of mortality (hazard ratios [HR], 1.19; 95% confidence interval [CI], 1.04-1.36). After adding the 5 quality measures to the model, the association was no longer significant (HR, 1.10; 95% CI, 0.96-1.26). Similarly, while schizophrenia (HR, 1.34; 95% CI, 1.01-1.67) and major affective disorders (HR, 1.11; 95% CI, 1.02-1.20) were each initially associated with increased mortality, after adding the quality variables, neither schizophrenia (HR, 1.23; 95% CI, 0.86-1.60) nor major affective disorder (HR, 1.05; 95% CI, 0.87-1.23) remained a significant predictor. Deficits in quality of medical care seemed to explain a substantial portion of the excess mortality experienced by patients with mental disorders after myocardial infarction. The study suggests the potential importance of improving these patients' medical care as a step toward reducing their excess mortality.

Neonatal tetanus

OBJECTIVE: Neonatal tetanus is an infection with high mortality, constituting a problem in underdeveloped countries, where there is faulty prenatal attendance. In spite of this and of the decreasing incidence of the disease in the state of Rio Grande do Sul, we report a case of neonatal tetanus identified in 1997. METHOD: We interviewed the infantacute;s mother and verified her vaccination history. We conducted a clinical examination of the newborn, anaerobic culture of umbilical stump and review of medical records. We also reviewed the literature and verified the epidemic profile of neonatal tetanus in Rio Grande do Sul.RESULTS: Healthy mother, with complete outline of tetanus vaccination 4 years ago, prenatal uncomplicated and hospital delivery. Family of good socioeconomic level, differing from the other cases notified in the State, in that most did not have prenatal care nor hospital delivery. The patient is a boy. In the 24th day of life he presented fever, cyanosis, lower and upper limbs muscle hypertonia and opisthotonos episodes. An anaerobic culture of the umbilical stump grew Clostridium tetani. He was treated with penicillin G, gentamicin, sedation and tetanus immunoglobulin. He left hospital in good conditions.CONCLUSIONS: Faulty prenatal care in underdeveloped countries is the largest risk factor for high incidence of this disease in these areas. However, in pregnant women with good socioeconomic level and prenatal care, as in the case described here, this diagnosis should not be excluded if there are suggestive signs of it.

Emergency reinstitution of cardiopulmonary bypass following cardiac surgery: outcome justifies the cost

Crash back on bypass (crash-BOB) is occasionally required in the resuscitation of patients developing life-threatening complications following cardiac surgery. This study aims to determine the incidence, aetiology and cost-effectiveness of such intervention. Retrospective review of all crash-BOB patients over 5.5 years at one hospital. The incidence of crash-BOB was 0.8% and occurred at a mean of 7 h post-operatively (range 1 h-20 days). Pre-operative Parsonnet scores were similar to the overall population of patients undergoing surgery in our institution (mean score 10; range 0-45). The original cardiac operations were coronary revascularization (39), valve surgery (12) and others (4). Indications for crash-BOB were cardiac arrest (23), bleeding (20), hypotension (7), ischaemia (1) and others (4). Of the 55 patients, 20 died on the operating table. Of the remaining 35, a further 12 died in hospital. Overall survival was therefore 42%. Where crash-BOB was for bleeding, 17 of 20 patients (85%) survived to leave theatre, of whom 11 patients (55%) left hospital alive. In the 35 non-bleeders, only 18 (51%) survived crash-BOB and 12 (34%) left hospital alive. Sixteen patients required a second period of aortic cross-clamping of whom 13 (81%) survived to leave theatre, and 11 (69%) left hospital alive. Conversely, of nine patients in whom no specific diagnosis was found during crash-BOB, only two (22%) survived the procedure and none survived to hospital discharge. Multiple logistic regression identified pre-operative Parsonnet score (P=0.045) and the need for aortic cross-clamping to deal with an identified surgical problem (P=0.03) as significant predictors of hospital survival. Indication for crash-BOB (bleeder/non-bleeder) failed to reach significance (P=0.08). Age, sex, intra-aortic balloon pump use at the primary procedure, and time following the primary procedure to crash-BOB were not identified as predictors of hospital survival. Of the 23 hospital survivors, three patients suffered a stroke post-operatively and made a good functional recovery prior to discharge. Two patients developed sternal wound dehiscence requiring surgical rewiring. At follow-up (mean 3 years, range 1-6 years), 19 patients were in NYHA class I and four were in class II. Crash-BOB patients required an average of 8 extra intensive care days and 2 extra ward days. The total cost of these resources was pound164900 (including theatre time, cardiopulmonary bypass and intra-aortic balloon pump use). This was equivalent to pound7170 per life saved. Crash-BOB occurred in 0.8% of cases and was associated with a survival to discharge of 42%, and a justifiable cost of only pound7170 per life saved. Establishing an accurate diagnosis for the cause of clinical deterioration resulting in crash-BOB intervention was important, and the need for a further period of aortic cross-clamping did not preclude a favourable outcome.

