Previously undiagnosed aortic stenosis revealed by auscultation in the hip fracture population--echocardiographic findings, management and outcome.

The 2001 Report of the National Confidential Enquiry into Perioperative Deaths recommended that an echocardiogram should be performed on patients with aortic stenosis prior to anaesthesia. In this study we present the patient details, management and outcome of the 272 hip fracture patients with a previously undiagnosed murmur and echocardiographically proven aortic stenosis admitted from 2001-2005 in our hospital. The patients with aortic stenosis were significantly older, and had significantly lower Abbreviated Mental Test Scores, than the control group of 3698 hip fracture patients without aortic stenosis. There were significant trends toward general anaesthesia over spinal anaesthesia, and use of invasive monitoring of blood pressure, as the severity of the aortic stenosis increased. There were no significant trends towards higher 30-day or 1-year mortality rates as the severity of the aortic stenosis increased. Resources for rapid pre-operative echocardiograms should be made available for hip fracture patients as the results have significant implications for their subsequent anaesthetic management.

Outcome following proximal femoral fracture in Northern Ireland.

OBJECTIVE: To study the outcome following treatment for proximal femoral fracture in elderly people. METHODS: All consecutive males and females admitted to the acute fracture service at the Royal Victoria Hospital and the Belfast City Hospital for the 3 years from 1999 to 2001 were studied. The data was collected by trained research nurses. Variables gathered included age, sex, marital status, mental state, pre-injury Barthel score and the American Society of Anaesthesiology (ASA) physical status grading. The information was gathered on admission to hospital and at four, six and 12 months after the injury. RESULTS: The total number of patients studied between January 1999 to December 2001 was 2834 of whom 77% were female and 23% were male. The mean (median) length of stay in the acute fracture service was 10.7 (9 days). The mean (median) length of stay in the rehabilitation ward was 35.3 (24 days). The 30-day mortality was 6.9%, the four-month mortality 15.6 % and one year mortality 22.3 %. Of those subjects living at home at the time of fracture 68% remained at home at one year. Factors predicting successful return home were higher mental test score, younger age, female sex, higher Barthel score, better pre-injury mobility and better ASA score. Of those able to walk independently outdoors before injury 40% regained this ability by 12 months. Factors predicting return of pre-injury mobility were poorer pre-injury mobility, younger age, higher mental test score, better ASA category, higher Barthel score, and previous residence at home. The proportion admitted from their own home and discharged by 56 days was 56%. CONCLUSION: The standardised measurement of outcome in hip fracture subjects enables comparison between units and facilitates improvement in standards of care available to the increasing number of elderly patients presenting with proximal femoral fracture.

A study of bone mineral density in women with forearm fracture in Northern Ireland.

A group of Northern Ireland women aged 40-75 years of age with low-trauma forearm fracture were studied to determine the incidence of such fractures and the prevalence of osteoporosis in this fracture population. A total of 1,147 subjects were identified in 1997 and 1998 throughout Northern Ireland following low-trauma forearm fractures, as well as 699 residents in the Eastern Health and Social Services Board (EHSSB), enabling calculation of the annual incidence rate of new low-trauma forearm fractures at 2.69/1,000 population aged 40-75. A total of 375 participants consented to have bone mineral density (BMD) measurements undertaken at the femoral neck, spine, and forearm using a Lunar Expert bone densitometer. Osteoporosis at the femur was present in 14% of women, at the spine in 29%, and at the forearm in 32%. A total of 45% were osteoporotic at one or more measured sites, but only 18% were on treatment for osteoporosis. Additional significant risk factors identified included an early menopause in 24.5% and current or previous corticosteroid use in 13%. Only 1.6% received information on treatment of osteoporosis at the time of fracture. Increased awareness is needed in both primary and secondary care including fracture services to improve treatment of women with low-trauma fracture.

Common guidelines and equitable service: variation between adjacent districts regarding admissions to elderly care institutions.

With the increasing number of older people, the cost of providing institutional care has become a major issue. In 1993 the introduction of care management and a needs-led approach aimed to remove the existing 'perverse incentive' to institutional care and to ensure equality in the dependency levels of those who were admitted to care. To test this consistency, we examined the dependency levels of all persons aged > or = 65 years admitted to residential and nursing homes in two adjacent Health and Social Services (HSS) Community Trusts in Belfast, Northern Ireland, in the year following the introduction of care management. We measured differences between the Trusts with respect to number of admissions, levels of dependency as determined by several standard scoring systems, financial support, source of admission and demographic information. A total of 389 people were surveyed. Trust A had significantly higher levels of physical dependency and mental impairment in both residential and nursing homes than Trust B. We also identified differences in dependency with respect to funding status, with those who were self-funding in Trust B having lower physical dependency in residential and nursing homes and less mental impairment in nursing homes than supplemented residents. This study reports the existence of variations between adjacent Community Trusts operating under the same policy guidelines with respect to the dependency levels of admissions to residential and nursing care. These differences may relate to number of places available, the economic status of the population, and the assessment procedures of the two Community Trusts. The need for standard assessment and eligibility criteria is highlighted.

