A pre-discharge ward for acute medical patients.

UNLABELLED: We describe and evaluate a ward developed to facilitate the discharge planning of general medical patients. DESCRIPTION: A 15-bed pre-discharge ward (PDW) with a ward coordinator was established in 1995, as a counterpoise to a medical assessment unit (MAU). METHOD: Data, analysed after the first year, included diagnosis, physiotherapy and occupational therapy referrals, length of stay and discharge destination. RESULTS: During its first year, 810 patients were admitted to the PDW; 39% were male, their mean age was 75 years (range, 16-99; standard deviation, 11.3). Respiratory illness (24%) was the commonest diagnosis, 62% required physiotherapy, 51% occupational therapy and 35% needed increased social support. Discharge was as follows: 681 (84.1%) patients were discharged to their admission address, 34 (4.2%) were taken over by the department for care of the elderly, 29 (3.6%) discharged to relatives, 23 (2.8%) to residential or nursing homes, 22 (2.7%) returned to acute medical beds, 12 (1.5%) to general practitioner beds and nine patients (1.1%) died. The average length of stay during a three-month period (October-December) for all acute medical patients was 7.47 days before the MAU and PDW were opened and 7.32 days afterwards. CONCLUSIONS: The PDW provides multidisciplinary assessment and focused discharge planning for patients of general physicians. This did not prolong their stay in acute medical beds.

Thrombolysis for elderly patients with myocardial infarction: experience in an integrated unit.

The Departments of Medicine and Geriatrics were integrated in the Ogwr Health Unit in 1984. Since then there has been a non-age-related acute admissions policy which has led to early, intensive investigations and appropriate treatment of all patients according to need rather than age. A retrospective analysis of the use of thrombolytic agents over a 12-month period in patients aged 65 or over was undertaken to assess whether our principles extended to care of elderly patients admitted with acute myocardial infarction. High rates of prescription of thrombolytic agents in the elderly were achieved by endorsing the philosophy that age contributes little to the prediction of patient outcome and should not be considered in patient management.

Ulcerative colitis in a husband and wife.

The case histories of a husband and wife who developed ulcerative colitis after 28 years of marriage are described. It is hoped this report will stimulate the systematic study of inflammatory bowel disease occurring in both partners of a marriage and clarify the comparative importance of constitutional and environmental factors in its pathogenesis.

Acute upper gastrointestinal haemorrhage in a district general hospital: audit of an agreed management policy.

All patients from an unselected population admitted with acute upper gastrointestinal (GI) haemorrhage to a District General Hospital (DGH) were studied prospectively over one year. Before the study period a management policy was agreed between physicians and surgeons. One-hundred-and-nine patients were admitted. Sixty-eight per cent were over 60 and 17% over 80 years of age. Sixty patients bled from peptic ulcers and seven patients rebled. Endoscopic stigmata (visible vessel, adherent clot, and oozing) were useful in identifying those at increased risk of rebleeding but not as an indication for surgery. Six patients underwent surgery for peptic ulceration with one postoperative death. There were four deaths among the other patient groups giving an overall mortality of 4.6%. This audit shows a low mortality after acute upper GI haemorrhage can be achieved even in an elderly population in a DGH without the establishment of a specialist unit but with an agreed policy of management.

Prolonged pharyngeal impaction of dentures following stroke.

Dysphagia is a well-recognized complication of stroke. We report two cases of dysphagia in stroke patients caused by the pharyngeal impaction of dental prostheses. Radiologic identification of such impaction is unreliable due to the increasing use of radiolucent material in dental prostheses. We recommend direct or indirect laryngoscopy to exclude foreign body impaction in all patients complaining of dysphagia.

Hypertrophic pulmonary osteoarthropathy complicating Celestin tube insertion.

A case is reported in which hypertrophic pulmonary osteoarthropathy (HPOA) developed following the insertion of a Celestin tube for a benign oesophageal stricture. The HPOA resolved completely following removal of the tube. It is believed that the Celestin tube was the major factor causing the HPOA, a complication of Celestin tube insertion not previously reported.

Benign stricture of the oesophagus: role of non-steroidal anti-inflammatory drugs.

The medication history of patients presenting with benign oesophageal stricture is compared with an age and sex matched control population selected from the community. Fifty five out of 151 consecutive admissions to a dysphagia clinic were found to have benign oesophageal stricture. Twenty six out of 53 (49%) had been prescribed non-steroidal anti-inflammatory drugs in the year preceding their clinic appointment. Ten patients (19%) had been prescribed other drugs implicated in oesophageal disease over the same period. In the control population, 20 out of 165 (12%) had been prescribed non-steroidal anti-inflammatory drugs, and 31 out of 165 had been prescribed 'other' drugs in the preceding year. The difference between numbers on non-steroidal anti-inflammatory drugs in the patient and control groups was highly significant (X2 = 23.87, p less than 0.1%). This study has shown an association between the prescribing of non-steroidal anti-inflammatory drugs and benign stricture of the oesophagus.