Henry Heimlich—Heimlich Maneuver

A postage stamp issued by Uganda in 1990 shows Mickey Mouse performing the Heimlich maneuver (manual thrust) on Donald Duck, who is choking on food. In the early 1970s, the American surgeon Henry Jay Heimlich observed that food and other objects that caused choking were not freed by the recommended technique of delivering sharp blows to the back. As an alternative, in 1974 he devised a method called the “Heimlich maneuver,” by which air expelled from the victim's lungs propels food or other material from the throat. In the Heimlich maneuver, the rescuer wraps his arm around the choking victim's waist from behind, makes a fist with one hand and holds the fist with the other hand between the naval and the rib cage, and presses forcefully into the victim's diaphragm to expel the food. Heimlich was born on February 3, 1920, in Wilmington, Del. He received a BA degree from Cornell University in Ithaca, NY, in 1941 and an MD degree in 1943. His internship at Boston City Hospital was interrupted in 1944 by service in the US Navy during World War II (1939-1945). He served as a surgeon with the Chinese guerrillas in the Gobi Desert and Inner Mongolia, service that was recognized and honored by the Chinese Ministry of Health in 1984. After the war, Heimlich served as a resident in thoracic surgery in several hospitals in the New York City area: Veterans Administration Hospital in The Bronx in 1946-1947, Mount Sinai Hospital in 1947-1948, Bellevue Hospital in 1948-1949, and Triboro Hospital (Jamaica, Queens) in 1949-1950. From 1950 to 1969, Heimlich was attending surgeon and director at Montefiore Hospital and Medical Center in New York City. In 1969, he moved to Cincinnati, Ohio, where he served as director of surgery at Jewish Hospital until 1977. In 1974, he tested his manual thrust theory on laboratory dogs. He left Hospital in 1977 to become professor of advanced clinical sciences of Xavier University in Cincinnati and to found the Heimlich Institute, where he served as president from 1977 to 1989. Heimlich is the author of Postoperative Care in Thoracic Surgery (1962) and coauthor of Surgery of the Stomach, Duodenum, and Diaphragm: Questions and Answers (1967). He has contributed many chapters to various books on surgery and has written numerous articles for medical journals. He is a diplomate of the American Board of Surgery and the American Board of Thoracic Surgery and a member of many scientific and medical societies. Among the honors he has received are honorary doctor of science degrees from Wilmington College (Del) in 1981, Adelphi University (NY) in 1982, Rider College (NJ) in 1983, and Alfred University (NY) in 1993. Besides being known for the Heimlich maneuver, Heimlich is credited with developing reversed gastric tube esophagoplasty for the replacement of the esophagus, developing a device for life-saving chest surgery, inventing a chest drain valve (Heimlich valve) for patients with chronic lung disease, and providing a method for enabling stroke patients to relearn the process of swallowing.

