Combined synchrotron X-ray tomography and X-ray powder diffraction using a fluorescing metal foil.

This study realizes the concept of simultaneous micro-X-ray computed tomography and X-ray powder diffraction using a synchrotron beamline. A thin zinc metal foil was placed in the primary, monochromatic synchrotron beam to generate a divergent wave to propagate through the samples of interest onto a CCD detector for tomographic imaging, thus removing the need for large beam illumination and high spatial resolution detection. Both low density materials (kapton tubing and a piece of plant) and higher density materials (Egyptian faience) were investigated, and elemental contrast was explored for the example of Cu and Ni meshes. The viability of parallel powder diffraction using the direct beam transmitted through the foil was demonstrated. The outcomes of this study enable further development of the technique towards in situ tomography∕diffraction studies combining micrometer and crystallographic length scales, and towards elemental contrast imaging and reconstruction methods using well defined fluorescence outputs from combinations of known fluorescence targets (elements).

The work of rehabilitation.

PURPOSE: To describe three years of activity of a rehabilitation unit and to make comparisons between clients who receive different levels of active rehabilitation. METHOD: A retrospective study set in an inpatient rehabilitation facility located in Dunedin, New Zealand, examining 874 inpatient admissions over three financial years (2000--2002). Outcome measures include Functional Independence Scores (FIM) at admission and discharge, length of stay, weekly gains in FIM scores, and changes in FIM sub-scores. RESULTS: Assessment and rehabilitation patients made significant FIM gains in comparison to assessment only and social relief (respite care) patients. Assessment and rehabilitation patients showed greater gains in the Physical dimensions of the FIM in comparison to the Cognitive although this is probably a function of different scaling. Floor and ceiling effects were not present in the FIM. CONCLUSIONS: The interdisciplinary rehabilitation program brings about real functional and cognitive gains in a range of patients as measured with the FIM. This adds to the considerable body of research which documents FIM gains and further provides evidence that physical and cognitive gains differ.

Verbal memory in non-demented patients with idiopathic Parkinson's disease.

This study assessed the verbal memory functions of 20 patients with idiopathic Parkinson's Disease (PD) without any clinical evidence of dementia and 20 Medical Control (MC) patients with similar levels of physical disability. Performance was compared on tests of immediate recall, word list learning in intentional and incidental contexts, word completion priming, remote memory, metamemory and awareness of mnestic abilities. Significant differences were found in new learning of verbal material under incidental but not intentional learning conditions. Group differences were also observed on measures of remote memory and metamemory. The groups did not differ in word completion priming performance or recognition memory. These findings are consistent with other evidence suggesting that PD patients without dementia may have subtle cognitive deficits that affect memory performance. These may be attributable to impairments of attention allocation, formulation of retrieval strategies, and effortful learning associated with frontal lobe dysfunction. The group differences could not be attributed to impairments of intellectual functions, verbal fluency, level of physical disability, or mood disturbance.

The true rates of injury among workers in New Zealand: comparing 1986 and 1991.

This study has established true injury rates in New Zealand in 1986 and 1991 for the general and working populations. The general population grew by 3% between the two censuses, while the injury rate increased by 23%. The workforce decreased by 7% while the workforce injury rate rose by 11%. The numbers of salary earners and wage earners fell by 10% and the number of self-employed workers rose by 4%, the injury rates in the former rising by 16% and falling by 7% in the latter group. This suggests either a lower injury rate or a lower claim rate among these latter workers. Young males have the highest injury rates in the general and workforce population. Women have half the injury rate of men, suggesting that women should pay lower insurance premiums. Detailed analysis revealed 'high injury rate/high cost' groups in whom targeted intervention strategies should be cost-effective. This study gives a baseline against which changes can be measured. We recommend that this study be repeated.

The Work Rehabilitation Impact Quotient: a tool to assess the effectiveness of early rehabilitation of injured workers.

The Work Rehabilitation Impact Quotient (WRIQ) compares the percentage of long term claimants in a classification group with the percentage of long term claimants overall in the scheme, a value greater than one indicating that more people than expected remain on compensation. We studied the Accident Rehabilitation and Compensation Insurance Corporation of New Zealand (ACC) claims from 1988 to 1994 and data from the 1986 and 1991 census. High WRIQs were found in workers over the age of 50, people injured in motor vehicle crashes, those with head and multiple location injuries, and those with amputations, dislocations, injuries to internal organs, and OOS (Overuse syndromes). Analysis by occupation and industry identified certain groups with high and very high WRIQs. The WRIQ value was not related to the rate of injury or to job availability, but was related to mean claim cost. Thirty six percent of claim costs paid in 1994 were in groups with high or very high WRIQs. Reduction of the WRIQ in these groups to low levels would produce savings of over $100 million in 1994 dollars.