The organisation and evaluation of an open-access dysphagia clinic.

We describe our experience in organising an open access dysphagia clinic. Any patient with dysphagia for solids of at least one week's duration can be seen within one week of referral. One hundred and nine 'new' patients were referred in the first year. Fifty-five (50.4%) had peptic or malignant strictures. The majority of these received definitive treatment within ten days of the date of referral. This system of referral and treatment improves the speed of detection and treatment of patients with oesophageal stenosis.

Osteomalacia in the elderly: the value of radio-isotope bone scanning in patients with equivocal biochemistry.

Radio-isotope bone scanning was used to detect osteomalacia in 17 elderly subjects who had equivocal biochemical evidence of this condition. The scan was positive in 10 of the 17 subjects. Bone biopsy confirmed osteomalacia in all 10, but also identified a further two cases. Isotope bone scanning is a practical and relatively non-invasive method of detecting osteomalacia in elderly subjects.

Changes in blood pressure and renal function after parathyroidectomy in primary hyperparathyroidism.

Changes in blood pressure and renal function were investigated in 62 patients with primary hyperparathyroidism treated surgically, in an attempt to assess whether or not hypertension and renal impairment should be regarded as important indications for parathyroidectomy. 29% were hypertensive pre-operatively and the blood pressure remained elevated after parathyroidectomy in all of these patients. Hypertension developed for the first time after parathyroidectomy in 45% of those patients who were normotensive before surgery. Renal function was normal initially in 73% and mild renal impairment developed after surgery in 9% of these patients. At the end of the follow-up period, the prevalence of hypertension was higher in patients with renal impairment pre-operatively (88%) than in those with normal renal function (51%). We conclude that hypertension alone should not be regarded as an indication for parathyroidectomy in asymptomatic hyperparathyroidism. No firm conclusions can be reached about the importance of mild renal failure as an indication for surgery and the question is unlikely to be resolved without conducting a prospective controlled trial.

Anxiety and actualization: further research.

In a recent article, Wilkins, Hjelle, and Thompson (1977) argued that unlike the Dabrowski-deGrace hypothesis, self-actualized Ss should have lower levels of manifest anxiety than low self-actualized Ss. Wilkins et al. demonstrated that this was indeed a preferable hypothesis. The present experiment concerns the relationship of actualization to state and trait anxiety. Ss were administered the Personal Orientation Inventory, the Taylor Manifest Anxiety Scale, and Catteil's measure of state-trait anxiety. The results support the Wilkins et al. reformulation by demonstrating that: (1) high self-actualized Ss had lower trait anxiety scores; and (2) high self-actualized Ss were susceptible to state anxiety within the limits established by their trait anxiety level.

Anxiety and actualization: a reconceptualization.

In line with Dabrowki's theory of Positive Disintegration, deGrace recently reported no significant difference in terms of anxiety level between groups of actualized and nonactualized Ss. Several methodological and theoretical flaws noted in the deGrace study led the present authors to hypothesize that actualized Ss would score significantly lower than nonactualized Ss on separate but conceptually related measures of manifest or neurotic anxiety. Ss (83 females and 42 males) were administered the Personal Orientation Inventory, the IPAT Anxiety Scale, and the Taylor Manifest Anxiety Scale. The results, which substantiate the hypothesis that levels of actualization and anxiety are correlated negatively, are discussed in relation to the conceptual distinction between debilitating and facilitating anxiety and their respective effects on psychological growth.

Trends in powerlessness: a ten year follow-up.

This experiment tested the hypothesis that there would be a significant increase in powerlessness scores over a 10 year period. The sample was drawn from a population of college students originally tested in 1964. At the 10 year follow-up, all Ss had graduated from college and were either professionally employed (mostly as teachers) or engaged in child-rearing/home activities. The average age of the 1974 sample was 29 years and consisted of 70 females and 30 males. The test instrument was the adult version of Rotter's Internal-External (I-E) Locus of Control Scale which consists of 23 forced-choice items. There were no significant differences on total I-E scores over the 10 year period. However, with use of the Mirels two-factor scoring system, significant increases in social-political control were found. No significant differences in personal control were found. It was concluded that care should be taken in utilizing cross-sectional findings and that utilizing multidimensional scores suggests different results for previously published reports.