Henry Heimlich—Heimlich Maneuver

A postage stamp issued by Uganda in 1990 shows Mickey Mouse performing the Heimlich maneuver (manual thrust) on Donald Duck, who is choking on food. In the early 1970s, the American surgeon Henry Jay Heimlich observed that food and other objects that caused choking were not freed by the recommended technique of delivering sharp blows to the back. As an alternative, in 1974 he devised a method called the “Heimlich maneuver,” by which air expelled from the victim's lungs propels food or other material from the throat. In the Heimlich maneuver, the rescuer wraps his arm around the choking victim's waist from behind, makes a fist with one hand and holds the fist with the other hand between the naval and the rib cage, and presses forcefully into the victim's diaphragm to expel the food. Heimlich was born on February 3, 1920, in Wilmington, Del. He received a BA degree from Cornell University in Ithaca, NY, in 1941 and an MD degree in 1943. His internship at Boston City Hospital was interrupted in 1944 by service in the US Navy during World War II (1939-1945). He served as a surgeon with the Chinese guerrillas in the Gobi Desert and Inner Mongolia, service that was recognized and honored by the Chinese Ministry of Health in 1984. After the war, Heimlich served as a resident in thoracic surgery in several hospitals in the New York City area: Veterans Administration Hospital in The Bronx in 1946-1947, Mount Sinai Hospital in 1947-1948, Bellevue Hospital in 1948-1949, and Triboro Hospital (Jamaica, Queens) in 1949-1950. From 1950 to 1969, Heimlich was attending surgeon and director at Montefiore Hospital and Medical Center in New York City. In 1969, he moved to Cincinnati, Ohio, where he served as director of surgery at Jewish Hospital until 1977. In 1974, he tested his manual thrust theory on laboratory dogs. He left Hospital in 1977 to become professor of advanced clinical sciences of Xavier University in Cincinnati and to found the Heimlich Institute, where he served as president from 1977 to 1989. Heimlich is the author of Postoperative Care in Thoracic Surgery (1962) and coauthor of Surgery of the Stomach, Duodenum, and Diaphragm: Questions and Answers (1967). He has contributed many chapters to various books on surgery and has written numerous articles for medical journals. He is a diplomate of the American Board of Surgery and the American Board of Thoracic Surgery and a member of many scientific and medical societies. Among the honors he has received are honorary doctor of science degrees from Wilmington College (Del) in 1981, Adelphi University (NY) in 1982, Rider College (NJ) in 1983, and Alfred University (NY) in 1993. Besides being known for the Heimlich maneuver, Heimlich is credited with developing reversed gastric tube esophagoplasty for the replacement of the esophagus, developing a device for life-saving chest surgery, inventing a chest drain valve (Heimlich valve) for patients with chronic lung disease, and providing a method for enabling stroke patients to relearn the process of swallowing.

Kill or cure

“Would you like some morphine, doctor? I've got more than I need.” One of my patients, newly discharged from hospital, telephoned to make me an offer I could not refuse. I went round after surgery and, after assuring me that he felt much better, he took me into the kitchen where he unpacked the goody bag of drugs presented to him when he left hospital.

Clinical experience of needle‐laparoscopic cholecystectomy

Forty‐eight cholecystectomy cases were successfully treated at Luohu hospital by needle laparoscopy. The patients were aged 22–69 years and included 36 cases of gallstones, 9 cases of gallbladder polyps, and 3 cases of gallbladder polyps with gallstones. All patients recovered and left hospital 1–3 days postoperatively (average 2.6 ± 0.6 days). There were minimal complications from the surgery and patients recovered quickly. Because the needle laparoscope is more difficult to use than the standard laparoscope, both surgeon and assistant must practise its use, first on cholecystitis cases with minor inflammation, especially in those patients whose gallbladder walls are thinner than 3 mm on ultrasound. Generally, the needle laparoscope is used for inserting titanium clips when the gallbladder is removed. The operation can best be performed by surgeons experienced in laparoscopic cholecystectomy using the standard laparoscope.

Quality of life after oesophagectomy: the patients' perspective.