Traumatic mutism in severe head injury relieved by oral diazepam.

A 34-year-old woman with a severe closed-head injury had many impairments including apparent global aphasia. After a diazepam premedication for a motor point block she was heard to speak a few words. A trial of oral diazepam succeeded in restoring speech adequate to make her needs known, which persisted on a maintenance dose of 5 mg t.d.s. The possible diagnoses and reasons for this phenomenon are discussed. We suggest that diazepam may be useful in assessing speech in selected people with severe head injuries.

Do 'social relief' admissions have any effect on patients or their care-givers?

Dependent patients and their care-givers were studied before and 1 week after a social relief admission in order to assess the effects on physical and psychological problems. Data about care-givers stress and mental health were gathered, as well as patient data. Patients' self-care abilities improved slightly but care requirements remained constant. Care-giver stress levels did not change, but there was a highly significant improvement in their mental health. The results suggest that social relief admissions enabled care-givers to continue to look after very dependent people in the community.

Rehabilitation services in the health sector: the perspectives of providers and consumers: Part 2.

AIMS: To gain information from consumers of rehabilitation services about service use and availability, and priorities for future development. To compare this with area health board (AHB) priorities for future services. METHOD: A postal survey of 740 consumers of rehabilitation services used the membership list of the Disabled Persons' Assembly (DPA) of New Zealand. There was a 311 (42%) response rate of whom 84% were people with disabilities and 16% were care givers. RESULTS: Causes of disability included illness (45%), congenital (26%), accidents (22%), and multiple causes (7%). Most people had physical (66%) or multiple disabilities (22%), while few had sensory (7%), intellectual (3%), psychiatric (3%), or learning disabilities (0.4%). The main factors affecting service delivery were lack of information, restricted service, needs not assessed, difficult access to services, lack of coordination, and transport difficulties. Most respondents were aware of statutory services such as district nursing, home help, occupational therapy, physiotherapy, social work and wheelchair assessment and maintenance. One third were aware of regular review, attendant care, and similar programmes. The services that were least known were advocacy and supported accommodation. Consumer priorities were regular review and disability information services, while AHB priorities were attendant care and supported accommodation. CONCLUSIONS: Lack of information, lack of regular assessment, and lack of coordination were major barriers to consumers obtaining adequate rehabilitation services. A single agency purchaser, clear entry points, case management and assessment would provide potent mechanisms for overcoming these difficulties. Priorities for consumers reflected their need for information and support, while provider priorities showed their commitment to the policy of de-institutionalisation. We conclude that it is important that consumers are involved in the planning process so that informed decisions are made about appropriate resource allocation.

Rehabilitation services in the health sector: the perspectives of providers and consumers: Part 1.

AIMS: To establish the degree of implementation of the Strategic Planning Guidelines for Area Health Boards--Services for Adults with Physical Disability, published by the Department of Health in 1989, the services being provided, and the priorities for future service provision. METHODS: Two postal surveys of area health boards (AHB's) were carried out in 1991. The first asked about the terminology of rehabilitation, administrative structure, advocacy, service audit, inventory of services, regional service delivery, and consultation processes. The second asked about the rehabilitation services provided, the type of disability of the consumers of the service, the reasons why services were or were not provided, the service gaps that existed, and the priorities that existed to fill those service gaps. RESULTS: The major finding was that while all area health boards adopted the rehabilitation concepts in principle, service development was impeded in many cases by the failure to provide resources to plan and develop the service. Some were providing comprehensive services. Most AHB's provided services for people with physical or multiple disabilities. All provided statutory services such as district nursing and home help, while most provided regular medical reviews, physiotherapy, occupational therapy, speech therapy, etc. Only about half provided attendant care, driving assessment, and swimming for people with disabilities, while less than half supported disability information services (DIS). Attendant care was seen as high priority to fill gaps in service, but was seen as the funding responsibility of the Department of Social Welfare. CONCLUSIONS: Service provision reflected a traditional approach to the provision of rehabilitation services. The development of innovative service delivery will require crown health enterprises to reevaluate their present level of commitment to rehabilitation services and to assess the effectiveness of reallocating some funds from acute services into rehabilitation.

Hospital morbidity due to head injuries in New Zealand in 1980-1988.

