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OBJECTIVE: To investigate whether the Australian National Sub-acute and Non-acute Patient Casemix Classification (SNAP) and Functional Independence Measure and Functional Related Group (Version 2) (FIM-FRG2) casemix systems can be used to predict functional outcome, and reduce the variance of length of stay (LOS) of patients undergoing rehabilitation after strokes. DESIGN AND SETTING: The study comprised a retrospective analysis of the records of patients admitted to the Cedar Court Healthsouth Rehabilitation Hospital for rehabilitation after stroke. SUBJECTS: The sample included 547 patients (83.3% of those admitted with stroke during this period). Patient data were stratified for analysis into the five SNAP or nine FIM-FRG2 groups, on the basis of the admission FIM scores and age. MAIN OUTCOMES: The AN-SNAP classification accounted for a 30.7% reduction of the variance of LOS, and 44.2% of motor FIM, and the FIM-FRG2 accounts for 33.5% and 56.4% reduction respectively. Comparison of the Cedar Court with the national AN-SNAP data showed differences in the LOS and functional outcomes of older, severely disabled patients. Intensive rehabilitation in selected patients of this type appears to have positive effects, albeit with a slightly longer period of inpatient rehabilitation. CONCLUSIONS: Casemix classifications can be powerful management tools. Although FIM-FRG2 accounts for more reduction in variance than SNAP, division into nine groups meant that some contained few subjects. This paper supports the introduction of AN-SNAP as the standard casemix tool for rehabilitation in Australia, which will hopefully lead to rational, adequate funding of the rehabilitation phase of care.

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There are many dangers associated with long-term urinary bladder drainage by catheter. For various reasons, the choice of catheter is important, and its initial insertion can be particularly hazardous. All catheterizations should, however, be safer when there is some urine (or other fluid) in the bladder. The appropriate choice of drainage system attached to the catheter can delay bacterial invasion of the bladder. Great care is needed to prevent blockage of the system, particularly when bacteriuria is present. Recent evidence indicates that some bacteria encourage the development of encrustations, so that, in some circumstances, catheters may become blocked within 24 hours. This, together with other considerations, strongly suggests that indwelling catheters should be changed at intervals of not more than 5 days. The practical implications of this are considered, as are the benefits that may accrue. Accidental catheter traction is another danger, and some possible methods of avoiding this are discussed. Finally, the need for a new kind of drainage-bag support is highlighted.

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It is often assumed that pressure sores are caused by the flattening of blood capillaries, resulting in tissue ischaemia. However, the available evidence, especially that from animal experiments, indicates that microvascular trauma has a significant part to play. Published curves showing the relationship between level of pressure and duration of application also show that simple ischaemia is an inadequate explanation of pressure sore pathogenesis. The crucial pressure (tissue pressure) is normally estimated from interface pressure measurements. However, the relationship between tissue pressure and interface pressure is more complex than is generally realized. Other factors, such as shearing and static friction, are discussed briefly, and recommendations are made for clinical practice and further research.

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Alternating-pressure air mattresses (APAMs) have a long history, and after some advances in their design, which began in the 1980s, have become widely used for pressure sore prevention. A recent variation in the inflation/deflation cycle of a 'large-cell' APAM, which allows the use of lower (peak) pressures for inflating the air cells, is used in the Quattro range of APAMs. This should make the new products more comfortable, more versatile, and more durable than earlier large-cell APAMs. This article discusses both the theoretical and practical advantages and disadvantages of these products. It also suggests a simple method of checking the suitability of a given support for promoting a healthy skin for highly dependent patients.

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AIMS: A study was designed to assess the effects of a standardized instructional videotape on reducing interobserver variability for several commonly used observer-dependent outcome measures. METHODS: During a single day, six rheumatologists independently examined six patients with fibromyalgia (FM) in a predetermined order using a Latin square design, before and after viewing a standardized videotape which demonstrated methods for performing dolorimetry and for detecting skinfold tenderness and reactive hyperaemia. Reliability coefficients were calculated based on the variance components of the analysis of variance (ANOVA) table. RESULTS: Prestandardization reliability coefficients were <0.80 for 8 measures. Following standardization all reliability coefficients approximated to or exceeded 0.80. CONCLUSIONS: An important and beneficial effect of the standardization procedure was noted for several outcome variables. Such reductions in observer variability have the potential to diminish sample size requirements for FM antirheumatic drug studies. The use of a videotape to achieve this goal has obvious cost and convenience advantages over one-on-one training procedures.

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The determination of fat in foodstuffs is a common analytical task. Hitherto there has been no authoritative comparative exercise to assess the available methods by means of results from a large number of laboratories. In this paper four different empirical methods of analysis for fat are compared using the results generated from a proficiency testing scheme. The results show significant bias between some of the different methods, confirming the empirical nature of the determination.

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Constant low-pressure supports such as soft mattresses can feel comfortable because they conform well to the shape of the body. When such mattresses are provided with a highly convoluted surface made up of contiguous foam pillars, their efficacy is improved. The Modular Propad is a highly convoluted, but shallow, foam mattress. It is used as an overlay for an ordinary mattress and seems to be superior to earlier forms of convoluted foam overlay. The Softform is a new mattress which has replaceable sections. The outermost sections of the Softform are convoluted foam sheets similar to the Modular Propad. This article discusses the advantages and disadvantages of these products and some potential problems with their covers. It also suggests that the use of a pressure sore risk assessment tool can facilitate the allocation of patients to these special supports.

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Low air loss bed systems have proved successful in the management of severe pressure sores but they tend to be expensive. The Convertible II promises to provide many of the features of a low air loss bed at a much reduced cost. It is essentially a mattress replacement that can be used for various beds, including contouring-base beds. It is a component of the Elite 3 bed system which comprises an electrically powered contouring bed (with its own air pump) and three different mattresses: the mattress of the Convertible II is Mattress 3 of this system; Mattress 2 is an alternating-pressure air mattress; and Mattress 1 is a static air mattress with a foam envelope. The advantages and disadvantages of these products are discussed and it is suggested that the allocation of patients to the various supports can be facilitated by using a pressure sore risk-assessment score.

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Twenty-five years of recommending dressing techniques for the most intractable pressure sores has taught the author some interesting lessons about the practical problems of wound healing when all else has failed. It is hoped that these personal experiences and opinions will be of some help to the many nurses who are involved in the management of pressure sores and chronic wounds.

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The Pegasus Airwave and the Bi-Wave Plus are examples of alternating-pressure air mattress (APAM) systems that are more reliable than the older generation of APAMs. The Pegasus Airwave is useful for managing severe pressure sores, as well as for preventing sores in 'high-risk' patients. The Bi-Wave Plus is more suitable for patients with a 'fairly high risk' of developing sores and some patients may find it more comfortable than the Pegasus Airwave.

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An elastic catheter in the male urethra produces an 'uncurling' force as it attempts to straighten itself. Where this force is sustained, it may result in some pressure necrosis, or pressure atrophy. This article describes how this in-vivo situation was modelled and the resultant pressures checked and recommends the type and size of catheter that should be used if it is needed for more than 2 days of continuous use.

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