Predictors of direct home discharge following fractured neck of femur.

INTRODUCTION Direct home discharge (DHD) following hip fracture surgery represents a challenging proposition. The aim of this study was to identify factors influencing the discharge destination (home vs alternative location) for patients admitted from their own home with a fractured neck of femur. METHODS A retrospective cohort study of prospectively collected major trauma centre data was performed, identifying 10,044 consecutive hip fracture admissions between 2000 and 2012. RESULTS Two-thirds of the patients (n=6,742, 67%) were admitted from their own home. Half of these (n=3,509, 52%) returned directly to their own home while two-fifths (n=2,640, 39%) were discharged to an alternative location; 593 (9%) died. The following were identified as independent variables associated with a higher likelihood of DHD: younger patients, female sex, an abbreviated mental test score of 10, absence of certain co-morbidities, cohabiting, walking independently outdoors, no use of walking aids, no assistance required with basic activities of daily living and intracapsular fracture. CONCLUSIONS Identifying those at risk of being discharged to an alternative location following admission from home on the basis of identified preoperative indices could assist in streamlining the postoperative care phase. Pre-emptive action may help increase the numbers of patients discharged directly home and reduce the number requiring additional rehabilitation prior to discharge home with its associated socioeconomic effect.

A study of candida esophagitis in elderly patients attending a district general hospital in the UK.

Candida esophagitis in elderly patients is an entity that has not been investigated. We studied candida esophagitis in a population older than 65 years comparing them with an age and sex matched control sample. Diagnosis was made by histological identification of candida associated with inflammation from biopsy material taken during endoscopy. Fifty-six cases and 56 controls were analysed aiming to identify presentation, upper gastrointestinal pathologies associated with candida esophagitis, risk associations and to see whether it was a marker of poor outcome. Classical features clinically associated with esophageal disease were relatively uncommon: dysphagia 14%, oropharyngeal candidiasis 2%, dyspepsia 2%, while anaemia and loss of weight were the main indications for endoscopy (70%). No gastrointestinal pathologies were significantly associated with candida esophagitis. Malignancy, chronic obstructive pulmonary disease and antibiotic use were significantly associated, while there was no association between candida esophagitis and diabetes mellitus, stroke disease or dementia. Survival was significantly less in those with candida esophagitis with a mortality at 6 months of 47% compared to 5% in controls and a 1 year survival of 38% compared to 93% in the control sample. This was independent of disability measured by the modified Rankin scale and patients' residence.

A preliminary study of the hospital-admitted older patients in a Sri Lankan tertiary care hospital.

OBJECTIVE: To provide reasons for admission, comorbidities, physical and psychosocial characteristics, and outcome of older patients admitted to hospital in Sri Lanka, and to assess adequacy of routine assessment. DESIGN: Descriptive study. SETTING: University Medical Unit, National Hospital of Sri Lanka during 10 weeks commencing August 2003. PATIENTS: All > or = 65 years admitted to the unit, excluding transfers for specialised management and direct admissions by consultants or clinics; 75 men and 75 women. MEASUREMENTS: Vision, hearing and speech, tests for tendency to fall, basic activities of daily living (BADL), mood and cognition, body mass index and waist circumference. RESULTS: Seventy three per cent and 40% had cognitive dysfunction and depression., 20% required assistance in > or = 5/9 BADL, 23% had unprovoked falls within past year, and 57% had a tendency to fall, 34% had < or =6/60 vision. CONCLUSIONS: Falls, depression, cognitive dysfunction and severe visual impairment were present in substantial proportions, unidentified by routine assessment of older patients.

Excess maternal transmission and familial aggregation of Type 2 diabetes in Sri Lanka.

INTRODUCTION: An excess of maternal transmission of Type 2 diabetes mellitus has been reported in Europid populations, but not in South India. METHOD: A questionnaire-based survey was carried out in 1000 (502 male) people with Type 2 diabetes to establish whether there is an excess of maternal transmission and familial aggregation in a Sri Lankan population. RESULTS: Mean age of onset was 47+/-12 (+/-S.D.) years and duration of diabetes was 9+/-7 years. Thirty-seven percent reported parents with diabetes, 46.9% had no parents with diabetes, 16.1% did not know the diabetes status of at least one parent and there was no diabetes in the other. Of the probands, 59.4% had at least one affected relative. When both parents' diabetes status was known and only one was affected, diabetes was more common among mothers (n = 156) than fathers (n = 125) of probands (P < 0.001). A further 54 probands had both parents with diabetes. Mean age of onset and duration of the disease among probands with parental diabetes was 43.1+/-(11.1) and 9.6+/-(6.8). In the previous generation, 21.2% of maternal grandmothers and 17.3% of maternal grandfathers in the maternal diabetes group and 4.8% of maternal grandmothers and 17% of maternal grandfathers in the paternal diabetes group had diabetes. Diabetes in siblings and children was more common in those with mothers who had diabetes (53.8% and 4.5%) when compared with those in whom fathers had diabetes (42.4% and 1.6%) (P < 0.0001 and P < 0.01). CONCLUSION: Familial aggregation and excess maternal transmission were observed in people with Type 2 diabetes in Sri Lanka.

Use of antivenom serum in snake bite: a prospective study of hospital practice in the Gampaha district.

