BRITISH MEDICAL JOURNAL
299
4 FEBRUARY 1978
Laboratory as due to influenza Al (H1 N1). The explosive spread of this organism started on 14 January. Within a few days of starting in any particular school, dormitory, or house it affected 50-60 % of children. The attack rate in adults has been variable but less than 10°. In the first 200 cases of influenza the usual symptoms have been pharyngitis, rhinitis, irritating cough, and pyrexia lasting not more than 2-3 days; 10-15%' have also had gastrointestinal symptoms. Typical influenza symptoms such as aching back, limbs, and head have affected only two children, though, coincidentally, another child with headache and pyrexia proved to have falciparum malaria. Ten days after the start of the outbreak, middle ear and chest complications have affected only 3 children. In the largest school detailed records show that the organism presented in the same way the first time round in January 1947 with a feverish head cold rather than typical influenza, but, while the outbreak was similarly explosive, adults were also affected that year. Comparison of immunised and nonimmunised individuals and schools makes it clear that the standard influenza vaccine this year has given little or no protection.
via a fire escape must obviously be a formidable if not an impossible undertaking. And there was a time when psychiatrically disturbed elderly patients could be admitted to hospital for a fortnight to give, say, the patient's daughter a well-needed holiday and respite from the onerous duty of looking after her mother. The current dearth of beds for psychogeriatric patients is putting an end to such a service. The answer to this problem is not to put up beds again and thereby overcrowd wards but for additional purpose-built accommodation to be made available for the management and treatment of psychogeriatric patients who cannot be adequately cared for in their own homes. J TODD High Royds Hospital, Ilkley, W Yorks
SIR,-The fall in the admission rate of old people to psychiatric units reported by Drs K Shulman and T Arie (21 January, p 156) came as a surprise to one whose experience of the psychiatry of old age is of full long-stay wards and blocked assessment units. One of the most likely reasons for the declining admission rate P T PENNY which the authors appear not to have considered is the inability to admit patients to Taunton, Somerset increasingly congested units. My own comparison of 150 elderly patients admitted to this hospital in 1974 with a similar cohort admitted in 1962-31 might bear this out. Fall in admission rate of old people to Age, sex, and diagnostic distribution was psychiatric wards similar in both studies. However, outcome at SIR,-I was interested to read the paper one year was very different and was most entitled the "Fall in admission rate of old marked in those with an organic diagnosis: people to psychiatric units" by Drs K Shulman and Tom Arie (21 January, p 156). Date of admission The steady reduction in the number of beds Outcome at one year 1974 1962-3 in the wards of psychiatric hospitals during the past decade has forced psychiatrists to Died in hospital 18-0o' 33.3° 32-1 O° 50-6 °. Still in hospital institute waiting lists in the knowledge that Discharged 30 4 o 34-600 many of those on such lists are in dire straits Not known 1 1 and that the combined efforts of community nurses, social workers, and relatives will be If this sample was representative the inadequate to deal with the problems presented by the confused and anorectic elderly patient increased proportion of those remaining in hospital compared with 11 years before could with nomadic tendencies. The efforts of psychiatrists to meet their account for a decline in the admission rate per obligations to the psychogeriatric patient and 100 000 of the over-65s in this area. On a society despite the reduction in the number of larger scale it would require details of bed beds available to them have tended to produce occupancy in psychiatric units for the elderly, an undesirable preponderance of geriatric including long-stay beds, over the study patients in wards designated as acute admission period to confirm my suggestion. wards. This results from the natural reluctance IAN PULLEN of a psychiatrist with an empty bed in an acute Andrew Duncan Clinic, Edinburgh Hospital, ward (but in no other ward) to refuse to admit Royal Edinburgh a patient merely because he or she is old. But as such patients are notoriously difficult to 1 Woodside, M, Gerontologia Clinica, 1965, 7, 286. discharge the acute admission ward invariably becomes "geriatrised" and therefore unsuitable is one simple possible explanation for the treatment of younger patients such as SIR,-There in fall admission rate of old people the for women suffering from a postnatal psychosis. dementia to psychiatric units (21 January, Moreover, reduction in the number of beds with earmarked for the care of geriatric patients has p 156)-they are in the non-geriatric beds of curtailed the psychiatrist's ability to classify general hospitals.' Patients with senile dementia are not patients and designate wards in a sensible accepted by psychiatric units because they are fashion. Vigorous and irritable geriatric geriatric. They are not accepted by part III patients cannot always be separated from frail accommodation or geriatric wards because geriatric patients nowadays, with the result they are psychiatric. They are put on a the over be latter by that the pushed may list and then wait waiting psychogeriatric former and sustain a fractured neck of the femur, with perhaps fatal consequences. And almost indefinitely for transfer. J H BARON a disturbing number of elderly patients with Charles St Hospital, to be are restricted having mobility grossly London W10 accommodated in upper-storey wards. In the event of a fire the evaucation of such patients 1 Baron, J H, British Medical Journal, 1977, 2, 124.
