Biomedical subjects
Publications and source records attributed to P Wanklyn.
Most elderly people in Britain live independently in their own homes. Moving to alternative accommodation may be necessary for some people but requires careful consideration. A multidisciplinary assessment should be performed when a person plans to move into residential care; this should include the input of a doctor trained in geriatric medicine. A range of housing options is open to elderly people and these options are discussed here.
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The prevalence of hemiplegic shoulder pain (HSP) and associated factors was studied in patients with a stroke followed for 6 months after discharge from hospital. A questionnaire was used to evaluate shoulder symptoms and an examination of the shoulder and arm was carried out three times over 6 months. A total of 108 patients were studied with a mean age of 71 years. Sixty-nine patients (63.8%) developed HSP at some time during the study period. The number with HSP was 39 at discharge from hospital, 59 at 8 weeks post-discharge and 36 at 6 months. Nine carers reported lifting the patient by pulling on the hemiplegic arm, even though six of them had received advice about correct lifting techniques. Reduced shoulder shrug was associated with HSP at all times and reduced pinch grip was also associated with HSP at discharge from hospital. Patients who required help with transfers were more likely to suffer with HSP. There was no difference in the prevalence of HSP in patients treated at the day hospital compared to those who received domiciliary physiotherapy. It is concluded that HSP is common after a stroke and the prevalence increases in the first weeks after discharge from hospital. Stroke patients and their carers need advice about correct handling of the hemiplegic arm, and more work is required to ensure that correct handling occurs after discharge in patients at high risk of this unpleasant complication.
Dysphagia is common after a stroke and is associated with a poor outcome in terms of survival or functional recovery. Percutaneous gastrostomy (PG) provides reliable and safe nutrition for patients with neurological dysphagia in the short term but little is known about the the subsequent outcome in stroke patients. We reviewed the medical records of all stroke patients who had required a PG in four West Yorkshire hospitals over a 30-month period. All patients alive at the time of the study were contacted and functional status was recorded. Forty-one stroke patients had undergone PG and 37 records were obtained. There were 24 men and 13 women with a mean age of 74 years. Thirty-three patients had had a hemiplegia while four patients presented acutely with dysphagia but no hemiplegia (all had cerebral infarcts on CT scan). The timing of PG varied with a median time from stroke of 26 days (range 12-131). Complications include five chest infections ( < 1 week after PG), three local infections, two tubes pulled out and one perforation. Three patients died in the first 5 days after the PG. Thirty-one of the 37 patients had died at the time of the assessment, 21 during the original hospital admission. The median survival from the time of PG was 53 days (range 2-528) with only 12 patients surviving for more than 3 months. Six patients were alive at the time of the study and all but one were severely disabled (mean modified Barthel Index seven). There is no consensus about patients selection or timing of PG and our data should lead to more careful consideration of the risks and benefits of the procedure in stroke patients.
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BACKGROUND AND PURPOSE: Some stroke patients complain of an unpleasant sensation of coldness in the hemiplegic arm. This study aimed to determine the prevalence of this symptom and any associated features. METHODS: A questionnaire about symptoms in the arms was sent to patients at least 12 months after stroke. Reflex sympathetic dystrophy (RSD) was diagnosed if four typical symptoms were present in the arm. RESULTS: One hundred patients were recruited and 75 complete replies received. The mean age of the patients was 74 years, and the mean time since the stroke was 19 months. Forty patients (53%) experienced unilateral coldness in the hemiplegic arm. In 14 this sensation was constant, and 10 rated the symptom as troublesome. The symptom developed at a median time of 1 month after stroke, but only 13 patients (32%) sought advice from a doctor. Sensory symptoms and arm and shoulder pain were common, but the only symptoms associated with coldness were numbness (P < .001) and color change (P < .05). Fifteen patients fulfilled the diagnostic criteria for RSD, 13 of whom had coldness only in the hemiplegic arm. CONCLUSIONS: A sensation of coldness in the hemiplegic arm is common and distressing. It is associated with numbness and color changes in the arm. Some cases are caused by RSD, but other patients have coldness that may be due to other causes such as a vasomotor abnormality.
BACKGROUND AND PURPOSE: Vasomotor changes occur in the arm after hemiplegic stroke. Previous studies have provided conflicting results, with most showing an increase in skin temperature of the hemiplegic arm. However, a number of patients complain of distressing coldness of the hemiplegic arm. METHODS: Eleven patients with symptomatic coldness and 10 patients with hemiplegia but no coldness were recruited. The severity of the symptom of coldness was compared by questionnaire with other common symptoms after stroke. A thermographic camera was used to record the finger skin temperature response to cold stress. Blood flow to both hands was also measured simultaneously by means of two plethysmographs. In all patients there were no symptoms in the unaffected arm, and this was used as a control. RESULTS: The symptom of coldness rated highly compared with other symptoms. In the symptomatic group the finger temperature on the hemiplegic side was lower at rest (median difference at rest, 0.65 degrees C; P < .0001) and at all times after cold stress. In the asymptomatic group the fingers on the hemiplegic side were colder at rest and after initial cooling (median temperature difference, 0.2 degrees C) but at no other time. Hand blood flow on the hemiplegic side was also decreased in the symptomatic group by 35%. This was not seen in the asymptomatic group. CONCLUSIONS: Coldness of the hand may be a severe and distressing symptom in some patients after hemiplegia. Symptomatic patients have lower finger skin temperatures at rest and after standard cold stress. These symptomatic patients also had reduced blood flow to the hemiplegic hand.
We studied the effectiveness of a dedicated medical receiving room (MRR) with senior registrar (SR) assessment of GP requests for medical admission. In the first of three 16-week study periods, patients were assessed by senior house officers or registrars. In the second period, patients were assessed by a single SR. In the third period, nine SRs manned the MRR on a rota. Outcome measures included same-day discharge rate, use of specialist beds and 28-day readmission rate. A questionnaire was sent to general practitioners (GPs) of patients discharged in period three to assess their satisfaction with the service. The same-day discharge rate increased from 3.6% in period one to 29% in period two (p < 0.001) and 15% in period three (p < 0.001). The use of specialist and off-site beds also increased from 1.2 per week in period one to 2.9 in period two and 3.1 in period three. The 28-day readmission rate was 13.3% in period one, 6.9% in period two and 6% in period three. The GPs were satisfied with the service provided by the MRR and all felt that the discharge was appropriate. Assessment of GP referrals for acute medical admission by SRs in a MRR allows more patients to be safely discharged on the same day than if the assessment is carried out by a more junior doctor. SRs also direct more patients to the relevant specialty, so improving patient care and effective use of available beds.