There have been formal publications which address the quality of life after oesophagectomy for oesophageal cancer, but what follows is an account of my own experience as a patient and of the experiences of the many fellow patients and their carers whom I have met during my 14 years as Chairman of the Oesophageal Patients' Association (UK). The Association works closely with clinicians and paramedical professionals and enables former patients to support new patients who have oesophageal problems. Because the incidence of adenocarcinoma is increasing rapidly in the Western world, the need for this type of support will be ever more pressing. I was invited to give the talk on which this article is based at the ISDE Congress in Montreal, Canada, in 1998. My hope is that dissemination of the experiences of others and myself will be of use to the wider clinical world involved in the treatment of this aggressive disease. In 1980, when only in my 40s, I developed an adenocarcinoma of the lower third of my oesophagus. An oesophageal resection, including 30% of my stomach and a pyloromyotomy, was performed. The remaining stomach was brought through my chest and joined to the oesophageal remnant in my neck. There was no nodal involvement. Three years later, I met, for the ®rst time, other patients who had had the same treatment and there was an immediate anity between us, with a feeling of mutual reassurance. This made me realize that others could be similarly helped by such contacts and, with the help of my surgeon, I founded the Oesophageal Patients' Association (OPA), which has been formally in existence since 1985. Since then, contact with over 4000 patients and work alongside the medical teams has given me some insight into quality-of-life aspects. I am quite clear that exchange of experience between new and former patients has a major in uence on patients' quality of life. Written information about these experiences and why they occur is enormously helpful. I left hospital 9 days after my operation with no information about recovery, what to do or not do, what to eat or not to eat. In retrospect, that experience has in fact helped my wife and me to develop the guidance lea ets that OPA now issues. The main problems I experienced were continued weight loss, extreme tiredness, eating very little, dramatic diarrhoea and nausea and milk intolerance. It is during this immediate post-operative period that many patients in the UK feel the isolation of their situation. After the operation, I lost a further 6.5 kg over 8 weeks, having lost 9.5 kg beforehand. I became extremely worried and was reluctant to let my doctor weigh me. My weight then levelled out and slowly increased over the next 9 months until I reached my present weight, i.e. about 6.5 kg lighter than I used to be. A hard way to lose weight! I have never felt so tired in my life as when I got home from hospital. Minor activity caused over-tiredness, and sleeping at night was disturbed (because of some pain). I did not feel that I was getting better. I found the answer was to go to bed (properly) for 2 h in the afternoon during the ®rst 5 or 6 recovery weeks. I have learned that men in particular can ®nd this dicult; they want to be back to normal habits soon after leaving hospital, but the body needs time and respect. Eating little can be more of a problem for the carer than the patient. The carer understandably wants the patient to start eating again after the months of not being able to eat well and of losing weight. It is very frustrating when the patients' favourite foods are prepared and then not really wanted. If you do try and then eat too much, the after-e€ects are dicult Address correspondence to: J. D. Kirby, Oesophageal Patients' Association, 16 White®elds Crescent, Solihull B91 3NU, UK. Tel: (+44) 121 704 9860; Fax: (+44) 121 704 9860; E-mail: opakirby@mcmail.com

Patterns of service use among people with learning disabilities discharged from long-stay hospital care in Northern Ireland

AbstractObjectives: Continuing deinstitutionalisation has led to growing concern about the availability and accessibility of services for people with learning disabilities transferring to community living. This study was undertaken in order to assess the configuration of services in terms of availability and uptake for people with learning disabilities who have left long-stay hospital care and to identify gaps or barriers to service provision within the unique integrated health and social services structure in Northern Ireland.Method: The ‘keyworkers’ of 195 people – most of whom were aged 40-59 years with a diagnosis of moderate intellectual impairment – were interviewed by a researcher one year after discharge using the Service Interview.Results: While a wide range of generic and specialist services was available, ‘packages’ of care consisted largely of public sector services (eg. GPs, chiropodists and social workers) and relied, to some extent, on the type of community accommodation. Although services appeared well co-ordinated in terms of care reviews and keyworker arrangements, 40% of people required more one-to-one support particularly in areas related to integration. However, services were perceived by care staff to be satisfactoryConclusions: The development of community care has been slower in Northern Ireland than elsewhere and a large proportion of resources remain tied up in hospital care. However, existing community-based services appear to be addressing individual needs. Some former patients, though, may have been subject to transinstitutionalisation in the sense that their choice of accommodation was restricted mainly to large private sector homes and work and daytime opportunities were insufficient to facilitate integration. Service planners and providers need to give further consideration to the likely effects of different forms of rehabilitation, reprovision and resettlement and to be aware that the pattern of service provision is likely to be different for the more dependent cohorts of people who leave hospital in the future.