Aid for the disabled SIR,-Mr M A Morris's article (7 January, p 25) draws attention again to the technique of vacuum consolidation which has in the past found a variety of uses in medical practice.1 2 The potential to characterise accurately body shape and the subsequent production of a rigid negative has found application in the "Oxford emergency vacuum splint,"3 now used by the Oxfordshire Ambulance Service, in the initial stage of the manufacture of a moulded body support,'-6 and in the production of splints to support fractures in severely deformed limbs.7 In severe Duchenne type muscular dystrophy the use of such an individually contoured support for sleeping has much to recommend it; careful positioning of the vacuum bag could prevent abduction occurring at the hips, often a cause of pain and discomfort, and could support the flexural contractures at the hip, knee, and ankle which are inevitable in this disease. A number of potential problems can be foreseen. Any system designed to support body weight for a lengthy period of time needs a soft cushioning layer for comfort. The Vac-Pac or similar bag when evacuated develops numerous ridges and depressions on its surface which might prove irritating and possibly result in local pressure necrosis despite the desired aim of total body surface contact. Many such vacuum systems tend to sag after evacuation; the position may be better maintained by enclosing the Vac-Pac bag in a constraining trough. It has been our experience with Duchenne muscular dystrophy that discomfort or pain develops quickly in the limbs if any position is maintained, and temporary relief can be obtained by slight alterations in posture. The need to alter posture could be fulfilled using the Vac-Pac system described, but this would require considerable time and effort on the part of the parent if many changes were necessary each night. Our recommendation is to use an electrically operated posturechanging bed with a suitably sensitive switch mechanism that can be managed by the patient. The frequency of limb pains appears to increase with disease deterioration, and assistance may be required up to 10 times each night. We would be very interested to hear from Mr Morris how he has managed this particular problem and for how long his patients have been able to continue using this particular system. DAVID BossINGHAM PHILIP NICHOLS Nuffield Orthopaedic Centre, Headington, Oxford
Germans, F H, et al, Inter Clinic Information Bulletin, 1975.
Povey, R W, Journal of Bone and Joint Surgery, 1970, 52B, 535. 3 Harris, J D. Personal communication. 4Nichols, P J R, and Strange, T V, Rheumatology and 2
Physical Medicine, 1972, 11, 356.
5 Nelham, R L, Biomedical Engineering, 1975, 10, 379. 6Strange, T V, Harris, J D, and Nichols, P J R, Rheumatology and Rehabilitation. In press. 7Bossingham, D H, Strange, T V, and Nichols, P J R, British MedicalYJournal. In press.