We studied the morbidity in New Zealand using hospital discharge data from 1980 to 1988, and found a reduced head injury (HI) rate over this time overall, but no change in the rate among Maori males and an increased rate among Maori females. In 1988 the rate was 228/100,000 with peaks among males and females aged under 10, males aged 15-25, and both sexes over 84 years old. The rate among young Maori males was higher than in other groups until the age of 55. Motor vehicle crashes caused most head injuries, followed by falls, non-intentional incidents (such as sporting injuries), assaults and pedal cycle accidents. Maori females had a high rate of assault. Hospital stay was longest among pedestrians, and increased with increasing age due to co-morbidity. Prevention strategies were based on the causes of HI.

Depression in Parkinson's disease.

OBJECTIVE: The authors assessed the prevalence of major depression (DSM-III-R) among Parkinson's disease patients and compared this rate with that of matched physically disabled subjects. METHOD: The 30-item General Health Questionnaire and measures of physical disability were completed by all patients in Dunedin, New Zealand, identified as having Parkinson's disease. Patients scoring over 5 on the General Health Questionnaire were interviewed with the Structured Clinical Interview for DSM-III-R--Non-Patient Version. Each patient living in the community was matched for age, sex, and level of physical disability with a comparison subject who did not have a neurological condition. RESULTS: Of the 73 subjects with Parkinson's disease who agreed to participate and were judged not to be demented, 34.2% scored higher than 5 on the 30-item General Health Questionnaire, but only 2.7% met the criteria for major depression. No difference from the comparison group was found. CONCLUSIONS: The prevalence of major depression in patients with Parkinson's disease may be no greater than in age- and sex-matched physically disabled persons.

Epidemiology of spinal cord injury in New Zealand.

Spinal cord injury (SCI) is a catastrophic and costly result of both intentional and unintentional injury. We present data from the Health Statistics Services files of New Zealand for the year 1988 on the epidemiology of SCI resulting in morbidity. New Zealand has one of the highest rates of SCI in the western world and since 1979 this has been increasing. It occurs most often to young, caucasian men and is typically the result of motor transport crashes. The ethnicity adjusted rates show high rates for Maori males. Children in New Zealand have greater than 4 times the risk of an SCI than American children. The rehabilitation and hospital costs for SCI are among the highest for all injuries. There were a higher number of high cervical injuries than reported in previous series and 92% of SCI were incomplete indicating the high rehabilitation potential of the sample. Some measures are suggested to reduce the incidence of SCI.

Is the prevalence of Parkinson's disease in New Zealand really changing?

The prevalence of idiopathic Parkinson's Disease (IPD) in Dunedin, New Zealand on 31st July 1990 was 110.4/100,000. When corrected to a standard population based on the 1960 U.S. census, the prevalence fell to 76.0/100,000 due to changes in the age structure of the population. The corrected prevalence in Wellington (another New Zealand city), in 1962 was 99.6 (before the introduction of levodopa), and in Aberdeen, Scotland in 1984 was 102.7. The principal difference was fewer people under 65 years of age in our study. Case finding methods and diagnostic criteria were similar in all three studies, and case ascertainment was adequate. Under representation of younger people could be due to either a lower incidence rate or poorer survival due to treatment with high doses of levodopa compounds. Prospective research is required to explain our findings.

Medications and their monitoring in Parkinson's disease in Dunedin.

AIMS: to establish the patterns of drug administration and monitoring in people with Parkinson's disease. METHOD: a total community sample was obtained. One hundred and one of the 116 people with Parkinson's disease in Dunedin, who were alive on 31 July 1990, had a full medical assessment. RESULTS: the general practitioner made the diagnosis in 51%, a neurologist in 22%, a geriatrician in 18%, and other in 9%. The general practitioner provided prescriptions for 51 of the 68 people living in the community, a neurologist for 11, and a geriatrician in six cases. The general practitioner provided prescriptions for 23 of the 33 living in an institution, and a geriatrician in ten cases. Medical review took place more frequently than three monthly in 49 cases. There were 81 general practitioners in practice on the prevalence day in the study area. Thirty-six had no patients with Parkinson's disease, 30 had one or two, and the other 15 had varying numbers. Fifty-eight of the 90 patients taking levodopa were taking it as the only therapy. Eight patients were taking phenothiazines. There was a high incidence of side effects and 70 patients had long term complications including loss of effectiveness over time, the end of dose and the on-off phenomena, and dyskinesias. CONCLUSIONS: monitoring of treatment appeared satisfactory but major concerns about drug management included the high use of levodopa monotherapy and the concurrent use by general practitioners of phenothiazines in eight cases. Because most general practitioners have very few patients with Parkinson's disease they will not develop the experience to manage complicated drug regimens in people whose management tends to become more difficult with time. With selegiline and controlled release levodopa only being available on specialist prescription, we suggest that all people with Parkinson's disease should have the benefit of a specialist review at least every two years.