OBJECTIVE: To record current practices in hospital management of snake bite, especially with regard to use of antivenom serum (AVS). METHODS: Management of all snake bite victims admitted to the four main hospitals of the Gampaha district was prospectively studied during a 5-month period. A pretested data collection sheet was used. Relevant information was obtained from patients, accompanying persons, medical staff and hospital records. RESULTS: 466 patients (M:F = 7:3; 402 adults and 64 children) were admitted following snake bite during the study. The offending snake was identified in 357 (76.6%) cases [172 (36.9%) by examining the dead snake, 185 by identification of the snake in a photograph]. 273 (76.5%) of the 357 admissions were due to hump nosed viper bite. AVS was given to 184 (39.5%) patients, including 99 (36.3%) with hump nosed viper bite. A sensitivity test of AVS was used in all 184 patients. Premedication with hydrocortisone and/or antihistamines before AVS infusion was given to 89 patients. Acute adverse reactions to AVS occurred in 102 (55.4%) patients given AVS. There was no significant difference in the rate of reactions whether premedication was given or not. CONCLUSION: Precise identification of the offending snake was not possible in many instances. Practices that are of no benefit in the treatment of snake bite are still widely used. Acute adverse reactions to AVS are common, and neither hydrocortisone nor antihistamines seem to be of benefit as prophylaxis. Evidence based management guidelines, especially with regard to AVS therapy, are urgently required.

Long-term complications in newly diagnosed Sri Lankan patients with type 2 diabetes mellitus.

We screened 597 newly-diagnosed diabetic patients (201 women) mean +/- SD age 42.3 +/- 6.2 years to determine the prevalence of diabetic complications; 22% presented because of symptoms of diabetes, 27% were diagnosed when hyperglycaemia was discovered at a health screening, and 36% were diagnosed while being treated for intercurrent illness. Neuropathy was present in 25.1%, nephropathy in 29%, retinopathy in 15%, coronary vascular disease in 21%, stroke in 5.6%, peripheral vascular disease in 4.8%, hypertension in 23%, obesity in 16%, central obesity in 21.3%, hypercholesterolaemia in 11%, hypertriglyceridaemia in 14%, and low high-density lipoprotein cholesterol in 12%. The prevalence of coronary vascular disease, hypertension, stroke, neuropathy and retinopathy at the time of diagnosis were higher in our patients than in Caucasian and Indo-Asian patients in the UK. Both a genetic predisposition to develop complications, and exposure to a longer duration of asymptomatic hyperglycaemia due to poor access to adequate health care, may contribute to the high frequency of complications at diagnosis. Since complications are already present at diagnosis, there is a case for implementing primary prevention programmes combined with screening for diabetes in high-risk groups.

The prevalence of peripheral neuropathy in newly diagnosed patients with non-insulin-dependent diabetes mellitus.

INTRODUCTION: Neuropathy is considered to be a longterm complication of diabetes. AIMS: To determine the prevalence of peripheral neuropathy in 112 Sri Lankan patients with recently diagnosed non-insulin-dependent diabetes and a control population of 100 people. METHODS: A diagnosis of peripheral neuropathy was made using a clinical symptom score, clinical examination, quantitative sensory testing and electrophysiological studies. RESULTS: 9.8% of diabetic patients at diagnosis had peripheral neuropathy, 2.6% had foot ulcers, 7.1% had signs of neuropathy, abnormal vibration perception threshold and nerve conduction abnormalities and 15.1% had abnormal nerve conduction velocity without signs or symptoms of neuropathy. The peroneal nerve conduction velocity was higher in diabetic patients when compared to controls. There was an inverse correlation between nerve conduction velocity and fasting blood glucose in diabetic patients (p < 0/05). This association was stronger for peroneal nerve conduction velocity (r = -0.73) than for median nerve motor conduction velocity (r = -0.42). CONCLUSIONS: Symptomatic peripheral neuropathy is common among Sri Lankans with newly diagnosed non-insulin-dependent diabetes. This may be due to a later presentation of diabetes or a genetic predisposition.

Prevalence of lipid abnormalities in Sri Lankan patients with non-insulin dependent diabetes mellitus.

OBJECTIVE: To determine the prevalence of hyperlipidaemia in Sri Lankan patients with non-insulin dependent diabetes mellitus (NIDDM) and a normal control population. DESIGN: A cross-sectional study. SETTING: Patients with NIDDM randomly selected from a diabetic clinic register and non-diabetic controls randomly selected from an electoral register. PATIENTS: 498 patients with NIDDM (197 females mean age 53.5, SD 6.2 years) and 253 non-diabetic controls (101 females, mean age 53, SD 5.5 years matched for age and sex. METHODS: Diabetes and impaired glucose tolerance (IGT) were excluded in the control group by a 75g oral glucose tolerance test. Total cholesterol, high density cholesterol and triglycerides were determined in fasting blood samples. RESULTS: The prevalence of lipid abnormalities was significantly higher in diabetic patients than in controls. The prevalence of hypercholesterolaemia was 21% vs 14% and that of hypertriglyceridaemia 16% vs 8.3%. Mean fasting blood glucose was higher (9.7 + 2.7) in hyperlipidaemic patients than in normolipidaemic diabetic patients (7.5 + 2.1) CONCLUSIONS: Hyperlipidaemias are common in Sri Lankan patients with NIDDM and screening for them should be an essential component of management of patients with diabetes mellitus.