A pragmatic digital health informatics based approach for aiding clinical prioritisation and reducing backlog of care: A study in cohort of 4022 people with diabetes.

BACKGROUND AND AIMS: The backlog of care in resource stretched healthcare systems requires innovative approaches to aid clinical prioritisation. Our aim was to develop an informatics tool to identify and prioritise people with diabetes who are likely to deteriorate whilst awaiting an appointment to optimise clinical outcomes and resources. MATERIALS AND METHODS: Using data from electronic health care records we identified 6 risk-factors that could be addressed in 4022 people (52% male, 30% non-Caucasian) with diabetes attending a large university hospital in London. The risk-factors were new clinical events/data occurring since their last routine clinic visit. To validate and compare data-led prioritisation tool to a traditional 'clinical approach' a sample of 450 patients were evaluated. RESULTS: Of the 4022 people, 549 (13.6%) were identified as having one or more risk events/factors. People with risk were more likely to be non-Caucasian and had greater socio-economic deprivation. Taking clinical prioritisation as the gold standard, informatics tool identified high risk patients with a sensitivity of 83% and lower risk patients with a specificity of 81%. An operational pilot pathway over 3 months using this approach demonstrated in 101 high risk people that 40% received interventions/care optimisation to prevent deterioration in health. CONCLUSION: A pragmatic data-driven method identifies people with diabetes at highest need for clinical prioritisation within restricted resources. Health informatics systems such as our can enhance care and improve operational efficiency and better healthcare delivery for people with diabetes.

Effect of amputation level on the stress transferred to the femur by an artificial limb directly attached to the bone.

Attachment of an artificial limb directly to the skeleton has a number of potential benefits and the technique has been implemented for several amputation sites. In this paper the transfer of stress from an external, transfemoral prosthesis to the femur during normal walking activity is investigated. The stress distribution in the femur and at the implant-bone interface is calculated using finite element analysis for the 3D geometry and inhomogeneous, anisotropic material properties obtained from a CT scan of a healthy femur. Attachment of the prosthetic leg at three different levels of amputation is considered. Stress concentrations are found at the distal end of the bone and adjacent to the implant tip and stress shielding is observed adjacent to the implant. It is found that the stress distribution in the femur distal to the epiphysis, where the femur geometry is close to cylindrical, can be predicted from a cylindrical finite element model, using the correct choice of bone diameter as measured from a radiograph. Proximal to the lesser trochanter the stress decreases as the femur geometry diverges significantly from a cylinder. The stress concentration at the distal, resected end of the bone is removed when a collared implant is employed. These findings form the basis for appropriate settings of an external fail-safe device to protect the bone from excessive stress in the event of an undue load.

The FOOTSTEP self-management foot care programme: are rheumatoid arthritis patients physically able to participate?

BACKGROUND: The FOOTSTEP self-management foot care programme is a clinical and cost-effective programme for basic foot care in the elderly. The aim of this study was to determine if patients with rheumatoid arthritis (RA) would be physically able to participate. METHODS: A consecutive cohort of RA patients undergoing podiatry care underwent tests for sight, reach and grip strength to determine their physical ability to undertake self-managed foot care. RESULTS: Thirty RA patients (10 male, 20 female), with a median age of 61 years (range 42 to 84) and disease duration of 10 years (range one to 40), were recruited. All patients passed the sight test, whereas the reach and grip tests were passed by 77% and 67% of patients, respectively. Only 57% of patients passed all the physical tests. Patients who failed the physical tests were older, and had longer disease duration and higher physical disability, pain and general health scores but these were not statistically different. CONCLUSIONS: Just over half the patients in this present cohort may be physically able to undertake some aspects of self-managed foot care, including nail clipping and filing, callus filing and daily hygiene and inspection.

An intensive self care training programme reduces admissions for the treatment of plantar ulcers.

This paper describes, in detail, an intensive 14 day Self Care Training Programme that is conducted at Lalgadh Leprosy Services Centre in Nepal. An evaluation of the programme was undertaken in which hospital admission for infected plantar ulceration was the outcome measure. It was found that those who had undertaken the programme were less likely to have been admitted for hospital treatment in a 3-month follow-up period (chi 2 = 5.1, P = 0.02). An odds ratio of 1:1.8 (95% CI = 0.15-0.01) was also calculated. This paper presents an overview of the issues related to impairment, a description of the Self Care Training Programme, an analysis of the evaluation results and a discussion of the findings.

Applications of automated simultaneous double fluorescence (SDF): I. Unbiased, quantitative HLA-A,B phenotyping.

An automated HLA typing method has been developed and standardized. The procedure involves simultaneous excitation and reading of two fluorochromes, carboxy-fluorescein diacetate and propidium iodide, by a purpose-built Terasaki tray scanner known as the Astroscan 2100. Data obtained from 95 donors typed by this method and by the classical NIH dye exclusion method prove this system to be suitable for routine HLA-A,-B typing (similarity coefficient 0.9861). This comparison has highlighted significant observer bias, whereby the observer tends to downgrade very weakly positive reactions to negative and upgrade moderately positive reactions to strong positive. Elimination of this bias reduces the chances of any clinically disastrous consequence.