Acute Renal Impairment Due To a Primary Aortocaval Fistula is Normalised After a Successful Operation

Objectivesto study renal function in patients with aortocaval fistula, before and after surgery.DesignRetrospective study.Material and methodsduring the last 22 years nine male patients (median age 67, age range 50–72) with spontaneous aortocaval fistula in combination with AAA were operated upon. This constitutes 4% of the patients with ruptured AAA and 1.5% of all patients with AAA.Resultsa preoperative diagnosis of aortocaval fistula was established in three of the nine cases. The medium duration of symptoms prior to surgery was 5 days (range 4 h–14 days). The fistula was combined with an extravasating ruptured AAA in only three patients. Seven of the patients had acute renal insufficiency, with creatinine levels of in median 292 μmol (IQR 218–342). Creatinine declined to 172 μmol/l (IQR 170–313) on the fifth postoperative day in uncomplicated cases and to 86 μmol at discharge. One patient died due to multi-organ failure, whereas the other left hospital well and alive with normal renal function.Conclusionacute preoperative renal insufficiency due to an aortocaval fistula in patients with AAA is often due to venous congestion, and is normalised after successful surgery.

From two weeks to twenty-two: one patient's experience of minor surgery

Two weeks in hospital! 'I'll cut them out, sew you up; you'll be as good as new and home again in a fortnight!' Thus said the consultant in 1996, 'them' being pre-cancerous polyps, later, thankfully, identified as benign. Innocent that I was in the ways of the National Health Service, I believed him. I went to the operating theatre in September 1996. Twenty-two weeks later I left hospital. In the interim I had various collapses and emergencies and acquired an infection which seems to be rife in every hospital in the country and is causing increasing concern MRSA, or methicillin-resistant Staphylococcus aureus, the bug which is resistant to all antibiotics except one, vancomycin, and which is a particular danger to the not-so-young, those recently operated on and those with an open wound. I filled all three categories. But, like the great majority of the general public, I had never heard of it. I'm told that several days after the operation I went into intensive care. Apparently at some time I acquired the MRSA bug. I was there for nine weeks during which time I had septicaemia, a heart attack, kidney failure, breathing problems and umpteen other things. Once I was within a couple of hours of not making it at all and my vicar was ready to administer the last rites. There were weeks of lying there drifting in and out of consciousness, experiencing hallucinations. Some of these were darkly worrying, others almost interesting! Surrounded by yellow sunshine I was convinced I was being nursed in the Middle East; at one time I knew I would be buried in St Paul's Cathedral next to Douglas Bader! I told myself I would complain about the bodies being left in the corner of the room when they should have been in the mortuary. I found myself repeating continuously a poem learnt at school, The Highwayman by Alfred Noyes.

Acute adult asthma — assessment of severity and management and comparison with British Thoracic Society Guidelines

To investigate the accuracy of clinical severity assessment of asthmatics and to compare emergency and subsequent ward management with British Thoracic Society (BTS) Guidelines, the records of all patients admitted for severe asthma (46) over a 5-month period to a District General Hospital were inspected. Variations from recommended management were revealed. Appropriate oxygen administration was often not provided in casualty and patients frequently left hospital before their discharge criteria were attained: recommended diurnal variations in peak flow were exceeded in 26%. Eleven per cent of discharges were against medical advice, making provision of adequate management logistically difficult. Adherence to BTS guidelines on the need for arterial blood gas (ABG) analysis would have led to a failure to detect significant hypoxaemia in 25% of cases. This study identified substantial variations from BTS management guidelines. It is suggested that oximetry is necessary on arrival to guide selection for arterial blood gas analysis.