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.

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.

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.

Communication of discharge information for elderly patients in hospital

The delivery of the discharge note to the general practitioners following discharge of elderly patients from a geriatric medical unit was studied over a two-month period. Handwritten discharge notes were received by the general practitioners in 75% of cases, and the delay was reduced to a median of two days by the use of a pre-printed envelope. Postal communications were also received by 89% of general practitioners after a median delay in two days. A dual system of hand-delivery and postal delivery would ensure faster and more complete receipt of information.

Outcome following proximal femoral fracture in the elderly female

Outcome after proximal femoral fracture was assessed in 89 elderly females. Mortality both in hospital and subsequent to discharge was identified, with a mortality rate of 13.5% at 30 days and 35% after one year. The median length of stay was 28 days, with 40% of subjects transferred for geriatric-orthopaedic care. Delay prior to surgery and its relationship to increased mortality was highlighted. The importance of the fracture population and its selection and influence on outcome is discussed, indicating the need for caution in comparative audit.

Care of the elderly in north and west Belfast

A survey of all elderly people aged 65 years and over from North and West Belfast receiving long-term care in residential and nursing homes, and in psycho-geriatric and geriatric care was undertaken. A total of 967 subjects was studied and physical dependency and mental impairment documented. The high dependency of residents in geriatric and psycho-geriatric care was highlighted, with greater levels of dependency than among those receiving nursing home care. Professional assessment prior to admission should be common to all long-term care facilities and is essential if services for the projected demographic increase in numbers of very elderly people are to be provided, and inappropriate admission and expenditure avoided.

Rh haemolytic disease: continuing problem of management

Eighteen patients with severe Rh haemolytic disease, all of whom underwent fetal blood sampling and intrauterine transfusion, were studied. Twelve babies survived (67%) all of whom were delivered by lower segment caesarean section. There were three intrauterine deaths resulting in late abortion, one stillbirth with trisomy 21, and two neonatal deaths (both from severe prematurity). The traditional prognostic indicators were all inaccurate, and fetal blood sampling and measurement of the fetal packed cell volume were the most direct methods of assessing haemolysis. The progression of severe Rh disease is unpredictable, and we believe that all cases should be referred to specialist centres for advice or treatment.

Mortality in the elderly during respite hospital care

This study examined the mortality in the elderly during 243 respite hospital admissions. Sixty-four dependent elderly patients entered a regular respite care scheme and were admitted to hospital for a period of 4 weeks out of every 12 weeks. The mortality rate in hospital was one death per 976 days, in comparison to one death per 1296 days at home. This small increase in mortality should not deprive patients and their carers from access to respite care.

The effect of intravascular transfusion for rhesus haemolytic disease on umbilical artery Doppler flow velocity waveforms

To test the hypothesis that an increase in fetal blood viscosity is associated with an increase in resistance to flow, the effect on Doppler flow velocity waveforms of percutaneous umbilical blood sampling and intravascular transfusion was studied in 20 patients undergoing a total of 35 procedures. All but four of the 22 transfusions were associated with a decrease in resistance to flow, as shown by a reduction in the umbilical artery systolic/diastolic ratio, and this also occurred on 10 of the 13 occasions when blood sampling only was performed. These findings suggest that acute changes in blood viscosity following intravascular transfusion are not associated with an increase in resistance to flow as assessed by Doppler velocimetry. Umbilical blood sampling per se may be associated with a humorally mediated reduction in placental vascular resistance to flow.

Diaphragmatic hernia presenting in utero as a unilateral hydrothorax

A right-sided diaphragmatic hernia presented as a fetal hydrothorax. The fluid-filled hernial sac enveloped the lung and presumably prevented serious compression effects. The implications of fetal thoracic anomalies are discussed.

Obstetric aspects of prenatal diagnostic methods

The vast improvements in ultrasound technology have proved to be an important starting point for invasive investigative procedures in obstetrics. These methods not only allow a more precise diagnosis to be made but also offer considerable scope for in utero therapy.

First trimester diagnosis of Gaucher disease in a fetus with trisomy 21

A 38-year-old lady, who had a previous infant with type 2 Gaucher disease, underwent prenatal diagnosis by chorionic villus sampling at 9 weeks' gestation. Results on the fresh villus revealed a 47,XY,+21 karyotype and a marked deficiency (2 per cent of control) of beta-glucosidase activity. Following termination, villus material was cultured which initially revealed only a partial enzyme deficiency and a normal female karyotype, i.e., maternal cells. A subsequent culture contained 47,XY,+21 cells which were deficient in beta-glucosidase activity, thus confirming the diagnosis. The results in this interesting case illustrate the potential dangers of maternal cell contamination in cultured villus cells.

Thyroid screening in elderly hospital patients

A screening programme of thyroid disease in 214 elderly patients attending hospital was undertaken incorporating clinical and biochemical assessment. The prevalence of untreated hypothyroidism was 2.8%, treated hypothyroidism 2.8%, untreated hyperthyroidism 0.9%, sub-clinical hypothyroidism 4.7%, and non-thyroidal illness 3.3%. One patient with hypopituitarism was identified. Clinical judgement alone was poor. The costs of such a screening programme are discussed and the benefits highlighted.

Maternal serum alpha-fetoprotein--a marker of fetal aplastic crisis during intrauterine human parvovirus infection

In 2 cases of hydrops fetalis and intrauterine death associated with human parvovirus B19 infection that produced very few symptoms during the second trimester of pregnancy, maternal serum alpha-fetoprotein levels were raised, before the ultrasonic detection of hydropic features. Fetal blood sampling in 1 case revealed the features of aplastic crisis. A retrospective study of 3 other affected and 11 unaffected cases of B19 infection during pregnancy showed a correlation between raised maternal serum alpha-fetoprotein level and poor prognosis for the affected pregnancies, with the subsequent development of hydrops fetalis.

Early prenatal investigation of a pregnancy at risk of adenosine deaminase deficiency using chorionic villi

A pregnancy at risk for adenosine deaminase deficiency and severe combined immunodeficiency disease was investigated using samples of chorionic villi obtained during the eighth week of pregnancy. Adenosine deaminase levels suggested that the fetus was a probable carrier and that a diagnosis of severe combined immunodeficiency disease could be excluded. Enzyme and chromosome results were available within 24 hours of the chorionic villous sampling procedure, and were confirmed on amniotic fluid cell cultures after amniocentesis at 17 weeks' gestation and on cord blood at delivery.

An analysis of the parental age effect for inv dup (15)

Parental ages and birth order were analysed in 16 sporadic cases of inv dup (15) using the method of Smith. A significant maternal age effect was apparent (dm = 5.989, SE 1.86; df = 2.02, SE 2.496; db = 0.138, SE 0.46).

Inv dup (15) with mental retardation but few dysmorphic features

We report a Scottish child with inv dup (15) and compare the clinical features with those of previously reported cases. Since the first report by Parker and Alfi in 1972, there have been 44 reports of patients with confirmed or suspected inv dup (15). The extra chromosomal material has been variously described, but in all cases there appears to be an additional G group sized chromosome in which both ends are derived from the short arm, centromere, and proximal long arm of chromosome 15. In most cases there are satellites at both ends of this extra chromosome. We report the first patient from Scotland with similar cytogenetic findings.