SIR,-The article by Mr M A Morris (7 January, p 25) describes the use of the VacPac by muscular dystrophy patients. He suggests that it has wider applications. We at Europ Assistance have been using a similar vacuum mattress, produced by Laerdal, to immobilise patients during aeromedical
299
4 FEBRUARY 1978
Laboratory as due to influenza Al (H1 N1). The explosive spread of this organism started on 14 January. Within a few days of starting in any particular school, dormitory, or house it affected 50-60 % of children. The attack rate in adults has been variable but less than 10°. In the first 200 cases of influenza the usual symptoms have been pharyngitis, rhinitis, irritating cough, and pyrexia lasting not more than 2-3 days; 10-15%' have also had gastrointestinal symptoms. Typical influenza symptoms such as aching back, limbs, and head have affected only two children, though, coincidentally, another child with headache and pyrexia proved to have falciparum malaria. Ten days after the start of the outbreak, middle ear and chest complications have affected only 3 children. In the largest school detailed records show that the organism presented in the same way the first time round in January 1947 with a feverish head cold rather than typical influenza, but, while the outbreak was similarly explosive, adults were also affected that year. Comparison of immunised and nonimmunised individuals and schools makes it clear that the standard influenza vaccine this year has given little or no protection.
via a fire escape must obviously be a formidable if not an impossible undertaking. And there was a time when psychiatrically disturbed elderly patients could be admitted to hospital for a fortnight to give, say, the patient's daughter a well-needed holiday and respite from the onerous duty of looking after her mother. The current dearth of beds for psychogeriatric patients is putting an end to such a service. The answer to this problem is not to put up beds again and thereby overcrowd wards but for additional purpose-built accommodation to be made available for the management and treatment of psychogeriatric patients who cannot be adequately cared for in their own homes. J TODD High Royds Hospital, Ilkley, W Yorks
SIR,-The fall in the admission rate of old people to psychiatric units reported by Drs K Shulman and T Arie (21 January, p 156) came as a surprise to one whose experience of the psychiatry of old age is of full long-stay wards and blocked assessment units. One of the most likely reasons for the declining admission rate P T PENNY which the authors appear not to have considered is the inability to admit patients to Taunton, Somerset increasingly congested units. My own comparison of 150 elderly patients admitted to this hospital in 1974 with a similar cohort admitted in 1962-31 might bear this out. Fall in admission rate of old people to Age, sex, and diagnostic distribution was psychiatric wards similar in both studies. However, outcome at SIR,-I was interested to read the paper one year was very different and was most entitled the "Fall in admission rate of old marked in those with an organic diagnosis: people to psychiatric units" by Drs K Shulman and Tom Arie (21 January, p 156). Date of admission The steady reduction in the number of beds Outcome at one year 1974 1962-3 in the wards of psychiatric hospitals during the past decade has forced psychiatrists to Died in hospital 18-0o' 33.3° 32-1 O° 50-6 °. Still in hospital institute waiting lists in the knowledge that Discharged 30 4 o 34-600 many of those on such lists are in dire straits Not known 1 1 and that the combined efforts of community nurses, social workers, and relatives will be If this sample was representative the inadequate to deal with the problems presented by the confused and anorectic elderly patient increased proportion of those remaining in hospital compared with 11 years before could with nomadic tendencies. The efforts of psychiatrists to meet their account for a decline in the admission rate per obligations to the psychogeriatric patient and 100 000 of the over-65s in this area. On a society despite the reduction in the number of larger scale it would require details of bed beds available to them have tended to produce occupancy in psychiatric units for the elderly, an undesirable preponderance of geriatric including long-stay beds, over the study patients in wards designated as acute admission period to confirm my suggestion. wards. This results from the natural reluctance IAN PULLEN of a psychiatrist with an empty bed in an acute Andrew Duncan Clinic, Edinburgh Hospital, ward (but in no other ward) to refuse to admit Royal Edinburgh a patient merely because he or she is old. But as such patients are notoriously difficult to 1 Woodside, M, Gerontologia Clinica, 1965, 7, 286. discharge the acute admission ward invariably becomes "geriatrised" and therefore unsuitable is one simple possible explanation for the treatment of younger patients such as SIR,-There in fall admission rate of old people the for women suffering from a postnatal psychosis. dementia to psychiatric units (21 January, Moreover, reduction in the number of beds with earmarked for the care of geriatric patients has p 156)-they are in the non-geriatric beds of curtailed the psychiatrist's ability to classify general hospitals.' Patients with senile dementia are not patients and designate wards in a sensible accepted by psychiatric units because they are fashion. Vigorous and irritable geriatric geriatric. They are not accepted by part III patients cannot always be separated from frail accommodation or geriatric wards because geriatric patients nowadays, with the result they are psychiatric. They are put on a the over be latter by that the pushed may list and then wait waiting psychogeriatric former and sustain a fractured neck of the femur, with perhaps fatal consequences. And almost indefinitely for transfer. J H BARON a disturbing number of elderly patients with Charles St Hospital, to be are restricted having mobility grossly London W10 accommodated in upper-storey wards. In the event of a fire the evaucation of such patients 1 Baron, J H, British Medical Journal, 1977, 2, 124.
