Summary
Postoperative pain is an important clinical problem that has received increasing attention in recent years. However, pain following craniotomy has been a comparatively neglected topic; this review seeks to redress this imbalance. A brief overview of the anatomy of the skull and its linings is given, with particular reference to innervation. The various approaches for craniotomies are classified, with their association with acute and long‐term effects on analgesic requirements. A comprehensive search of the literature was undertaken to ascertain the incidence of acute pain post craniotomy and current thoughts on pharmacological management, touching briefly on pre‐emptive treatment. Also discussed is the much neglected but nevertheless real incidence of chronic pain following craniotomy and its underlying pathogenesis, prevention and treatment.
Objective: To evaluate the benefits of coordinating community services through the Post‐Acute Care (PAC) program in older patients after discharge from hospital.
Design: Prospective multicentre, randomised controlled trial with six months of follow‐up with blinded outcome measurement.
Setting: Four university‐affiliated metropolitan general hospitals in Victoria.
Participants: All patients aged 65 years and over who were discharged between August 1998 and October 1999 and required community services after discharge.
Interventions: Participants were randomly allocated to receive services of a Post‐Acute Care (PAC) coordinator (intervention) versus usual discharge planning (control).
Main outcome measures: Comparison of quality of life and carer stress at one‐month post‐discharge, mortality, hospital readmissions, use of community services and community and hospital costs over the six months post‐discharge.
Results: 654 patients were randomised, and 598 were included in the analysis (311 in the PAC group and 287 in the control group). There was no difference in mortality between the groups (both 6%), but significantly greater overall quality‐of‐life scores at one‐month follow‐up in the PAC group. There was no difference in unplanned readmissions, but PAC patients used significantly fewer hospital bed‐days in the six months after discharge (mean, 3.0 days; 95% CI, 2.1–3.9) than control patients (5.2 days; 95% CI, 3.8–6.7). Total costs (including hospitalisation, community services and the intervention) were lower in the PAC than the control group (mean difference, $1545; 95% CI, $11–$3078).
Conclusions: The PAC program is beneficial in the transition from hospital to the community in older patients.
What is the impact of engaging with natural environments delivered via virtual reality on the psycho-emotional health of people with spinal cord injury receiving rehabilitation in hospital? Findings from a pilot randomized controlled trial
Objective: To determine trends in use of Australian acute hospital inpatient services by older patients.
Design and data sources: Secondary analysis of hospital data from the Australian Institute of Health and Welfare in the period 1993–94 to 2001–02, with population data for this period from the Australian Bureau of Statistics.
Outcome measures: Population‐based rates of hospital separations and bed utilisation.
Results: The Australian aged population (65 years and older) increased by 18% compared with total population growth of 10%, yet the proportion of hospital beds occupied by older patients remained stable at 47%. The most substantial changes were observed in the population aged 75 years and older, with separations increasing by 89%, length of stay reducing by 35% and bed utilisation increasing by 23%. However, rates of bed utilisation (in relation to population) declined among older groups (10% decline in per capita use in population 75 years and older), but increased in the younger population (1% increase in per capita use in people younger than 65 years).
Conclusion: Important trends in use of inpatient services were identified in this study. These trends are contrary to common perception. Ageing of the Australian population was not associated with an increase in the proportion of hospital beds used by older patients.
Transition care is a new program to Australia that is designed to facilitate transitions of frail older people between the hospital and aged care systems.
This program is designed to deliver potentially important improvements to the Australian health care system — but will it deliver?
The current evidence base regarding the efficacy of this type of program is mixed, and there is little evidence to indicate improved patient outcomes.
An average transition care episode is expensive (about $11 000). Therefore, careful consideration of the relative cost‐effectiveness compared with other interface programs such as inpatient subacute services is essential.
Transition care services should be established within the context of overall regional plans for aged care, incorporating hospital acute and subacute inpatient services, and long‐term community and residential care programs.
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