Fatal hepatotoxicity after re-exposure to isoflurane: a case report and review of the literature.

A 76-year-old Caucasian woman developed fulminant hepatic necrosis 6 days after an uneventful operation under isoflurane anaesthesia. Laboratory findings included elevated bilirubin, grossly elevated transaminases and prolonged prothrombin time. Radiological investigation showed no evidence of extra-hepatic disease. Serological studies were negative for acute viral hepatitis and autoimmune disease. The patient may have been previously sensitized by exposure to isoflurane 3 years previously but antibodies to tri-fluoro acetate, present in 70% of cases of halothane hepatitis, were not detected in pre-operative or postoperative samples of blood. On the seventh postoperative day the patient died and postmortem examination demonstrated centrilobular necrosis of the liver, with a histological pattern similar to changes associated with halothane hepatitis.

Correctable visual impairment in stroke rehabilitation patients.

BACKGROUND: after stroke, visual impairment may exacerbate the impact of other impairments on overall disability and negatively influence rehabilitation. OBJECTIVE: to examine the visual status of patients after stroke and determine whether this can be improved by simple interventions. DESIGN: prospective study. SETTINGS: stroke rehabilitation unit in a Belfast teaching hospital. SUBJECTS: 77 consecutive patients admitted for rehabilitation after acute stroke. METHODS: full optometric and ophthalmic assessment within 2 weeks of admission. RESULTS: of 70 patients with glasses, 19 did not have their glasses in hospital before prompting and 18 had glasses in unacceptable condition. Twenty patients had impaired visual acuity (6/12 or worse) with existing glasses (if helpful); 11 of these improved to better than 6/12 with refractive correction. CONCLUSIONS: stroke professionals need to enquire about patients' spectacles and assess their condition. Patients with reduced visual acuity in the absence of significant non-refractive disease should be referred to an optometrist: in this series 14% of patients had visual impairment which benefited from refractive correction.

Proximal femoral fracture in Northern Ireland between 1985-1997--trends and future projections.

The aims of this study were to identify changing trends with time of the incidence of proximal femoral fracture and to enable future number of hip fractures to be projected. Hospital theatre records in Northern Ireland were surveyed in 1985, 1991, 1994 and 1997 to establish the number of surgical procedures for proximal femoral fracture. The age and sex specific rates for males and females aged 50+ years were calculated. Analysis of age and sex specific incidence rates was undertaken using linear regression and Poisson regression. A 1.6% increase per annum (95% CI 1.0-2.2) was noted in males and females from 1985 to 1997. Projected increases in rates of proximal femoral fracture were calculated using population projection for 2001, 2006, 2011 and 2016. Modelling (a) assuming the age standardised rates in 1997 remain static and continue predicted a 55% fracture increase in males and a 29% increase in females by 2016, (b) assuming the secular increases continued predicted a 93% fracture increase in males and a 67% increase in females and (c) assuming further linear growth on a log-scale predicted a fracture increase in males of 135% and 99% in females. The number of proximal femoral fractures in Northern Ireland is increasing faster than that anticipated due to demographic changes alone, supporting a secular increase which was evident throughout the period of time studied, in contrast to that reported from other regions in the United Kingdom.

Acute medical bed usage by nursing home residents.

An increasing number of elderly patients in nursing home care appears to be presenting to hospital for acute medical admission. A survey of acute hospital care was undertaken to establish accurately the number and character of such admissions. A total of 1300 acute medical beds was surveyed in Northern Ireland in June 1996 and January 1997 on a single day using a standardised proforma. Demographic details, diagnosis and length of admission were recorded. A total of 84 patients over the age of 65 (mean 79.5 years) admitted from nursing home care was identified in June 1996 and a total of 125 (mean 83.3 years) in January 1997. A total of 88 (70%) of admissions in 1997 were accompanied by a general practitioner's letter. The assessing doctor judged that 12 (9.6%) of admissions in 1997 could have had investigations and or treatment reasonably instituted in a nursing home. The proportion of acute medical beds occupied by nursing home residents was 6% in June 1996 rising to 10% in January 1997. The study accurately identifies the significant contribution of nursing home patients to acute medical admissions and the low proportion in whom admission was unnecessary. Closure of long stay hospital facilities should be accompanied by investment in community medical services and also reinvestment in acute hospital care for elderly people.