Aid for the disabled SIR,-Mr M A Morris's article (7 January, p 25) draws attention again to the technique of vacuum consolidation which has in the past found a variety of uses in medical practice.1 2 The potential to characterise accurately body shape and the subsequent production of a rigid negative has found application in the "Oxford emergency vacuum splint,"3 now used by the Oxfordshire Ambulance Service, in the initial stage of the manufacture of a moulded body support,'-6 and in the production of splints to support fractures in severely deformed limbs.7 In severe Duchenne type muscular dystrophy the use of such an individually contoured support for sleeping has much to recommend it; careful positioning of the vacuum bag could prevent abduction occurring at the hips, often a cause of pain and discomfort, and could support the flexural contractures at the hip, knee, and ankle which are inevitable in this disease. A number of potential problems can be foreseen. Any system designed to support body weight for a lengthy period of time needs a soft cushioning layer for comfort. The Vac-Pac or similar bag when evacuated develops numerous ridges and depressions on its surface which might prove irritating and possibly result in local pressure necrosis despite the desired aim of total body surface contact. Many such vacuum systems tend to sag after evacuation; the position may be better maintained by enclosing the Vac-Pac bag in a constraining trough. It has been our experience with Duchenne muscular dystrophy that discomfort or pain develops quickly in the limbs if any position is maintained, and temporary relief can be obtained by slight alterations in posture. The need to alter posture could be fulfilled using the Vac-Pac system described, but this would require considerable time and effort on the part of the parent if many changes were necessary each night. Our recommendation is to use an electrically operated posturechanging bed with a suitably sensitive switch mechanism that can be managed by the patient. The frequency of limb pains appears to increase with disease deterioration, and assistance may be required up to 10 times each night. We would be very interested to hear from Mr Morris how he has managed this particular problem and for how long his patients have been able to continue using this particular system. DAVID BossINGHAM PHILIP NICHOLS Nuffield Orthopaedic Centre, Headington, Oxford
Germans, F H, et al, Inter Clinic Information Bulletin, 1975.
Povey, R W, Journal of Bone and Joint Surgery, 1970, 52B, 535. 3 Harris, J D. Personal communication. 4Nichols, P J R, and Strange, T V, Rheumatology and 2
Physical Medicine, 1972, 11, 356.
5 Nelham, R L, Biomedical Engineering, 1975, 10, 379. 6Strange, T V, Harris, J D, and Nichols, P J R, Rheumatology and Rehabilitation. In press. 7Bossingham, D H, Strange, T V, and Nichols, P J R, British MedicalYJournal. In press.
SIR,-The article by Mr M A Morris (7 January, p 25) describes the use of the VacPac by muscular dystrophy patients. He suggests that it has wider applications. We at Europ Assistance have been using a similar vacuum mattress, produced by Laerdal, to immobilise patients during aeromedical