Informed consent for cardiopulmonary resuscitation in elderly patients.

OBJECT: to determine if a semistructured interview would enable elderly patients to give adequately informed consent for cardiopulmonary resuscitation (CPR). METHOD: one hundred consecutive patients admitted to Wakari assessment and rehabilitation unit for the elderly, who satisfied study criteria, were randomly allocated to receive a detailed discussion on CPR or to act as controls. Subsequently knowledge about CPR was tested in both groups. RESULTS: of the 49 study subjects, 27 (55%) wished to have CPR in the event of a cardiac arrest. After the interview knowledge about the CPR was significantly better in the study group than the controls, but there was still a lack of appreciation of the possible complications and an overly optimistic view of the likely outcome. CONCLUSIONS: careful explanation of the procedures involved in CPR does increase knowledge and assist in making an informed decision. However, the decision may still be based on poor understanding of the likely outcome and possible complications.

Stress in caregivers of elderly patients: the effect of an admission to a rehabilitation unit.

OBJECT: to study stress in caregivers of elderly dependent persons after admission to a geriatric assessment and rehabilitation unit. METHOD: in 1986-7 we studied patients admitted to a geriatric assessment and rehabilitation unit in Dunedin to establish the relationship between caregiver stress, their psychological health and social functioning, and patient variables such as physical dependency. RESULTS: of the 64 patients who were admitted from the community and who had a caregiver, 42 were discharged back to the community, and 30 remained there until six weeks. On admission caregiver stress was increased by problems perceived in social function (lack of companionship, excessive responsibilities and financial problems) and decreased when the caregiver had a high sense of psychological wellbeing. It was not associated with high patient dependency or the level of social support. Caregiver stress one week after discharge was lower among those with high emotional support and those with an internal locus of control. If caregiver stress one week after discharge was high there was an increased rate of readmission. CONCLUSION: rehabilitation should include interventions directed towards the psychological health and social function of the caregiver as well as the physical independence of the patient. Improved financial support and the provision of companionship through community support groups may result in reduced caregiver stress, which should help dependent elderly people to continue to live in the community.

The cost benefit of rehabilitation of injured workers in New Zealand.

A multidisciplinary rehabilitation centre was established to address the needs of people with mild to moderate disability who had not worked for prolonged periods of time. A fitness based programme assisted 10 of the 20 who had been off work for more than six months to return to activity. Six and eighteen month follow up confirmed the durability of placement of most workers who had returned to work, and that projected benefits were achieved. Benefits were defined as savings in earnings related compensation (ERC), and compared to the costs of establishing and running the centre. Sensitivity analysis ascribing between 100% and 50% of benefit to the programme showed a positive benefit cost ratio, with benefits discounted at a rate of 10% over 10 years. With 75% ascribed, the project produced benefit cost ratio of about 1.5:1 in the first year, 2.8:1 in the second year, and rising to 6.2:1 in the fifth year and 10:1 by the tenth year. With only 50% ascribed, the benefit over the same times was 1.0:1, 1.9:1, 4.1:1 and 6.7:1 by the tenth year. These calculations probably underestimate true benefits.

The rehabilitation of injured workers in New Zealand: a pilot study.

At the request of the local office of the Accident Compensation Corporation (ACC) we established a centre which offered a multidisciplinary rehabilitation programme consisting of a full assessment and an eight week individually planned and monitored fitness programme. The clients progressed to occupational therapy, work trials, and later to paid work. The programme included education about back care and health maintenance, and relaxation techniques. Of the 48 injured people who attended the centre, 37 were assessed as suitable to enter the programme, and 32 people took part. Outcome, measured as return to work or change in assessed fitness to work, was not related to age, sex, marital status, length of time since accident, or work category. Only 25% of workers returned to jobs in medium or heavy manual work. Sickness impact profile total and physical scores improved over the programme, but did not correlate significantly with return to work or fitness for work. Client perception of benefit was not significantly related to outcome. We analysed data from the 20 clients with claims longer than 6 months separately because matched case controls could not be provided by the ACC. Six months after completion of the programme, four were in paid employment, four in prolonged work trials, one in a job partly paid by the ACC, and one setting up his own business. Their return to the work force demonstrated the effectiveness of the centre in restoring people to function after prolonged periods of inactivity.