Re-admission of elderly patients after in-patient rehabilitation.

The re-admission rates of a cohort of 97 elderly patients discharged from hospital were ascertained. The overall re-admission rate at 30 days was 15%, at 90 days 24% and at 180 days, 30%. On 4 occasions (9%) re-admission was deemed avoidable by the general practitioner. Deterioration of existing disease accounted for 16 (36%) and a new medical event for 22 (49%) re-admissions.

Audit of surgical delay in relationship to outcome after proximal femoral fracture.

To ascertain the influence of surgical delay on outcome after proximal femoral fracture in elderly females, a cohort study of patients presenting in 1987 was compared to 1989/90. Organisational changes in the intervening period were introduced to reduce delay to surgical intervention. Two hundred and eighty females aged 65 years and over presenting from the local catchment area of an acute inner-city teaching hospital were enrolled in the study. Seventy-nine patients received surgery in 1987 and 186 in 1989/90. The one year mortality was 34% and 26% respectively. The proportion receiving surgery within 24 hours rose from 34% in 1987 to 57% in 1989/90. The relative hazard of the group receiving surgery on day 2 in comparison to day 1 was 1.7 (95% CI 1.0 to 2.9) when adjusted for co-variance of age and mental score. Medically fit elderly patients presenting with proximal femoral fracture have improved survival with early surgery within 24 hours of admission. Improvements in the organisation of hospital care will result in important benefits for the increasing number of elderly females presenting with proximal femoral fracture.

The effect of minimal exercise on fitness in elderly women after hip surgery.

To determine the effect of minimal exercise on functional fitness following total hip replacement in elderly women, 20 women (13 exercisers, 7 controls) who had undergone unilateral or bilateral hip replacement surgery for primary osteoarthritis were studied. An exercise treadmill test with respiratory gas and blood lactate analyses, and a field test of walking speed on a measured course, were administered before and after a twice weekly exercise programme of three months' duration. Markers of cardiorespiratory fitness, including peak achieved oxygen uptake (VO2) and ventilatory and lactate thresholds were measured. Maximum self-selected walking speed was also measured over a flat course. Peak VO2 increased in the exercise group when compared to baseline (P < 0.05) but did not differ from the control group. The exercise group significantly improved their walking speed by 10.1% compared with non-exercising controls (1.41 vs 1.20 m/sec, P < 0.05), and increased VO2 at lactate threshold. The improvements occurred despite the twice weekly exercise sessions being below the recommended frequency of exercise for improving cardiorespiratory fitness. Minimal exercise in elderly women after hip surgery can substantially improve submaximal exercise capacity, as well as walking speed.

Comparison of nursing home residents admitted from home or hospital.

A growing elderly population coupled with a reduction in hospital long term care has led to an increase in the independent nursing home sector. This is an expensive resource. Proper placement is therefore essential to ensure its efficient use. Prior to the introduction of care management there was no standard assessment procedure for admission to nursing home care from different sources. A nursing home population (n = 624) in North and West Belfast was studied and mental scores, levels of disability, and the source of admission to the nursing home recorded. Residents admitted from geriatric medical units (n = 132) were compared with those from general medical and surgical wards (n = 168) and those from home (n = 243). Residents who were admitted from a geriatric unit were the most disabled, those admitted from home were the least and those from general wards had intermediate levels of disability (p < 0.005). This is likely to be the result of different assessment procedures for prospective nursing home residents. With the introduction of care management, it is hoped that standardised assessment will follow. The roles of different medical specialists in this process is not yet clear. Further study is needed to assess the appropriateness of placement in nursing homes under care management.

Benefits of an exercise class for elderly women following hip surgery.

A prospective cohort study of a twice weekly exercise programme for six months was undertaken to determine the benefits of an exercise class for 28 elderly women following hip surgery. The effects of the exercise programme were monitored using cycle ergometry. Walking speed was measured on entry and at 3, 6 and 12 months. Twenty-six subjects completed the programme with an overall attendance rate of 88%. Measures of fitness, calculated from cycle ergometry, did not improve significantly apart from test duration. In contrast there was a significant improvement in mean walking speed, with a 50% increase between 0 and 3 months and a further 21% increase between 3 and 6 months. This improvement was maintained at 12 months.